Every finding on record at Flatrock River Lodge

Based on interview, observation, and record review, the facility failed to ensure a resident was treated with dignity by timely assisting with care for 1 of 4 residents reviewed for dignity. (Resident 22)Findings include:The clinical record for Resident 22 was reviewed on 04/09/2026 1:42 PM. The medical diagnoses included, but were not limited to, chronic respiratory issues (the lungs cannot adequately exchange oxygen and carbon dioxide) and muscle wasting. A Quarterly Minimum Data Set Assessment, dated 1/9/2026, indicated Resident 22 was cognitively intact. The resident needed substantial to maximal assistance with personal hygiene, dressing, and toilet hygiene. The resident needed partial to moderate assistance with sitting to standing transferring, toilet transferring, and walking. Resident 22 was frequently incontinent of urine and always continent of bowel.A fall care plan, dated 5/27/2025 and last revised 3/2/2026, indicated Resident 22 needed assistance with ambulating, transferring, and toileting.During an interview and observation, on 4/7/2026 at 12:10 PM, Resident 22 indicated she had asked for assistance to get up at 7:00 AM and needed to use the restroom. The CNA advised the resident she was passing breakfast trays and she (the CNA) would have to come back later. The facility staff did not come to assist her until after 8:00 AM, over an hour later. Resident 22 indicated having to wait made her mad and upset because she needed to use the restroom and had an accident.A grievance form, dated 4/7/2026, indicated Resident 22 stated she woke up at 7:00 am and rang her call light to be toileted. An unnamed staff member came in and told her she would have to wait until after breakfast. Staff did not come to assist her with toileting until after 8:00 AM. During an interview, on 4/8/2026 at 1:35 PM, CNA 5 indicated Resident 22 report needing to use the restroom and get up for the day. CNA 5 was in the middle of breakfast service and could not stop because of .infection control. measures. During an interview, on 4/9/2026 at 12:00 PM, the DON indicated Resident 22 report having to wait to get assistance on 4/7/2026 during breakfast. When the DON spoke with the CNA assigned to Resident 22, CNA 5 indicated the resident was not assisted right a way because of infection control measures. The DON indicated this was not an appropriate response and CNA 5 should have assisted Resident 22 and/or sought help from other staff members. A policy entitled, Resident Rights, was provided by the Clinical & Quality Consultant on 4/9/2026 at 12:40 PM. The policy indicated resident have the right to a dignified existence, to be treated with dignity and respect, and to receive services with reasonable accommodations.410 IAC (Indiana Administrative Code) 3.1-3(t) 410 IAC 3.1-3(u)(1)

Based on interview and record review, the facility failed to file grievances on behalf of a resident voicing concerns with staff for 1 of 3 residents reviewed for grievances.Findings include:The clinical record for Resident 1 was reviewed on 04/09/2026 1:57 PM. The medical diagnoses included, but were not limited to, a lung infection known as diabetes (chronic high blood sugar levels), and heart failure (a chronic condition where the heart cannot pump enough blood to meet the body's requirements). A Quarterly Minimum Data Set Assessment, dated 1/9/2026, indicated Resident 1 was cognitively intact, exhibited no behaviors noted, and needed substantial to maximal assistance from staff for toileting hygiene, dressing, and transferring.A care plan, dated 1/21/2026 and last revised on 2/18/2026, indicated Resident 1 used multiple psychotropic medications for behaviors issues. The interventions included, but were not limited to, allowing Resident 1 to express her feelings and to provide emotional support. During an interview and observation, on 4/7/2026 at 1:19 PM, Resident 1 reported CNA 5 and CNA 6 were rude to her. Resident 1 indicated she had reported the staff being rude to her multiple times to the DON but it was not getting better. In the last week, CNA 5 came in to get her up for the day and Resident 1 requested some time to wake up. CNA 1 advised Resident 1 that the staff would get the mechanical full body lift if Resident 1 did not get up. Resident 1 indicated she did not like to use the full body mechanical lift. During an interview, on 4/8/2026 at 1:35 PM, CNA 5 indicated Resident 1 only required as needed assistance with the use of a full body mechanical lift. CNA 5 indicated she tried to do care in pairs with Resident 1. During an interview, on 4/9/2026 at 12:00 PM, the DON indicated Resident 1 had reported issues to the DON regarding staff being rude. Resident 1 had voiced issues with CNA 5 and CNA 6. The DON indicated the facility implemented care in pairs and she had adjusted the schedule for those employees to not be the primary care for Resident 1, but she did not file grievances forms on the concerns for Resident 1. (A grievance form was a form used to log issues with respect to care and treatment furnished or allegedly not furnished, behavior of staff members and/or other residents, and any other concerns regarding their facility stay).A policy entitled, Grievance Protocol, was provided by the Clinical & Quality Consultant on 4/9/2026 at 12:40 PM. The policy indicated residents have the right to file a formalized grievance orally or in writing. Grievance included issues with respect to care and treatment furnished or allegedly not furnished, behavior of staff members and/or other residents, and any other concerns regarding their facility stay. If a resident brought a concern to a staff member, and the issue which rises to the level of grievance, the staff member receiving the report should file a grievance410 IAC (Indiana Administrative Code) 3.1-7(3)(b)

Based on observation, interview, and record review, the facility failed to assist a resident with eating who required cuing for 1 of 2 residents reviewed for Activities of Daily Living. (Resident 15) Findings include:The clinical record for Resident 15 was reviewed on 4/8/26 at 9:26 a.m. The diagnoses included, but were not limited to, bilateral chronic angle-closure glaucoma (eye condition where the iris progressively blocks both eye's drainage angle, causing high eye pressure and irreversible optic nerve damage) severe stage, abnormal involuntary movements, dementia (mental decline), muscle weakness, and lack of coordination (needing assistance with personal care). The Quarterly Minimum Data Set (MDS) assessment, dated 1/8/26, indicated Resident 15 was severely cognitively impaired, had no behaviors for rejection of care, and was a set up/clean up assistance with eating, which required cutting up the resident's food and cuing the resident to eat. During an observation on 4/7/26 at 1:03 p.m., Resident 15 was sitting in the dining room at a the assistive table. Resident 15 was feeding herself and was observed to have trouble getting the food on a fork and up to her mouth. No staff were observed cuing resident or assisting her with eating. A physician's order, dated 11/12/25, indicated Resident 15 had a regular diet texture with thin liquids. A progress note, dated 1/23/26, indicated Resident 15 fed herself with tray set up and lots of cuing and encouragement. A dietician fax order sheet, dated 2/27/26, indicated Resident 15 was placed at the assisted section a while back for consistent cuing at all meals. A progress note, dated 3/18/26, indicated Resident 15 required more assistance with activities of daily living (ADLs) and eating, the resident was having difficulty taking regular bites, and staff were assisting with feedings. During an observation, on 4/9/26 from 12:35 p.m. to 12:50 p.m., Resident 15 was sitting in the dining room at the staff assisted section for lunch. She was observed attempting to feed herself. Resident 15 was scooping her fork across her plate unable to get the food on her fork for 10 minutes of the observation. She made several attempts to get bites of food up to her mouth and would drop the food in her lap, then she would eat the food by hand out of her lap. Resident 15 had a chicken enchilada that was not cut up by staff for the resident. She continually attempted to cut her enchilada with a plastic fork and plastic knife and was unable. Certified Nursing Assistant (CNA) 2 was sitting to the right of Resident 15 assisting another resident and CNA 3 was sitting to the left of Resident 15 assisting another resident. No assistance or cuing were offered to Resident 15 throughout the meal observation by staff. Resident 15 was observed to eat only a few bites of her meal tray during the observation. During an interview with CNA 2, on 4/9/26 at 12:50 p.m., the CNA indicated Resident 15 was assisted sometimes but she always started out good. CNA 2 indicated quite often they did have to cue the resident to eat. The staff usually would cut the resident's food up for her, but it looked like no one cut her food up for her that day. During an interview with CNA 3, on 4/9/26 at 1:23 p.m., the CNA indicated Resident 15 sometimes required the assistance of staff with eating. The staff always cut her food up while they were attending to her, but they did not set her tray up today (cut up food into small pieces and prepared for ease of the resident). During an interview with Licensed Practical Nurse (LPN) 4, on 4/9/26 at 2:30 p.m., the LPN indicated she observed Resident 15 needing more encouragement to eat, cuing her to eat, and setting her food up. LPN 4 indicated Resident 15 did require assistance with eating sometimes and she had noticed a decline in the resident's ADLs over the past few months. A plan of care, dated 2/27/26, indicated Resident 15 had potential for weight changes and protein-calorie malnutrition related to dementia with varied meal intakes. The interventions included, but were not limited to, staff were to encourage the resident's food/fluid intake. A plan of care, dated 8/29/24, indicated Resident 15 had self care deficit by needing assistance with ADLs. The interventions included, but were not limited to, staff were to assist the resident with ADLs as needed. During an interview with the Clinical and Quality Consultant, on 4/10/26 at 11:17 p.m., the consultant indicated any of the staff who had the ability to assist a resident with eating could have assisted Resident 15 when she was having trouble eating. The CNAs or anyone else who observed Resident 15 could have stopped and assisted her. The staff were to re-directed, assisted, or cue the resident to eat. The Meal Service Standards policy was provided by the Clinical & Quality Consultant on 4/10/26 at 10:00 a.m. It indicated .4. Dining Assistance and Supervision: a. Residents identified as needing supervision, cuing/prompting or assistance with dining will eat in an assisted dining area where the facility staff will provide the required level of assistance or supervision. 410 IAC (Indiana Administrative Code) 3.1-38(a)(2)(D)

Based on interview and record review, the facility failed to timely document weekly wound assessment and ensure a primary care provider's visit was completed for 1 of 4 residents reviewed for quality of care concerns. (Resident C) Findings include:The clinical record for Resident C was reviewed on 1/39/2026 at 10:15 a.m. The resident's diagnoses included, but were not limited to, Chronic Obstructive Pulmonary Disease (progressive, lung disease characterized by chronic airway inflammation, narrowed airways, and damaged air sacs-[COPD]), heart failure, and kidney failure. A Quarterly MDS Assessment, dated 9/15/2025, indicated Resident C was cognitively impaired, did not have behaviors, did not reject care, needed staffs' assistance with hygiene, and did not have pressure areas.a. A behavioral care plan, revised 9/22/2025, indicated staff were to make referrals as needed.A provider's visit note, dated 11/12/2025, indicated Resident C was having behavioral issues. The plan of care reflected medication changes and to follow up in two to three weeks or soon if indicated.During an interview, on 1/30/2026 at 2:45 p.m., Nurse Practitioner (NP) 5 indicated Resident C was not seen after 11/12/2025.b. A skin care plan, revised 9/22/2025, indicated Resident C had skin impairments, the interventions included, but were not limited to, inspected skin every shift and reporting changes in the skin.A weekly wound assessment, dated 11/11/2025, indicated Resident C had a blister to her left leg.The clinical record for Resident C lacked a weekly wound assessment from11/12/2025 through 11/25/2025.A weekly wound assessment, dated 11/26/2025, indicated Resident C had two venous ulcers to her left leg.The clinical record for Resident C lacked a weekly wound assessment from 11/27/2025 through 12/8/2025.A weekly wound assessment, dated 12/9/2025, indicated Resident C had two venous ulcers to her left leg and one venous ulcer to her right leg.A policy, entitled Skin Management, was provided by the Clinical Support Nurse on 1/29/2026 at 11:45 a.m. The policy indicated, .When a resident is admitted with or develops a pressure injury or any other open area, immediate treatment will be initiated.A weekly assessment will be done by the nurse and all ongoing wound documentation will be entered into the Pressure-Injury Assessment fold (for any pressure-injuries) or Non-Pressure Wounds folder 3.1-37This citation relates to Intakes 2710696 and 2715782.

Based on interview and record review, the facility failed to timely implement inventions of a pressure relieving boots for 1 of 3 residents reviewed for skin condition. (Resident J)Findings include:The clinical record for Resident was reviewed on 1/30/2026 at 2:05 p.m. The resident's diagnoses included, but were not limited to, dementia (decline in mental abilities) and adult failure to thrive (a decline in physical and mental wellbeing). A skin care plan, revised 1/4/2026, indicated Resident J had an condition on her left heel which progressed to an unstageable ulcer on 12/24/2025. The intervention for the resident's area to the left heel, included staff were to apply heel protectors to both feet while in bed. A nursing assessment, dated 12/24/2025, indicated the area to Resident J's left heel had increased in size from 1.4 x (by) 1.8 cm on 12/17/2025 to 2.4 x 2.9 cm. The interventions, included but were not limited to, use of heel protector boots. A physician's order, dated 12/26/2025, indicated a request for routine treatment. The order was addressed on 12/29/2025 with a response of dressing order as well as, .Apply heel protectors when not up in wc [wheelchair]. The treatment administration record for Resident J, dated December 2025, indicated heel protectors were not started until 12/31/2025. During an interview, on 1/30/2026 at 3:05 p.m., the Clinical Support Nurse 6 indicated it was the expectations that new orders are processed as soon as possible, but at least within 24 hours. A policy, entitled Prescriber Medication Order, was provided by the Director of Nursing on 1/30/2026 at 3:30 p.m. The policy indicated for new handwritten orders, .the nurse on dity at the [NAME] the order is received enter it on the physician order sheet. This citation relates to Intakes 2710696 and 2715782. 3.1-40

Based on interview and record review, the facility failed to timely follow up on fall interventions (Resident D) and notify a family of a fall (Resident E) for 2 of 3 residents reviewed for falls. Findings include:1. The clinical record for Resident D was reviewed on 1/29/2026 at 2:45 p.m. The resident's diagnoses included, but were not limited to, diabetes and dementia (decline in mental abilities).A Quarterly MDS, dated [DATE], indicated Resident D was cognitively intact and needed assistance of staff for transferring with activities of daily living.A incident note, dated 12/23/2025, indicated Resident D had a fall in her room. The immediate intervention indicated, .Requested for OT Eval and Bed Mobility.A physician's order, signed 12/29/2025, indicated for Resident was to have an Occupation Therapy evaluation and treatment as indicated related to her rolling out of bed.During an interview, on 1/29/2026, the Clinical Support 6 indicated the therapy evaluation was not completed and she could not find documentation as to why it was not completed.A nursing note, dated 1/30/2026, indicated that the therapy evaluation was not completed, but was reordered due to her decline after chronic illness.2. The clinical record for Resident E was reviewed on 1/29/2026 at 3:15 p.m. The resident's diagnoses included, but were not limited to, kidney disease (a condition where the kidneys were damaged or cannot filter blood properly) and tachycardia (a heart rate that exceeds 100 beats per minute in adults while at rest).An admission MDS Assessment, dated 11/3/2025, indicated Resident E was cognitively impaired and needed assistance of staff with transferring for activities of daily living.A fall care plan, dated 11/5/2025, indicated Resident E needed assistance of two staff members for transferring.An incident note, dated 11/4/2025, indicated Resident E had a fall in her room. Under family/contact notification, the documentation stated .Res. is own Responsible Party.During an interview, on 1/29/2026 2:50 p.m., Family Member 4 indicated she was only aware of two falls for her family member during the resident's stay at the facility.A policy, entitled Fall Assessment and Prevention Protocol, was provided by the Clinical Support Nurse 6 on 1/29/2026 at 11:45 a.m. The policy indicated, If/when a resident experiences a fall, a root cause analysis will be conducted to assist in planning appropriate evidence-based interventions to prevent further falls. and .Notify the POA or other legal representative.3.1.45(a)This citation relates to Intakes 2710696 and 2715782.

Based on observation, interview, and record review, the facility failed to ensure a resident had compression stockings on as ordered for 1 of 1 resident reviewed for edema. (Resident 9) Findings include: The clinical record for Resident 9 was reviewed on 4/8/25 at 11:45 a.m. The diagnoses included, but were not limited to, osteoarthritis and diabetes mellitus. During an observation and interview on 4/8/25 at 9:48 a.m., Resident 9 was fully dressed for the day and indicated she did not have her TED (Thrombo-Embolic Deterrent) hose on. During an interview with Resident 9 on 4/8/25 at 10:36 a.m., she indicated the facility staff had taken her TED hose to be washed the day before and they have not brought them back. During an observation and interview on 4/9/25 at 10:49 a.m., Resident 9 did not have her TED hose on. She indicated that staff have not brought them back to her after being washed. Resident 9 had a physician's order, dated 3/6/23, that indicated to apply TED hose to both lower extremities (for edema) daily, on in the morning and off in the evening. Resident 9's Treatment Administration Record (TAR) was reviewed on 4/9/25 at 11:30 a.m. The TAR indicated Resident 9 had TED hose applied in the morning, on 4/8/25, and removed, on 4/8/25, in the evening. The TAR also indicated Resident 9 had TED hose applied in the morning of 4/9/25. A care plan for Resident 9, dated 10/26/23, indicated to apply TED hose in the morning and remove in the evening/bedtime. During an interview with the Director of Nursing (DON) on 4/9/25 at 1:50 p.m., she indicated nursing was responsible for making sure Resident 9's TED hose were on. A Medication/Treatment Administration Error Policy was provided by the Nurse Consultant on 4/10/25 at 10:11 a.m. The policy indicated .1. A facility medication/treatment error occurs when .n. Failure to complete a medically related procedure/treatment as ordered by the physician . 3.1-37(a)

Based on interview and observations, the facility failed to date open and/or prepare food products in the walk-in refrigerator. This deficient practices had the potential to aversively affect 34 of 34 residents who receive foods from the dietary department. Findings include: During an observation on 3/4/2024 at 6:50 p.m., three small bowls of prepared cottage cheese, a small bowl of prepared tomatoes, a plastic container of what Dietary Aide 2 identified as barbequed beef, a pitcher of orange liquid, and a cart with multiple glasses prepared with various drinks were all noted to not to be dated of when it was opened/prepared or with a use-by date. During an interview with Dietary Aide 2 on 3/4/2024 at 6:55 p.m., she indicated that they do not label the drinks on the cart because they go through them so quickly. During an interview with the Dietary Manager on 3/5/2024 at 10:35 a.m., he indicated all 34 residents receive food from the kitchen and food items should be dated. A policy entitled, Food Storage Standards, was provided by the Clinical Operations Liaison on 3/6/2024 at 3:00 p.m. The policy indicated, .Ready-to-eat refrigerated foods are labeled according to FDA or state standards . A supportive documented to the policy, entitled Food Storage Guide, was provided by the Clinical Operations Liaison on 3/7/2024 at 10:30 a.m. The guide indicated .Date food packages . 3.1-21(i)(3)

Based on observation, interview and record review the facility failed to complete an accurate skin assessment and provide treatment for a resident experiencing bilateral foot and ankle swelling for 1 of 1 resident reviewed for edema (Resident 30). Finding include: During an observation and interview with Resident 30 on 3/05/24 at 11:39 a.m., the resident had bilateral feet and ankle swelling. The resident indicated they had been swollen for a week and she needed a water pill. The resident was unable to tie her tennis shoes all the way due to the swelling. The resident indicated her feet and ankles felt tight but she was not experiencing pain. During an observation and interview with Resident 30 on 3/06/24 at 11:11 a.m., the resident was observed to have bilateral swelling of her feet and ankles and was not able to tie her shoes due to the swelling. The resident indicated the facility had not provided treatment for the swelling. The resident indicated she had reported the swelling to all the staff. During an observation on 3/07/24 at 1:53 p.m., Resident 30 was observed to have bilateral swelling of her feet and ankles and was unable to tie her shoes due to the swelling. Review of the record of Resident 30 on 3/6/24 at 11:50 a.m., indicated the diagnoses included, but were not limited to, hypertension, arthritis, L arm post polio contractures and peripheral edema. The skin and body assessment for Resident 30, dated 3/6/24, indicated the resident had no skin issues and no edema. The Admission Minimum Data (MDS) assessment for Resident 30, dated 1/26/24, indicated the resident was cognitively intact, decisions consistent and reasonable. During an interview with the Administrator in Training on 3/07/24 at 1:58 p.m., indicated the nurses were responsible to complete a weekly skin assessment for Resident 30. The resident's bilateral feet and ankle swelling was reported at this time. The physician order for Resident 30, dated 3/7/24 at 3:38 p.m., indicated the resident was ordered [NAME] hose in the morning and off at night. The skin management policy provided by the Regional Clinical Liaison on 3/8/24 at 9:30 a.m., indicated skin was to monitored routinely during care giving and problems identified would be documented. 3.1-37(a)

Based on observation, interview, and record review, the facility failed to ensure a resident's fluids were in reach for 4 of the 6 survey days. This affected 1 of 1 resident reviewed for accommodation of needs. (Resident 9) Findings include: During an observation, on 1/04/23 at 10:59 a.m., Resident 9 did not appear to be dehydrated, but her water was on the bedside table at the end of her bed, out of reach. On 1/5/23, at 9:50 a.m., Resident 9 was lying in bed, eyes closed, her water pitcher was on her over bed table out of her reach. On 1/6/23, at 2:41 p.m., Resident 9 was in bed, eyes closed, her water pitcher was on her over bed table out of her reach, about 3 feet from the side of her bed. On 1/9/23, at 10:07 a.m., Resident 9 was in bed, her water pitcher was out of reach on her over bed table. Resident 9's record was reviewed on 1/9/23 at 11:45 a.m. and indicated diagnoses, that included, but were not limited to, generalized muscle weakness, high blood pressure, age related physical debility, disorientation, osteoporosis, pain, Alzheimer's disease late onset, and dementia without behaviors, psychosis, mood or anxiety. An Annual Minimum Data Set assessment, dated 10/4/22, indicated Resident 9 was severely impaired in cognitively skills for daily decision making, and eating was extensive assist of one. Current physician's orders for fluids indicated an order dated 2/24/21 to encourage fluids with assistance, 240 milliliters three times a day/evening a.m. and p.m. and to monitor intake and output every a.m., p.m., and night with nights obtaining a 24 hour intake. 1/10/23 at 12:20 a.m., Resident 9 was sitting in the dining room eating and drinking independently. Interview with CNA 3 indicated the resident does feed herself and drink independently, that sometimes she starts out feeding herself and at the end of the meal staff will have to help her. She said the resident has good days and bad days. A Policy for Hydration Management was provided by the Administrator on 1/10/23 at 3:25 p.m. The policy included, but was not limited to, Purpose: Hydration management will be accomplished through an individualized plan to promote adequate hydration based on risk factor identification and assessment and to determine if intake and/or output monitoring is indicated .3. Fluids will be provided consistently throughout the day 3.1-3(v)(1)

Based on interview and record review, the facility failed to ensure a resident's choice for shower times was honored. This affected 1 of 1 resident reviewed for choices. (Resident 30) Findings include: During an interview, on 1/03/23 at 12:49 p.m., Resident 30 indicated she didn't get her bath when she wants it, she prefers during the day and gets a shower on second shift around 9:30 - 10:00 p.m. On 1/09/23, at 1:58 p.m., Resident 30 was lying in bed dressed in street clothes and said she still prefers to have a shower during the day. Resident 30's record was reviewed on 1/5/23 at 12:59 p.m. The record indicated diagnoses that included, but were not limited to, repeated falls, altered mental status, high blood pressure, anxiety, depression, and vascular dementia. An Annual Minimum Data Set assessment, dated 4/22/22, indicated Resident 30 was cognitively intact, speech was clear, and had no moods or behaviors. A Quarterly Minimum Data Set (MDS) assessment, dated 11/28/22, indicated Resident 30 was cognitively intact, speech was clear, makes self understood, understands others, and had no behaviors. An Annual MDS, dated [DATE], indicated Resident 30 was cognitively intact, speech was clear, makes self understood and understands others, and had no behaviors. A data collection tool, for preferences for customary routine and activities had not been filled out, and had no date. On 1/10/23 at 12:18 p.m., the Activity Director indicated the above form was one of two they used, on admission and once a year after that. She said she usually only keeps one copy in the book, and the assessment had been pulled and not turned back in. She said Resident 30 likes to take a shower but wasn't specific on the time, that in the past she told her she didn't care when she got one as long as she got one. She said she would fill out another assessment and place it in her book, which she did and provided a copy of it. A Policy for Resident Personal Hygiene and Cares was provided by the Administrator on 1/10/23 at 3:25 p.m. The policy indicated, but was not limited to, Purpose: To provide uniform guidance to C.N.A's on standard hygiene and personal care tasks for residents that comprise AM and HS cares and the bathing/showering process .4. Bathing/Showering Process: a. Upon admission to the nursing home, a resident preference interview will be completed with regard to preferred bathing method, frequency and time of day. b. The C.N.A. assignment sheet will be updated to include the information in the Bathing column of the C.N.A assignment sheet 3.1-3(a)

Based on observation, interview, and record review, the facility failed to utilize two staff for transfers for Resident 188, resulting in a fall, failed to use a gait belt during a transfer for Resident 188, failed to implement fall interventions for Resident 139, and failed to use a gait belt during a transfer for Resident 140. This affected 3 of 5 residents reviewed for accidents. (Residents 188, 139, and 140) Findings include: 1. During an interview, on 1/03/23 at 2:10 p.m., Resident 188 indicated she fell and hurt her left lower leg and cut a big gash in her left leg. Resident 188's record was reviewed on 1/04/23 at 3:11 p.m. and indicated diagnoses that included, but were not limited to, heart failure, atrial fibrillation, chronic obstructive pulmonary disease, with acute exacerbation, depression, and asthma. An Admission Minimum Data Set assessment, dated 12/4/22, indicated Resident 188 was moderately impaired in cognitive skills for daily decision making, received hospice services, had a fall prior to admission, but none since admission, required extensive assistance of 2 for bed mobility, transfers, and toilet use, did not walk, balance was unsteady, she was only able to stabilize with staff assistance. A baseline care plan, dated 11/21/22, indicated Resident 188 was alert, occasionally confused, had a history of falls within the last 180 days, is a fall risk due to weakness, and was assist of one for transfers and toileting. Incident documentation of the fall, dated 12/15/22 at 8:40 p.m., indicated Resident 188 had been lowered to the floor on 12/15/22 at 6:00 p.m. She was in the bathroom and the activity at the time was transferring, the equipment involved was a wheelchair. The injury was a skin tear on the left leg 5 centimeters by 0.5 centimeters. A follow up of incident dated 12/19/22, indicated the resident had a laceration of her left lower leg, she was being toileted by a CNA and her knees became weak and she had to be sat on the floor. A second CNA came to assist the resident up and cut resident's leg on the foot pedal of her wheelchair. First aid was applied and hospice was called. The Interdisciplinary Team had updated the care plan and made the resident an assist of 2. On 1/06/23 at 9:39 a.m., the Director of Nursing indicated Resident 188 was being toileted with one person assist, she had to lower her to the floor then she got assistance to get her up. When they were helping her stand, her leg was cut on her wheelchair. This happened on 12/15/22. The new intervention was to have her be a two person assist. On 1/10/23 at 1:18 p.m., Resident 188 was observed as she was transferred from her wheelchair her recliner chair with CNA 3 and CNA 4. CNA 4 took the resident's catheter drainage bag and hooked it to her front pocket, both CNA's took hold of her arms and helped the resident to stand, then sat her back down in her wheelchair. The Director of Nursing then instructed the CNA's to use a gait belt and let the resident hold the catheter drainage bag. They placed the gait belt around the resident's waist and stood her up, then pivoted her into the recliner. 25054 2.) During an observation on 1/3/23 at 12:50 p.m., Resident 139 was in his room sitting in a wheelchair watching TV, there was no staff present. The resident did not have an alarm on his wheelchair or bed. During an observation on 1/4/23 at 1:50 p.m., , Resident 139 was in his room sitting in a wheelchair watching TV, there was no staff present. The resident did not have an alarm on his wheelchair or bed. During an observation on 1/5/23 at 1:38 p.m., Resident 139 was in his room sitting in a wheelchair watching TV, there was no staff present. The resident did not have an alarm on his wheelchair or bed. During an observation and interview on 1/6/23 at 2:42 p.m., with the Director Of Nursing (DON) Resident 139 was laying in bed. The DON verified the resident had no alarm on his bed or wheelchair. The DON indicated she not aware that the resident had been left in his room alone in his wheelchair. Review of the record of Resident 139 on 1/5/23 at 1:20 p.m., indicated the resident's diagnoses included, but were not limited, reduced mobility, dehydration, kidney disorder, age related physical debility, atrial fibrillation, dementia, fall, diabetes, weakness and heart failure. The Admission Minimum Data Set (MDS) assessment for Resident 139, dated 12/18/22, indicated the resident was severely cognitively impaired for daily decision making. The resident required extensive assistance of two people to transfer. The resident did not ambulate. The resident used a wheelchair as a mobility device. The resident had a fall in the last month and a fracture from a fall in the pas six months prior to admission. The plan of care for Resident 139, dated 1/4/23, indicated the resident had the potential for falls related unsteady gait and weakness. The interventions included, but were not limited to, chair alarm on when in the chair and bed alarm. The special care remarks indicated the resident was not to be left in his wheelchair in his room alone. The fall risk assessment for Resident 139, dated 1/3/22, indicated the resident was incontinent, received a hypnotic that could contribute to falls, the resident was unable to ambulate and used a wheelchair as a mobility device The incident report for Resident 139, dated 12/19/22, indicated the resident was found on the floor in his room. The resident had been moving around in bed. The resident had an abrasion 4 cm by 6 cm (no location)(right knee). Neurological assessment completed. The immediate intervention was the resident's bed in the lowest position. The incident report for Resident 139, dated 1/3/22 at 4:20 p.m., indicated the resident was found on the floor. The resident had been in bed resting. No apparent injury. 3.) During an observation on 1/4/23 at 1:54 p.m., CNA 1 and CNA 2 transferred Resident 140 from the wheelchair to the toilet by holding her underneath her arms and the back of her pants, no gait belt was used. CNA 1 and CNA 2 transferred the resident from the toilet to the wheelchair by holding her underneath her arms and the back of her brief, there was no gait belt used. The resident was unable to assist with the transfer and was totally dependent on staff for the transfer. During an interview with Resident 140's family member on 1/5/23 at 12:49 p.m., indicated the resident had not been at the facility long. The reason Resident 140 came to the facility was because she fell at home and broke her clavicle. During an interview with the DON on 1/10/23 at 10:16 a.m., indicated the protocol was staff were to use a gait belt when transferring Resident 140. The safe resident handling and mobility program provided by the Administrator on 1/10/23 at 10:25 a.m., indicated the facility would train staff in the use of a gait belt with transfers. Review of the record of Resident 140 on 1/10/23 at 1:07 p.m., indicated the resident's diagnoses included, but were not limited to, fracture of the right clavicle, right hip contusion, heart failure, unspecified fall, age related debility, diabetes, atrial fibrillation, anxiety disorder, osteoporosis and chest pain. The Admission Minimum Data Set (MDS) assessment for Resident 140, dated 1/4/23, indicated the resident was moderately impaired for daily decision making. The resident required extensive assistance of two people for transfers and did not ambulate. The resident had a fall in the last month prior to admission. The fall assessment for Resident 140, dated 12/28/22, indicated the resident had 4 diagnoses that contributed to falls, had a history of falls, fell at home and broke her right clavicle, required cueing when to turn around and sit down, used a walker/wheelchair for mobility, had a decline in her functional status in the last 90 days and wears glasses. The fall care plan for Resident 140, dated 1/3/23, indicated the resident had potential for falls related to unsteady gait manifested by history of falls, unsteady gait (or near fall) in the last 180 days and recent hospital stay. The intervention included, but were not limited to, call light in reach, encourage to ask for assistance and 2 assist with a gait belt (1/10/23). 3.1-45(a)(1) 3.1-45(a)(2)

Based on observation, interview and record review the facility failed to have an indication for the use of an antipsychotic medication, failed to implement behavioral interventions, failed to monitor antipsychotic medication and failed to provide education of the risk of using an antipsychotic medication for 3 of 5 residents reviewed for unnecessary medication use (Resident 20, Resident 30 and Resident 4). Findings include: 1.) Review of the record of Resident 20 on 1/4/22 at 1:20 p.m., indicated the resident's diagnoses included, but were not limited to, Alzheimer's disease, altered mental status, cerebral infarction, history of falling, diabetes mellitus, hypertension, dementia,, osteoarthritis and anxiety. The CNA behavior communication form for Resident 20, dated 8/18/22, indicated the resident was being physically abusive to the staff and was hitting and kicking. There were no documented interventions attempted. The CNA behavior communication form for Resident 20, dated 8/30/22, indicated the resident was pulling the staff's hair. The interventions were talk/listen to the resident and reassured. These interventions were successful. The CNA behavior communication form for Resident 20, dated 8/30/22, indicated the resident was being physically abusive to staff and was scratching the staff's arm. The interventions were talk/listen to the resident and reassured. These interventions were successful. The CNA behavior communication form for Resident 20, dated 8/31/22, indicated the resident was being physically abusive to staff and was hitting, biting, kicking and scratching. The interventions were talk/listen to the resident and reassured. These interventions were successful. The CNA behavior communication form for Resident 20, dated 9/1//22, indicated the resident was being physically abusive to staff and was hitting, biting, yelling and scratching. The interventions were talk/listen to the resident and reassured. These interventions were successful. The CNA behavior communication form for Resident 20, dated 9/3//22, indicated the resident was being physically abusive to staff and was hitting, pinching and kicking. The interventions were talk/listen to the resident and offered a quiet area. These interventions were unsuccessful. The CNA behavior communication form for Resident 20, dated 9/7//22, indicated the resident was being physically abusive to staff and was pinching and digging her nails in the staff's hand. The intervention was leave the resident alone. The CNA behavior communication form for Resident 20, dated 9/13//22, indicated the resident was being physically abusive to staff and was scratching and made the staff's hand bleed. The intervention was reassure the resident and it was successful. The CNA behavior communication form for Resident 20, dated 9/20//22, indicated the resident was being physically abusive to staff and was hitting and pinching staff. The interventions were talk/listen to the resident and reassured. These interventions were successful. There were no further CNA behavior communication forms documented. The nursing behavior note for Resident 20, dated 9/2/22, indicated the resident had a behavior of pinching and scratching staff. Intervention was 1:1 conversation and reassured. These interventions were successful. The nursing behavior note for Resident 20, dated 9/3/22, indicated the resident was scratching and punching staff when they tried to get her up in the morning. The staff attempted to take her to activities and the resident scratched the staff's arm and grabbing their shirt and kicking at staff. The staff talked with resident and listened to the resident and offered a quiet area. The resident remained unchanged. The nursing behavior note for Resident 20, dated 9/13/22, indicated the resident scratched staff hand while in the shower room. The intervention was resident left alone and reapproached. The nursing behavior note for Resident 20, dated 10/1/22 through 10/15/22 the resident had no documented behavior. The nursing behavior note for Resident 20, dated 10/16/22, indicated the resident was pinching scratching and spitting at staff. The intervention was 1:1 and talking. The behavior remained unchanged. The nursing behavior note for Resident 20, dated 10/19/22, indicated the resident was kicking and hitting staff. The intervention was reassured resident. The behavior remained unchanged. The nursing behavior note for Resident 20, dated 10/20/22 through 11/4/22, the resident had no behaviors. The nursing behavior note for Resident 20, dated 11/5/22, indicated the resident was kicking and hitting staff. The interventions were reassured the resident and talked with her and walked away. The intervention was successful. The nursing behavior note for Resident 20, dated 11/6/22 through 11/17/22, the resident had no documented behaviors. The nursing behavior note for Resident 20, dated 11/18/22, indicated the resident was yelling and crying very loudly in the hallway before dinner. Staff attempted to redirect the resident but this did not work. The resident went into the dining room and continued to yell at others and crying. The resident threw a small vase and broke it. Staff attempted to assist the resident with eating but was unsuccessful. The resident continued to yell at others and crying while making her way out of the dining room. The resident attempted to hit, grab and bite staff. The staff took the resident to her room and once in front of her bed the resident mostly stopped her behaviors. The stated she wanted to go to bed and staff assisted her to bed and covered her up. The resident cried for a couple more minutes, but then completely calmed down and went to sleep. The facility would review the resident's medications and complete a pain assessment, the resident does have dementia. The physician order for Resident 20, dated 11/22/22, indicated the resident was ordered seroquel (antipsychotic medication) 25 milligrams (mg) at night for dementia with behaviors. During an observation on 1/4/23 at 2:12 p.m., Resident 20 was laying in bed with her eyes closed. During an observation on 1/5/23 at 1:46 p.m., Resident 20 was laying in bed with her eyes closed. During an interview with the Administrator on 1/5/23 at 2:01 p.m., the facility had not been monitoring for side effects of the seroquel for Resident 20, but they would be now. The resident had not seen psychiatric services. During an observation on 1/6/23 at 11:00 a.m., Resident 20 was laying in bed. CNA 1 asked the resident if she was ready to get up and the resident shook her head no and pointed to the door for staff to leave. CNA 2 was standing there and when queried if the facility attempted different care givers to see if the resident would get up, CNA 2 indicated yes they did. CNA 2 did not attempt to see if the resident would get up for him and no other interventions were attempted. During an observation on 1/9/23 at 2:16 p.m., Resident 20 was laying in bed with her eyes closed. During an interview with the Administrator on 1/10/23 at 10:14 a.m., indicated the facility had not provided Resident 20's family education on the risk of seroquel and the education would be mailed to them today. The Administrator provided a copy the education that would be mailed to the resident's family. During an interview with Resident 20's Nurse Practitioner (NP) on 1/10/23 at 10:36 a.m., indicated the rationale behind why the medication of an antipsychotic was being used to treat Resident 20's dementia, the NP indicated the resident was combative with staff and the facility ruled out infection and started her on seroquel. When queried if the NP had been aware that the non pharmalogical interventions staff were using for Resident 20's behaviors were mostly successful, the NP indicated it was not reported to her that the non pharmalogical interventions had been successful for her behaviors. The informed consent for the medication seroquel for Resident 20's family dated 1/10/23, indicated warning: [Black Box Warning] Increased mortality in elderly patents with dementia related psychosis: Elderly patients with dementia related psychosis treated with atypical antipsychotic drugs are at an increased risk of death compared to placebo. Although the causes of death varied, most of the deaths appeared to be either cardiovascular (e.g. heart failure, sudden death) or infectious (e.g. pneumonia) in nature. This drug is not approved for the treatment of patients with dementia-related psychosis. 15909 2. Resident 30's record was reviewed on 1/5/23 at 12:59 p.m. The record indicated diagnoses that included, but were not limited to, repeated falls, altered mental status, high blood pressure, anxiety, depression, and vascular dementia. An Annual Minimum Data Set (MDS) assessment, dated 4/22/22, indicated Resident 30 was cognitively intact, speech was clear, had no moods or behaviors, did not receive antipsychotic medications. A Quarterly MDS assessment, dated 11/28/22, indicated Resident 30 was cognitively intact, speech was clear, had moods of feeling down, depressed or hopeless, trouble falling or staying asleep, or sleeping too much, feeling tired or having little energy, poor appetite or overeating, had no behaviors, received an antipsychotic routinely for seven out of seven days of the assessment, a gradual dose reduction had not been attempted, and a gradual dose reduction has not been documented by a physician as clinically contraindicated. A care plan, dated 6/1/22, indicated a problem of Disruptive verbally. This res is rude to her peers; makes fun of them, laughs at them, tells them what to do, etc. Diagnosis of Mood Disorder .6/15/22 Manifested by: verbal outbursts, verbal intimidation. Approach: Nurses - provide calm environment, administer medications as ordered by physician; Abilify, redirect, do not reorient or argue with [Resident 30], if need be remove her from her peers if able. Nurse Aide - Positive approach with resident, count verbal outbursts, document and report behaviors to nurse and/or social services, maintain safety of resident and other residents, and other staff, if able remove [Resident 30] from the area Current physician's orders included an order for an antipsychotic medication - Abilify (generic name is aripiprazole) 2 milligrams by mouth every day, for mood disorder, with a start date of 5/5/22. On 1/10/23 at 10:45 a.m., the Nurse Practitioner said Resident 30 was on Abilify and she doesn't get a report of signs and symptoms but the Director of Nursing will call and let her know what is going on. She wasn't aware that mood disorder was not an accepted diagnosis for the use of an antipsychotic. An Informed Consent for Medication for the use of Abilify, indicated Completion of this form is voluntary. If not completed, the medication cannot be administered without a court order unless in an emergency. This consent is maintained in the client's record and is accessible to authorized users The consent was signed by the resident on 1/10/23 and the Ability had been administered since 5/5/22. The informed consent included, but was not limited to, side effects and cautions such as changes in thinking, fever, muscle stiffness, low blood pressure when standing, fall risk, weight gain, and seizure. The following was indicated on the Informed Consent for Medication: Warning: [Black Box Warning]: Increased Mortality in Elderly Patients with Dementia Related Psychosis: Elderly patients with dementia related psychosis treated with atypical antipsychotic drugs are at an increased risk of death compared to placebo. Analyses of 17 placebo controlled trials (modal duration of 10 weeks), largely in patients taking atypical antipsychotic drugs, revealed a risk of death in the drug treated patients of between 1.6 to 1.7 times that seen in placebo treated patients. Over the course of a typical 10-week controlled trial, the rate of death in drug treated patients was about 4.5% compared to a rate of about 2.6% in the placebo group. Although the causes of death were varied, most of the deaths appeared to be either cardiovascular (e.g., heart failure, sudden death) or infectious (e.g., pneumonia) in nature. Observational studies suggest that, similar to atypical antipsychotic drugs, treatment with conventional antipsychotic drugs may increase mortality. The extent to which the findings of increased mortality in observational studies may be attributed to the antipsychotic drug as opposed to some characteristic(s) of the patients is not clear. Aripiprazole is not approved for the treatment of patients with dementia-related psychosis. 3. Resident 4's record was reviewed on 1/04/23 at 1:20 p.m. and indicated diagnoses that included, but were not limited to, cardiac arrhythmia, age-related physical debility, repeated falls, osteoporosis, hypertension, dementia with behavior disturbance, and heart failure. A Quarterly MDS, dated [DATE], indicated Resident 4 was severely impaired in cognitive skills for daily decision making, had no moods or behaviors, did not walk, and did not receive an antipsychotic medication. A Significant Change MDS, dated [DATE], indicated Resident 4 was severely impaired in cognitive skills for daily decision making, had a diagnosis of non-Alzheimer's dementia, did not walk, and received an antipsychotic medication. A care plan, dated 9/15/22, indicated a problem for Potential for adverse medication side effects related to antipsychotic use manifested by: possible side effects: lethargy, loss of appetite, involuntary movements, tremors, chewing and /or tongue movements, muscle twitching, gait changes. Approach: Nurses - Monitor for side effects q (every) shift, notify physician of symptoms. Nurse Aide - report unusual behavior, report change in physical condition, report change in appetite. [Social Services] Involve family, make referrals, referred her to psych services, discuss in the monthly behavior management meeting. Goal: No adverse affects d/t (due to) med regimen, prevent and/or minimize the side effects of the psychotropic medications. Resident will receive the lowest possible dose necessary to control symptoms. On 1/05/23 at 9:46 a.m., Resident 4 was in bed, eyes closed. On 1/09/23 at 10:05 a.m., Resident 4 was in bed with her eyes closed. On 1/09/23 at 01:48 p.m., Resident 4 was up in her wheelchair in the activity room, sitting quietly with other residents, the activity aide was in the room. Current physician's orders included an order for the antipsychotic Seroquel 25 milligrams by mouth at bedtime for dementia, with a start date of 9/8/22. A Pharmacy review, dated 9/29/22, indicated: [Resident 4] is receiving the antipsychotic agent Seroquel but lacks an allowable diagnosis to support its use. The following are considered appropriate diagnoses/conditions: .Dementing illnesses with associated behavioral symptoms. The physician selected Agree and chose Dementia with behavioral disturbance. Signed 9/29/22 by the Nurse Practitioner. During an interview, on 1/10/23 at 10:37 a.m., the Nurse Practitioner indicated they started Resident 4 on the Seroquel when she started to have behaviors with her dementia, they got psych involved, and she wasn't aware that a dementing illness with associated behavioral symptoms was not an accepted diagnosis for the use of an antipsychotic. A policy for Psychoactive Medication Protocol was provided by the Interim Executive Director on 1/6/23 at 1:22 p.m. The policy included, but was not limited to, Purpose: To ensure appropriate procedures are followed and subsequent documentation is completed prior to the initiation or change of a psychoactive medication and to ensure ongoing targeted behavior tracking for comprehensive assessment and evaluation purposes. Protocol: 1. Psychoactive medications include antipsychotics, antianxiety agents, sedatives/hypnotics, antidepressants and other medications as described below .2. The Interdisciplinary Team will identify target behaviors and develop a care plan to include treatment goals and evaluation of precipitating events, if any, in the resident's environment .3. Enter the appropriate target behaviors in the appropriate [treatment administration record] folder and begin documenting every shift. Make an appropriate corresponding entry in the medical record as warranted. 5. Physician order obtained MUST include an appropriate diagnosis for medication use and the desired therapeutic goal for the medication (i.e. reduction in the frequency or severity of a targeted behavior) for any psychoactive medications 3.1-48(a)(3) 3.1-48(b)(2)

Based on observation, interview and record review the facility failed to provide routine dental services for a resident who had poor fitting dentures for 1 of 2 residents reviewed for dental status (Resident 12). Findings include: During an observation on 1/3/23 at 11:31 a.m., Resident 12 was laying in bed, the resident had no teeth. During an observation on 1/4/23 at 2:13 p.m., Resident 12 was laying in bed, the resident had no teeth. During an observation and interview on 1/5/23 at 12:53 p.m., Resident 12 was laying in her bed with no teeth. Interview with Resident 12's family member indicated the resident did have dentures but she did not always wear them because they fall out. The family member indicated even when staff used denture adhesive they still fell out and it aggravated the resident so she did not wear her dentures often. The family member indicated she needed to see a dentist to see if they could be adjusted or replaced. The resident's family member was unsure how long the resident's dentures had not fit but it had been going on for awhile. Review of the record of Resident 12 on 1/10/23 at 1:38 p.m., dementia, hypertension, iron deficiency anemia, anxiety, age related debility and chronic pain syndrome. During an interview with the Administrator on 1/6/23 at 10:29 a.m., the facility could not find documentation that Resident 12 had ever seen a dentist. During an interview with the Administrator on 1/6/23 at 1:45 p.m., indicated residents at the facility did not receive routine dental visits and were only seen on a as needed basis. During an interview with the Administrator on 1/9/23 at 10:32 a.m., indicated the dental company the facility used stopped provided services in 2020. The facility is now going to contract with a different dental company. The new dental company had not started at the facility yet, but if a resident needs to be seen the facility would make arrangements with the local dentist. During an interview with the Administrator on 1/10/23 at 3:26 p.m., Resident 12 would be seen by a dentist on 1/13/23. The dental services policy provided by the Administrator on 1/6/23 at 1:45 p.m., indicated the dental needs of residents shall be adequately cared for through proper hygiene and regular and emergency dental care. 3.1-24(a)(1)

Based on interview and record review the facility failed to notify the physician of low and high blood sugars and failed to assess the resident for hypoglycemia (low blood sugar) and hyperglycemia (high blood sugar) for 1 of 5 residents reviewed for unnecessary medication (Resident 1). Finding include: Review of the record of Resident 1 on 1/6/23 at 10:21 a.m., indicated the resident's diagnosis included, but were not limited to, diabetes mellitus. The physician order for Resident 1, dated January 2023, indicated the resident was ordered levemir (insulin) 52 units in the morning and at night. The physician order indicated if the resident's blood sugar (BS) was below 70 or above 400 the physician was to be notified. Review of Resident 1's blood sugar, dated 11/18/22 was 50, 11/25/22 was 454 and 12/6/22 was 58. During an interview with the Director Of Nursing (DON) on 1/9/23 at 2:49 p.m., indicated there was no documentation the physician was notified of Resident 1's blood sugars on 11/18/22, 11/25/22 or 12/6/22. There was no documentation of any assessment of Resident 1 for hyperglycemia or hypoglycemia symptoms in the resident's record. The DON provided a 24 hour report sheet, dated 12/6/22, with Resident 1's name on it and documentation of BS 58 orange juice given and rechecked and was 79. The diabetic blood sugar monitoring policy provided by the DON on 1/10/23 at 11:20 a.m., indicated hypo/hyperglycemic episodes will be reported and treated appropriately. Assess for symptoms of hypoglycemia. from milder, more common indicators to most severe, signs and symptoms of low blood sugar include: feeling shaky, being nervous/anxious, sweating, chills, clamminess, confusion, [NAME] heartbeat, lightheaded, dizzy, hunger, nausea, pale skin, sleepy, feeling weak, blurred/impaired vision, tingling or numbness of lips, tongue and cheeks, headaches, coordination problems, nightmares or seizures. If a blood sugar are less than 70 recheck the blood sugar and notify the physician. Hold scheduled insulin/diabetic medication until the physician addresses. If the residents blood sugar is above 300 recheck the blood sugar and notify the physician. 3.1-37(a)

Based on observation, interview and record review, the facility failed to ensure staff wear the appropriate personal protective equipment (PPE) while conducting Covid-19 testing for residents and staff ensure face masks are worn to cover the nose and mouth when in resident-care areas. (LPN 3 and CNA 4) Findings include: 1. During a tour of the facility on 8-3-22 at 11:12 a.m., an observation was conducted of LPN 3 preparing to conduct Covid-19 testing with Resident G. Resident G was located in the 200 hallway when LPN 3 was observed explaining to her she needed to see her for testing. LPN 3 was observed assisting Resident G by wheeling her to the Covid-19 testing supply cart, located in the hallway, outside of room [ROOM NUMBER]. LPN 3 was observed preparing Covid-19 testing materials to conduct testing of Resident G in the hallway, outside of room [ROOM NUMBER], within 10 feet of one visitor and 2 staff members. LPN 3 was wearing a surgical mask, goggles and gloves. LPN 3 was not wearing any type of protective gown or an N-95 mask. LPN 3 was halted from conducting the Covid-19 testing in the hallway, immediately prior to inserting the nasal swab into the nares of Resident G. LPN 3 was then observed to assist Resident G to her room to conduct Covid-19 testing. Upon completion of Resident G's Covid-19 testing, LPN 3 was queried as to any education she has received regarding the type of PPE to wear when testing residents for Covid-19. She indicated she is aware she needs to wear a mask, gloves and goggles or facemask when conducting Covid testing. LPN 3 indicated she has already tested 20 to 25 residents this morning with all results thus far being negative. She indicated she has not been wearing any type of gown or wearing an N-95 mask as part of her PPE while conducting the Covid-19 testing this morning. On 8-4-22 at 11:44 a.m., Corporate Staff 5, provided copies of educational materials that had been identified as provided to LPN 3 in the recent past, specific to Covid-19 and PPE. Corporate Staff 5 indicated the information provided in this particular training can also be utilized not only for provision of care with a breathing treatment, but also for any type of potential AGP (aerosol generating procedure), such as conducting Covid-19 testing. A Continuing Education Record - Group attendance sheet was signed by LPN 3 on 4-28-22, for the topic of Respiratory Assessment & Protocol, which included the sub-topic of Proper PPE while administering Tx [treatment] This packet of information included, but was not limited to, a one-page flyer from the Indiana Department of Health which can be posted on the doorway of any resident who receives any type of nebulizing respiratory treatment. This poster indicates, Aerosol-Generating Procedure in Progress, with a stop sign present. It further indicates, PPE Required to Enter! Hand Hygiene, N-95 [Mask], Eyewear, Gown, Gloves. Keep Door Closed During Use and 1 Hour Post Treatment. Corporate Staff 5 provided an attendance document signed by LPN 3 on 4-26-22, regarding an educational offering on the topic of correct donning and doffing of PPE. Corporate Staff 5 provided a copy of a document entitled, Employee Warning, dated 8-3-22. The reason cited for the warning was indicated as Not wearing proper PPE while Covid testing residents, with the recommendation for the employee to abide by Infection Control Policy. 2. In an observation on 8-3-22 at 1:52 p.m., of CNA 4, she was observed to be documenting in the 200 hall computer, located near room [ROOM NUMBER]. CNA 4 was observed with her N-95 mask pulled to below her nose. In an interview with CNA 4 at this time, she indicated she was hot and had lowered her mask. The Covid-19 vaccine status of CNA 4 was documented as unvaccinated with a religious exemption in place. A notice on the entry door of the facility on 8-3-22 and 8-4-22 indicated the facility was currently in outbreak status. Corporate Staff 5 indicated the county positivity rate was red or high. On 8-4-22 at 11:50 a.m., Corporate Staff 5 provided a copy of a policy entitled, Coronavirus (Covid-19) - Personal Protective Equipment Guidelines. This policy was indicated to be the current policy in use by the facility and had a revision date of 3-15-22. This policy indicated its purpose is to provide guidance for PPE usage for residents, employees and visitors. This policy indicated for staff who are not up-to-date with all recommended Covid-19 vaccine doses, the employee should wear an N-95 mask in all areas of resident-care areas of the facility and must wear eye protection, unless the county positivity rate is low. On 8-4-22, an informational poster was obtained from the Centers for Disease Control (CDC) website at cdc.gov/coronavirus. The poster, entitled, Facemask Do's and Don't's, (6-2-2020) indicated, a facial mask should fully covers [sic] your mouth and nose . This Federal tag relates to Complaint IN 936. 3.1-18(a)

Based on interview and record review, the facility failed to allow 1 of 3 residents reviewed for residents admission, transfer and discharge rights and had been sent out to the local emergency room (ER), to be able to return to the facility. (Resident B) Findings include: The clinical record of Resident B was reviewed on 4-18-22 at 10:50 a.m. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Her admission Minimum Data Set (MDS) assessment, dated 3-24-22, indicated her cognitive status was undetermined, but was able to be understood and was able to be understood by others, she required supervision of one person for bed mobility, transferring from one surface to another, to ambulate, for eating, dressing, toileting and hygiene and did have unspecified delusions. In review of Resident B's nursing progress notes, it indicated on 4-2-22 at 8:46 a.m., Resident B's attending physician was notified of a change in her mental status of significant lethargy and confusion. Nursing progress notes on 4-2-22 at 5:19 a.m. indicated Resident B has been confused at times throughout the night .walking up and down the hall, gait unsteady at times. Other notations indicated on the morning of 4-2-22, noticed resident with altered mental status. Resident normally fairly independent with ADL's [activities of daily living] find resident unable to perform simple tasks or follow simple commands. Resident not safe to have medications administered, does not know where she is and is naked in her chair. Resident had been incontinent in chair which is also abnormal for resident. Noted to be acting similarly to when she was sent out recently and had elevated ammonia levels . The attending physician immediately provided an order to send her to the local ER for evaluation and treatment. The local emergency medical services was notified and transferred her to the localER on [DATE] at 9:00 a.m. In review of Resident B's emergency room notes, dated 4-2-22, it indicated the resident was seen by an ER physician at 9:14 a.m., for altered mental status (AMS). It indicated she had an elevated ammonia level two days prior and had been hospitalized the end of March, 2022, related to hepatic [CONDITION(S)]. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . It indicated a urine drug screen was negative. Due to her recent hospitalization for similar issues, a determination was rendered for the need for a higher level of care and was accepted for transfer to an area hospital and was admitted into the area hospital for care. In review of the notes from the area hospital, it indicated she had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] .[CONDITION(S)] history with [CONDITION(S)] .IVDU [intravenous drug use] was a problem in the past, too. It indicated a drug screen showed positive for [MEDICATION(S)] or [MEDICATION(S)], a medication used in the treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident B's medication lists while at the facility, the local ER and the area ER did not include the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . In an interview with the Director of Nursing (DON) on 4-18-22 at 12:30 p.m., she indicated Resident B was admitted to the facility for medication management. During her stay, she left the faciity on a leave of absence (LOA) with one instance of her not returning until the next day. She was sent to the local ER and then transferred to an area hospital for altered mental status. The drug screen at the local ER was negative, but at the area hospital, it positive for a controlled substance that had not been ordered from here or the local ER. The area hospital was upset with us, because our doctor would not accept her back due to having a controlled substance in her system that was not prescribed to her. Reached out to the medical director (MD) and his NP. The MD told me that he was not willing to take her back due to her drug use. The MD sent me a text message, dated 4-4-22 at 1:14 p.m., which indicated, If he [area hospital's hospitalist] calls again, I don't mind talking to him But if she is leaving the nursing home to get high, she doesn't need physical rehab, she needs drug rehab. The DON indicated Resident B had admitted from another facility. She indicated her prior facility did not provide a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . They did say that she had left their facility AMA [against medical advice], but we were willing to give her a chance. The resident did not share any history of drug or [CONDITION(S)]. On 4-18-22 at 2:15 p.m., the DON provided a copy of a policy entitled, Transfer and Discharge Policy, with revision date of 2/2020, and identified as the facility's current policy in use. It indicated, The facility will comply with regulations regarding initiating a transfer or discharge of a resident and the accompanying documentation that must be included in the medical record .If the facility decides to discharge the resident is hospitalized , the facility will send a notice of discharge to the resident and resident representative and at the same time also send a copy of the discharge notice to a representative of the Office of the State LTC Ombudsman . This Federal tag relates to Complaint IN 191. 3.1-12(a)(5)(A) 3.1-12(a)(6)(A)i 3.1-12(a)(5)(A)ii 3.1-12(a)(5)(A)iii 3.1-12(a)(5)(A)iv 3.1-12(a)(5)(A)v 3.1-12(a)(5)(A)vii 3.1-12(a)(5)(B) 3.1-12(a)(5)(A)

Based on observation, interview and record review, the facility failed to ensure 1 of 9 staff members with a non-medical Covid-19 vaccination exemption wear appropriate personal protective equipment (PPE) when within six feet of a resident. (Staff Member 5) Findings include: During an observation on 4-19-22 at 4:10 p.m., of staff members with non-medical Covid-19 vaccination exemptions were wearing the appropriate PPE when within six feet of a resident. Staff Member 5, with an approved non-medical exemption, was observed at the nurse's station wearing a surgical mask and no eye protection while within 3 feet of a female resident. In an interview with Staff Member 5 at this time, she indicated she has an approved non-medical exemption. She indicated she was not aware of any PPE requirements related to her exemption, but was aware that she must have a Covid-19 test conducted twice weekly, related to her non-medical exemption. She added, to the best of her knowledge, all staff are allowed to wear surgical masks, whether or not they have any type of Covid-19 vaccine exemption. She shared the facility provided education regarding the Covid-19 and had made the process of applying for and receiving the exemption very easy for her. On 4-19-22 at 10:00 a.m., the Director of Nursing provided a copy of a policy entitled, Coronavirus (Covid-19) Vaccination - Employee, with a revision date of 1-26-22 and identified as the current policy in use by the facility. This policy indicated, It is the policy of this facility to coordinate the procurement and administration of the Coronavirus vaccine for all employees .The Centers for Medicare and Medicaid Services (CMS) has made the vaccinations mandatory for all eligible staff .Coronavirus vaccination is federally mandated for eligible staff working at a facility that participates in Medicare and Medicaid program .For religious exemptions, RPHF Human Resources will grant exemptions in accord [sic] with the Equal Employment Opportunity Commission's Manual on Religious Discrimination .Once the exemption is verified and approved, the staff member will comply with the following requirements to minimize the risk of transmission of Covid-19 to residents and peers: Staff will be Covid-tested twice weekly prior to the starting the shift. A NIOSH-approved N-95 or equivalent or higher-level respirator and eye protection will be worn at all times while inside the facility. Staff will adhere to universal source control and physical distancing measures even in areas that are restricted from resident access (such as staff meeting rooms, kitchen, etc.) The facility will have a designated space for unvaccinated/exempt staff to take their breaks/lunch. 3.1-18(a)

Based on interview and record review, the facility failed to safeguard the personal property of 1 of 2 residents reviewed for misappropriation of property, identified as 3 rings, of unknown value, upon admission. (Resident B) Findings include: The clinical record of Resident B was reviewed on 2-10-22 at 10:15 a.m. Her diagnoses included, but were not limited to, dementia with behavioral disturbance, hypertension, diabetes, [CONDITION(S)] premature depolarization (premature heart beat or skipped beat) and [CONDITION(S)]. Her most recent Minimum Data Set (MDS) analysis, dated 5-22-21, indicated she was severely cognitively impaired, experienced hallucinations and wandered about the facility daily, placing her at risk of potentially dangerous situations and was independently ambulatory. The nursing progress notes indicated she was alert and oriented to self only. Resident B's Inventory of Personal Effects, indicated upon admission on 5-15-21, had 3 rings listed on the form. The document had 3 drawings of the rings documented, one identified as a ring with a center stone, a second ring with several white stones and the third with several colorful stones. The form had information as follows, in which all lines were blank: Certification of Receipt Upon Admission, with Resident Signature, and Staff Signature. Certification Upon Discharge with Resident Signature, and Staff Signature. Immediately below this area was Resident B's signature and the signature of a staff LPN and date of 5-18-21 listed for the date the inventory was conducted. In an interview on 2-10-22 at 10:49 a.m., with Resident B's POA, he indicated he received a call from an unknown facility staff member, several week's after admission. asking him to pick up his mother's rings, as they were in the facility's safe. Mom wore her 3 rings all the time. I have no idea how they ever got those rings off because she wore them all the time and, kind of like a nervous tick, she twisted them around all the time. He indicated he went to pick them up sometime in June, between 6:00 p.m. and 8:00 p.m., and the safe was unable to be accessed. He indicated he called the facility back sometime later about the rings and the facility told him once they gained entry into the safe, they could not find the rings. He recalled he called the nursing home's corporate offices some time prior to calling the Indiana Department of Health's Long Term Care Division (IDOH), date unknown. I don't know who I talked to (at the facility's corporate offices), some guy and I don't know his name, but he said they wasn't going to pay us back for those rings. The POA indicated he was his mother's POA. The POA indicated he did not recall filling out a personal inventory record at admission for his mother. He indicated somebody told him the prosecutor's office and the the local police department didn't feel they had enough evidence to charge anyone with a crime. In an interview on 2-10-22 at 2:30 p.m., with the Admissions Coordinator, she indicated she recalled receiving a call from Resident B's son after Resident B had discharged from the facility, somewhere around the first part of September. I remember he said something about he had gotten a call from somebody here at the nursing home, but he couldn't remember their name, for him to come and pick up his mother's rings. He said when he came in the first time, no one could open the safe. He did come in around the end of September, the note is dated for 9-28-21, to pick up all of personal belongings. I did receive a phone call from one of [the POA's family members] about some issues surrounding [Resident B's] rings. He said his personal belief was that [the POA] himself had taken the rings as there were similar type issues with some [personal property] that went missing when [a family member] passed away. In an interview on 2-10-22 at 22 at 4:30 p.m., with CNA 3 and the Executive Director (ED), she indicated she has been employed at the facility for approximately 4 years and normally works on the evening shift. She indicated she recalled being aware of the POA wanting to get his mother's ring, specifically the wedding set with a plain band & an engagement-type ring with a single white stone. It seems like she may have worn other rings, but this is the one, actually set, he wanted. It looked kind of old to me, kind of tarnished. We hadn't been able to get those rings off, but was able to get that set off while she was in the shower. I don't remember him [POA] coming in to pick up the rings for a couple of days and it was dark outside. [The POA] said he had just come from work and I remember him being in a t-shirt and it was dirty. She [Resident B] was here during warm weather, so it would have been after 8:00 p.m., or later. I would guess it would have been closer to [her] admitted , as opposed to her discharge. After we got the rings, I put them in a small manilla envelope and it was hanging at the nurse's station with a note those were [Resident B's] ring. So when the son called and said he was here to pick up the rings, I grabbed the envelope and took it to him. I thought it was odd that her son didn't want to come in and see his mother, especially since he brought some snacks, mints that she rarely ate, and a $200.00 gift card and gave me a hug, which kind of surprised me. I gave the gift card to the Activities person. I'm sorry, I can't remember exact dates and times, but it has been a while. I don't recall me or him signing in or out that he took the rings from the facility. Normally, I would add or remove any belongings on the inventory record, but I don't remember doing that. In an interview on 2-11-22 at 1:32 p.m., with the Director of Nursing (DON), she indicated Resident B's POA did not complain of anything about the rings until well after his mother discharged . She recalled at the time of discharge, the POA did ask about the rings, but was told the facility was still looking for them and he seemed fine with that. When he came in to pick up his mother's belongings, he refused to sign the inventory record, he seemed rather odd about that. It wasn't until some time after that, he began to get more difficult and downright rude to us about the rings. My expectation, as far as the inventory record is that the staff ensure it get completed at admission and at discharge. It doesn't necessarily require the staff member and resident or family sign it. We don't have a specific policy on the inventory record, just follow the regulations about it. In an interview on 2-11-22 at 11:15 a.m., with the ED, he indicated the facility does not have a specific policy or procedure related to the inventory of the residents' property. When I spoke with my supervisor, she simply said that we follow the state regulation. I have a copy here for you of the state regulation that addresses the facility 'shall exercise reasonable care for the protection of the resident's property,' plus there should be a documented inventory at admission and discharge of the person's effects' and it does say it is the resident's responsibility to maintain and update the inventory listing of the resident's personal property and valuables. He indicated during the time the resident was in the facility, the [POA] did not seem upset, more concerned, that the rings were missing and seemed to understand that we were continuing to look for them. It was only after [Resident B] discharged elsewhere that he seemed to become very upset. We did not submit this as a potential misappropriation during the time of her being here. Prior to discharge, [POA] seemed ok with us continuing to look for the items. The reality is that the resident continued to wear her rings from admission forward, until the rings that he had requested were be removed. I wish this had been documented. But my point is that she could have removed them and left them any number of places. She discharged here on 9-3-21, and he asked for the rings at that time. He said that someone had told him they were in the safe. I am the only person who has access to the safe. He came around 9-21-21, to pick up his mother's belongings. He refused to sign the inventory record. He indicated the Admissions Coordinator told him we would continue to look for them. The Admissions Coordinator even got in touch with the hospital she discharged to from here to see if she was wearing them, but she didn't have them. In November, the POA called again about the rings. The Admissions Coordinator told him we still hadn't found them. He threatened us with calling the police. The police contacted the previous ED. The police investigated and closed it, without any findings. Not long after that, we had a visit from the Attorney General's office of the Medicaid Fraud Department, and it was essentially the same thing, no findings. I was not aware of this situation until after the previous ED left. I do recall talking with [the POA] at least once when he was yelling and cursing at me, when I was trying to speak with him about the issues at hand. He seemed much more upset when I explained we have done what we can and will not be reimbursing him for the rings. The admission paperwork that was signed addresses personal property and making efforts to safeguard personal property and resident responsibility as well. On 2-11-22 at 11:55 a.m., the ED provided a timeline of the events surrounding the issues of the missing rings of Resident B. -It indicated sometime in the summer of 2021, the POA contacted the facility, requesting two of his mother's rings. He was told they would try to get them off but her fingers were swelled and they would not come off. CNA 3 was able to remove two rings during a shower. The POA was contacted to pick them up. The POA called and said he was there to pick up the rings. CNA 3 met him at the front entrance and provided the rings to the POA. -Resident B discharged from the facility on 9-3-21. The POA asked about the rings. -The POA picked up Resident B's belongings on 9-21-21. He refused to sign the inventory record of the resident's belongings. The Admissions Coordinator informed the POA the facility was still trying to locate the rings. -The POA called the facility on/about 10-26-21, inquiring about the rings. The Admissions Coordinator informed him the facility continued to look for the rings. -The Maintenance Staff opened the safe sometime in October, 2021, but the rings were not in the safe. -In November, 2021, the POA called wanting the rings. The Admissions Coordinator informed the POA the rings had not been located. He indicated his sister told him the rings were valued at $3,000.00 and insisted on reimbursement. The POA indicated if reimbursement was not done, he was calling the police. The local police contacted the ED; an investigation was conducted with no findings. -The POA called back around Thanksgiving, 2021, and informed the facility the value of the rings was $30,000.00. He insisted the facility pay him for the rings. He indicated he was talking to an attorney, going to [NAME] the facility and take the facility to court. Another investigation was conducted by the facility with no rings located. The POA was informed of the investigation resulted in the rings not being located and the investigation closed. [Name of POA] began cursing at us demanding we pay for them. [Name of ED] explained he had signed on the admission contract that we are not responsible for missing items. -Around Christmas, 2021, the OIG, representing the Medicaid Fraud Department, contacted the facility about missing rings, requesting documents. -January, 2022, the facility provided the documents requested by the OIG. Phone interviews were conducted by the OIG. On 1-20-22, The OIG representative informed the ED he had no findings and he would notify the POA of this. On 2-11-2022 at 11:20 a.m., the ED provided an undated copy of a document which included the subject, Resident's Personal Property. This policy indicated, The Facility strongly discourages the keeping of valuable jewelry, papers, large sums of money, or other items considered to be of value in the Facility. The Facility shall make reasonable efforts to safeguard the Resident's property which the Resident chooses to keep in his/her possession, however, cannot be held responsible for property which is lost or stolen. The Resident agrees to inform the Facility of all vauable property upon admission. This Federal tag relates to Complaint IN 250. 3.1-9(a) 3.1-9(b) 3.1-9(g)

Based on observation, interview and record review the facility failed to ensure a resident's call light was within reach to request for assistance with care for 1 of 3 resident's reviewed for accommodation of needs (Resident C). Finding include: During an observation and interview on 6/15/21 at 10:30 a.m., Resident C was yelling from her bedroom repeatedly please help me. Upon entering the resident's room, the resident was sitting on the side of her bed fully clothed crying and the resident's call light was across the room out of her reach. The resident indicated she was soaked with urine and was unable to get out of bed to get her call light. The resident's call light was activated. CNA 3 came into the resident's room and apologized to the resident for her call light being out of reach and provided the resident with her call light. CNA 3 indicated she had just arrived at work and was unsure who had left the resident in bed without her call light being available. Resident C indicated she had been without her call light since Midnight and had urinated on herself twice since then. The resident continued to cry and asked CNA 3 to take her to the bathroom and clean her up. CNA 3 agreed the resident's clothes, pad on the bed and sheets were soaked with urine and assisted the resident to the bathroom. CNA 4 indicated she was a float CNA and had not seen Resident C since around 4:00 a.m., and was unsure who left the resident without her call light. Review of the record of Resident C on 6/16/21 at 2:20 p.m., indicated the resident's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly MDS for Resident C, dated 4/22/21, indicated the resident was independent with daily decision making and decisions were consistent and reasonable. The resident required extensive assistance of one person to transfer and to walk in her room. The plan of care for Resident C, dated 2/18/2020, indicated the resident had the potential for trauma-falls due to an unsteady gait. The interventions included, but were not limited to, encourage to ask for assistance and keep call light in reach. The call light policy provided by Corporate Compliance on 6/17/21 at 4:03 p.m., indicated long-term care facilities are required to have systems, often called call lights, so that residents can call for help whenever they need it. This is the primary way a resident can call for help. Staff must check each time before leaving a room to make sure that the call light is within the resident's reach. The Resident Rights policy provided by Corporate Compliance on 6/17/21 at 4:05 p.m., indicated the resident had the right to be treated with respect and dignity, including but not limited to, the right to reside and receive services in the facility with reasonable accommodation of the resident's needs and preferences. This Federal tag relates to Complaint IN 988. 3.1-3(v)(1)

Based on interview and record review, the facility failed to ensure the accuracy of medications administered to 1 of 3 residents reviewed for medication administration accuracy, which resulted in two medication errors. One of the errors resulted in the resident having very low blood pressure and requiring a three day hospitalization . (Resident #A) Findings include: Resident #A's clinical record was reviewed on 8-8-16 at 1:35 p.m. Her admission [DIAGNOSES REDACTED]. An admission Social Services note, dated 1-19-16, indicated she was alert and oriented to person and place, but requiring looking at the clock for time. It indicated she was able to make her needs and wants known. In review of the hospital discharge summary, dated 1-26-16, it indicated the admitting and discharge [DIAGNOSES REDACTED]. It indicated the Hospital Course, included, but was not limited to, (Name of Resident #A) was admitted to med/surg floor after getting 0.6 mg Clonidine PO (orally) by mistake of nurse at (name of facility) 18 hours prior to admission. She became hypotensive with systolics in the 70's. In the ER, she was given IV fluid bolus ultimately of 3 L (liters) in ER. BP (blood pressure) was started on dopamine drip (IV medication to enhance blood pressure). She was weaned off Dopamine yesterday. This AM she is normotensive (blood pressure within normal range), but her BP is occasionally on the lower side. This morning she is feeling well and c/o only chronic right knee pain. I will discharge her again to (name of facility) today for continuing strengthening and rehab. In review of a faxed note to the attending physician from the facility, dated 1-22-16 at 12:55 p.m., it indicated the resident c/o (complained of) R (right) knee pain, knee is swollen, red, warm to touch. (Sign for elevated) Temp 100.1 (degrees Fahrenheit). Denies any specific injury. Res. (resident) can hardly bear any wt (weight) on R leg .Res states had polio as child and sometimes will have this pain in her knees. As far as redness and warmth, res denies any hx (history) of cellulitis. Res does have weakness and joint pain from osteoporosis but this is new onset according to res. The attending physician's faxed response, dated 1-22-16, indicated new orders for an xray of the right knee, colchicine 0.6 milligrams (mg) by mouth daily (medication used for gout) and to schedule an appointment with an area orthopedist. In an interview with the Administrator on 8-9-16 at 11:17 a.m., she indicated Resident #A, had a new order for colchicine 0.6 mg for gout on 1-22-16. (The medication ) was entered to start on 1-23-16, but did not come in from pharmacy. Was not in EDK (Emergency Drug Kit). One of the nurses looked in the EDK and pulled clonidine of 0.1 mg, 6 tabs, were pulled and given to the resident. Upon returning to the med room to document the med administration, she noticed she had pulled the wrong med. The doctor was immediately notified. He ordered to initially monitor BP hourly, then called back and changed it to every 15 minutes. Upon finding BP at 78, doctor was notified and he ordered to start an IV and to send out to the ER. The doctor requested the family contact information in order to contact them himself. She remained in the hospital and returned on 1-26-16 at her normal baseline. The Administrator indicated Resident #A had a second medication error, upon returning from the hospital. Prior to going to the hospital, she had been on Zocor 40 mg. When she returned, the Zocor had been changed to 20 mg and she still had the 40 mg in her (medication) drawer. It was given in error. When the doctor was notified, he ended up changing the dose back to 40 mg. On 8-9-16 at 2:25 p.m., the Administrator provided a list of all medications in the facility's EDK. It indicated clonidine 0.1 mg, six tablets were available. It did not indicate colchicine was available in the EDK. In interview with the Administrator on 8-9-16 at 2:10 p.m., she indicated, Right now, I can think of one resident that has a routine order for this medicine (clonidine) and a few others that may have it as a prn (as needed) order. But those residents would have it in the routine meds, not from the EDK. As far as I know, the EDK has not changed since the error. The Nursing 2014 Drug Handbook, it indicates clonidine is an antihypertensive medication in which an initial dosage is typically 0.1 mg twice daily and may be tapered up to 0.2 to 0.6 mg daily in divided doses. It indicates signs and symptoms of overdosage may include, but is not limited to, early hypertension followed by hypotension, low heart rate, respiratory and central nervous system depression, drowsiness and weakness, with elderly persons potentially more sensitive to the hypotensive effects of this medication. On 8-9-16 at 4:10 p.m., the Administrator provided a copy of a policy entitled, Medication Administration-General Guidelines, with an effective date of January, 2007. This policy indicated, Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to administer medications do so only after they have familiarized themselves with the medication .Prior to administration, the medication and dosage schedule on the resident's Medication Administration Record [REDACTED]. If the label and MAR indicated [REDACTED].Medications are administered in accordance with written orders of the attending physician . On 8-9-16 at 4:10 p.m., the Administrator provided a copy of a policy entitled, Medication/Treatment Error Administration Policy, with a revision date of July, 2015. This policy indicated, This policy has been established to enable the facility to adopt a consistent approach in responding to medication and treatment administration errors. A facility medication/treatment error occurs when: a prescribed medication is not administered .the wrong medication is administered .failure to compare doctor's orders with pharmacy labels and Medication Administration Record [REDACTED] The Nursing 2014 Drug Handbook, identifies The eight 'rights' of medication administration, as the following: 1. The right drug: Check the drug label and verify that the drug and form to be given is the drug that was prescribed. 2. The right patient: Confirm the patient's identity by checking two patient identifiers. 3. The right dose: Verify that the dose and form to be given is appropriate for the patient, and check the drug label with the prescriber's order. 4. The right time: Ensure that the drug is administered at the correct time and frequency. 5. The right route: Verify that the route by which the drug is to be given is specified by the prescriber and is appropriate for the patient . 6. The right reason: Verify that the drug prescribed is appropriate to treat the patient's condition. 7. The right response: Monitor the patient's response to the drug administered. 8. The right documentation: Completely and accurately document in the patient's medical record the drug administered, the monitoring of the patient, including his response, and other nursing interventions. This Federal tag relates to Complaint IN 504. 3.1-25(b) 3.1-25(b)(2) 3.1-25(b)(9)

Based on interview and record review, the facility failed to ensure the physician orders [REDACTED]. Resident #A) Findings include: Resident #A's clinical record was reviewed on 8-8-16 at 1:35 p.m. Her admission [DIAGNOSES REDACTED]. An admission Social Services note, dated 1-19-16, indicated she was alert and oriented to person and place, but requiring looking at the clock for time. It indicated she was able to make her needs and wants known. In review of a faxed note to the attending physician from the facility, dated 1-22-16 at 12:55 p.m., it indicated the resident c/o (complained of) R (right) knee pain, knee is swollen, red, warm to touch. (Sign for elevated) Temp 100.1 (degrees Fahrenheit). Denies any specific injury. Res. (resident) can hardly bear any wt (weight) on R leg .Res states had polio as child and sometimes will have this pain in her knees. As far as redness and warmth, res denies any hx (history) of [MEDICAL CONDITION]. Res does have weakness and joint pain from [MEDICAL CONDITION] but this is new onset according to res. The attending physician's faxed response, dated 1-22-16, indicated new orders for an xray of the right knee, [MEDICATION NAME] 0.6 milligrams (mg) by mouth daily (medication used for gout) and to schedule an appointment with an area orthopedist. In an interview with the Administrator on 8-9-16 at 11:17 a.m., she indicated Resident #A, had a new order for [MEDICATION NAME] 0.6 mg for gout on 1-22-16. (The medication ) was entered to start on 1-23-16, but did not come in from pharmacy. Was not in EDK (Emergency Drug Kit). One of the nurses looked in the EDK and pulled [MEDICATION NAME] of 0.1 mg, 6 tabs, were pulled and given to the resident. Upon returning to the med room to document the med administration, she noticed she had pulled the wrong med. The doctor was immediately notified. He ordered to initially monitor BP hourly, then called back and changed it to every 15 minutes. Upon finding BP at 78, doctor was notified and he ordered to start an IV and to send out to the ER. The doctor requested the family contact information in order to contact them himself. She remained in the hospital and returned on 1-26-16 at her normal baseline. The Administrator indicated Resident #A had a second medication error, upon returning from the hospital. Prior to going to the hospital, she had been on [MEDICATION NAME] 40 mg. When she returned, the [MEDICATION NAME] had been changed to 20 mg and she still had the 40 mg in her (medication) drawer. It was given in error. When the doctor was notified, he ended up changing the dose back to 40 mg. On 8-9-16 at 2:25 p.m., the Administrator provided a list of all medications in the facility's EDK. It indicated [MEDICATION NAME] 0.1 mg, six tablets were available. It did not indicate [MEDICATION NAME] was available in the EDK. In interview with the Administrator on 8-9-16 at 2:10 p.m., she indicated, Right now, I can think of one resident that has a routine order for this medicine ([MEDICATION NAME]) and a few others that may have it as a prn (as needed) order. But those residents would have it in the routine meds, not from the EDK. As far as I know, the EDK has not changed since the error. In review of the hospital discharge summary, dated 1-26-16, it indicated the admitting and discharge [DIAGNOSES REDACTED]. It indicated the Hospital Course, included, but was not limited to, (Name of Resident #A) was admitted to med/surg floor after getting 0.6 mg [MEDICATION NAME] PO (orally) by mistake of nurse at (name of facility) 18 hours prior to admission. She became hypotensive with systolics in the 70's. In the ER, she was given IV fluid bolus ultimately of 3 L (liters) in ER. BP (blood pressure) was started on [MEDICATION NAME] drip (IV medication to enhance blood pressure). She was weaned off [MEDICATION NAME] yesterday. This AM she is normotensive (blood pressure within normal range), but her BP is occasionally on the lower side. This morning she is feeling well and c/o only chronic right knee pain. I will discharge her again to (name of facility) today for continuing strengthening and rehab. The Nursing 2014 Drug Handbook, it indicates [MEDICATION NAME] is an antihypertensive medication in which an initial dosage is typically 0.1 mg twice daily and may be tapered up to 0.2 to 0.6 mg daily in divided doses. It indicates signs and symptoms of overdosage may include, but is not limited to, early hypertension followed by [MEDICAL CONDITION], low heart rate, respiratory and central nervous system depression, drowsiness and weakness, with elderly persons potentially more sensitive to the hypotensive effects of this medication. On 8-9-16 at 4:10 p.m., the Administrator provided a copy of a policy entitled, Medication Administration-General Guidelines, with an effective date of January, 2007. This policy indicated, Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to administer medications do so only after they have familiarized themselves with the medication .Prior to administration, the medication and dosage schedule on the resident's Medication Administration Record [REDACTED]. If the label and MAR indicated [REDACTED].Medications are administered in accordance with written orders of the attending physician . On 8-9-16 at 4:10 p.m., the Administrator provided a copy of a policy entitled, Medication/Treatment Error Administration Policy, with a revision date of July, 2015. This policy indicated, This policy has been established to enable the facility to adopt a consistent approach in responding to medication and treatment administration errors. A facility medication/treatment error occurs when: a prescribed medication is not administered .the wrong medication is administered .failure to compare doctor's orders with pharmacy labels and Medication Administration Record [REDACTED] The Nursing 2014 Drug Handbook, identifies The eight 'rights' of medication administration, as the following: 1. The right drug: Check the drug label and verify that the drug and form to be given is the drug that was prescribed. 2. The right patient: Confirm the patient's identity by checking two patient identifiers. 3. The right dose: Verify that the dose and form to be given is appropriate for the patient, and check the drug label with the prescriber's order. 4. The right time: Ensure that the drug is administered at the correct time and frequency. 5. The right route: Verify that the route by which the drug is to be given is specified by the prescriber and is appropriate for the patient . 6. The right reason: Verify that the drug prescribed is appropriate to treat the patient's condition. 7. The right response: Monitor the patient's response to the drug administered. 8. The right documentation: Completely and accurately document in the patient's medical record the drug administered, the monitoring of the patient, including his response, and other nursing interventions. This Federal tag relates to Complaint IN 504. 3.1-35(g)(2)

Based on interview and record review, the facility failed to ensure CNA's followed care guidelines. This deficient practice resulted in 2 of 3 residents reviewed for falls, in a sample of 3, having falls in which one resident fell from a wheelchair and a second resident had 2 assisted falls to the floor. (Resident #A, Resident #C, CNA #1 and CNA #4) Findings include: 1. Resident #A's clinical record was reviewed on 3-3-14 at 2:00 p.m. Her [DIAGNOSES REDACTED]. It indicated her date of admission was 6-27-13. In review of Resident #A's "CNA Assignment Sheet", identified by the DON for 2-7-14, it indicated "Supportive Devices" to include, "Wheelchair with cushion, 1/2 tray on right side of W/C (wheelchair), foot board on wheelchair." It indicated she required 2 persons to assist with transfers. In review of Resident #A's current care plan related to "Potential for Trauma-Falls," with an original date of 6-27-13 and revision date of 2-12-14, it indicated to encourage resident to ask for assistance; instruct resident in use of adaptive equipment; observe for decline due to [MEDICAL CONDITION] (mediation) use; reassure resident staff will assist with activities of daily living; transfers to, be conducted with 2 staff and mechanical lift; keep legs elevated in wheelchair with the use of the leg rests; use of tray to the right side of the wheelchair for her right arm; 2 staff to assist with toileting and with positioning in bed; keep the bed in low position and head of bed elevated when assisting the resident with eating in bed. A CT Scan of Resident's #A head, dated 2/7/14 at 7:19 p.m., indicated the reason for the test was "fall with hematoma rt (right) forehead." The CT results indicated, "Multiple small hemorrhages (small bleeding areas) in the right frontoparietal region." A hospital "Discharge Summary," dated 2/12/14, indicated the resident had a discharge [DIAGNOSES REDACTED]. It indicated the resident was returning to the facility. On 3-5-14 at 9:15 a.m., the Director of Nursing (DON) provided a copy of the facility's "Incident Report Form," which was emailed to the Indiana State Department of Health (ISDH) on 2-10-14. The report indicated on 2-7-14 at 7:15 p.m., Resident #A was found in front of her wheelchair in the activity room. This report indicated the resident was assessed by the licensed nurse and sent immediately to the local emergency room with bruising and was diagnosed with [REDACTED]." On 3-5-14 at 9:15 a.m., the Director of Nursing (DON) provided a copy of the facility's "Incident Report Form," which was emailed to the Indiana State Department of Health (ISDH) on 2-10-14. The report indicated on 2-7-14 at 7:15 p.m., Resident #A was found in front of her wheelchair in the activities room. This report indicated the resident was assessed by the licensed nurse and sent immediately to the local emergency room with bruising and was diagnosed with [REDACTED]." In an interview with the DON on 3-3-14 at 4:30 p.m., she indicated on the evening in which Resident #A fell from her wheelchair, CNA #1 was working with the resident. She indicated CNA #1 had forgotten to replace the resident's foot pedals and footboard onto the wheelchair prior to returning the resident to the activity room. In an interview with CNA #1 on 3-4-14 at 11:40 a.m., she indicated she was assigned to care for Resident #A on the evening shift of 2-7-14. She indicated after the resident had eaten supper, she took her down to her room to get her ready for bed as usual. She indicated she removed the resident's shoes and the foot pedals and footboard of the wheelchair. She indicated Resident #A told her she was not ready to go to bed yet and she returned her to the activity room. "I didn't get her shoes, foot pedals or footboard back on, just forgot." She indicated the resident was not toileted while she was in the resident's room, as she and the resident were in the room for approximately 2 minutes. She indicated she and CNA #3 had planned for her (CNA #1) to get the resident prepared for bed and for CNA #3 to meet her Resident #A's room in order to transfer the resident from the wheelchair to the bed. She indicated, "It takes 2 people to transfer her." She indicated she and the resident met CNA #3 in the hallway as they returned to the activity room. She indicated she went to supper after assisting the resident into the activity room and had planned on assisting the resident with going to bed upon her return from her supper break. In an interview with CNA #1 on 3-4-14 at 11:40 a.m., she indicated she did have a CNA assignment sheet, "but did not look at it. I got written up for not following the assignment sheet." 2. Resident #C's clinical record was reviewed on 3-4-14 at 1:15 p.m. Her [DIAGNOSES REDACTED]. In an interview with Resident #C on 3-4-14 at 1:15 p.m., she indicated she also had been diagnosed with [REDACTED]. In review of the nursing notes, incidents were documented on 12-23-13 at 8:20 a.m. and on 2-20-13 at 8:15 a.m. in which the resident was assisted with toileting by CNA staff while in the resident's bathroom. The "Incident Report," dated 12-23-14 at 8:20 a.m., indicated the resident had a witnessed fall in the bathroom while toileting. It indicated the resident had no apparent injury. It indicated, "Resident assessed and assisted into her w/c (wheelchair) by staff x2 (2 staff persons). CNA educated to always follow CNA assignment sheet. Resident is to have assist of 2 for transfers for toilet use. CNA did not follow assignment sheet and used 1 assist for resident." The "Incident Report," dated 2-20-14 at 8:15 a.m., indicated the resident was lowered to the floor with no apparent injury. It indicated the resident was being transferred from the toilet to the wheelchair. It indicated, "Resident is to have assist of 2 (persons) for transfers on and off the toilet and CNA transferred her with assist of one." It indicated, "CNA educated on following CNA assignment sheet." Review of faxes sent to Resident #C's attending physician on 12-23-13 at 9:30 a.m. and on 2-20-14 at 8:15 a.m., indicated the resident had been lowered to the floor and sustained no apparent injuries. Review of Resident #C's care plan related to potential for falls, dated 10-24-12 and updated on 9-4-13 and 12-30-13, it indicated the resident required 1 assist for transfers and 2 assists for toileting. Review of the resident's "CNA Assignment Sheet" indicated she required 2 persons to assist her with toileting needs. In interview with CNA #4 on 3-5-14 at 10:00 a.m., she indicated she had been providing care to Resident #C both times in which she had the assisted falls to the floor. She indicated both times she was toileting the resident by herself. She indicated the resident was not injured in either assisted fall. She indicated after the first assisted fall, the nurse spoke to her about making sure she had the aide assignment sheet with her and checking it to make sure she was doing what it said. CNA #4 indicated she received a written write up after the second assisted fall. She indicated, "The aide assignment sheet both times said she should have 2 people assisting her with toileting." On 3-3-14 at 4:30 p.m., the DON provided a copy of a policy entitled, "Fall Assessment & Prevention Protocol." This policy indicated, "All staff members are regularly inservices on resident fall prevention and safety, including proper placement of safety devices, use of different kinds of available safety equipment and daily surveillance of possible hazards." On 3-5-14 at 9:15 a.m., the DON provided a copy of a policy entitled, "Assignments, CNA." This policy indicated, "The C.N.A. assignments are part of resident's plan of care and are prepared and reviewed by a licensed nurse and are issued on a daily basis...C.N.A.'s are expected to carry out their daily assignments in a professional manner and in accordance with established nursing procedures. Teaming with other C.N.A.'s for rounds and care giving is acceptable, however, the individual assigned holds the responsibility for all residents on his/her assignment..." The ISDH "Division of Long Term Care Nurse Aide Training Program," (July 1998) indicated, under "Topic 2: Role of the Nurse Aide" the following: "...The CNA must exhibit ethical behavior...Perform to the best of your ability...Carry out your supervisor's instructions..." This Federal tag relates to Complaint IN 156. 3.1-14(i)

Based on interview and record review, the facility failed to ensure safety/positioning equipment of foot pedals and a footboard for one resident's wheelchair were in place while the resident was in the wheelchair, which contributed to the resident falling from the wheelchair and sustaining a skull fracture, rib fractures, with bruising to the right side of the body. (Resident #A) The facility also failed to ensure two staff members assisted with toileting needs, which resulted in a resident having two assisted falls to the floor with no injuries. (Resident #B) Findings include: 1. Resident #A's clinical record was reviewed on 3-3-14 at 2:00 p.m. Her [DIAGNOSES REDACTED]. It indicated her date of admission was 6-27-13. In review of Resident #A's "Fall Assessments", dated 6-27-13, 7-5-13, 9-27-13, 12-18-13, 2-7-14 and 2-27-14, it indicated Resident #A was at risk for falls. In review of Resident #A;s current care plan related to "Potential for Trauma-Falls," with an original date of 6-27-13 and revision date of 2-12-14, it indicated to encourage resident to ask for assistance; instruct resident in use of adaptive equipment; observe for decline due to psychotropic (mediation) use; reassure resident staff will assist with activities of daily living; transfers to be conducted with 2 staff and mechanical lift; keep legs elevated in wheelchair with the use of the leg rests; use of tray to the right side of the wheelchair for her right arm; 2 staff to assist with toileting and with positioning in bed; keep the bed in low position and head of bed elevated when assisting the resident with eating in bed. A CT Scan of Resident's #A head, dated 2/7/14 at 7:19 p.m., indicated the reason for the test was "fall with hematoma rt (right) forehead." The CT results indicated, "Multiple small hemorrhages (small bleeding areas) in the right frontoparietal region." A hospital "Discharge Summary," dated 2/12/14, indicated the resident had a discharge [DIAGNOSES REDACTED]. It indicated the resident was returning to the facility. On 3-5-14 at 9:15 a.m., the Director of Nursing (DON) provided a copy of the facility's "Incident Report Form," which was emailed to the Indiana State Department of Health (ISDH) on 2-10-14. The report indicated on 2-7-14 at 7:15 p.m., Resident #A was found in front of her wheelchair in the activity room. This report indicated the resident was assessed by the licensed nurse and sent immediately to the local emergency room with bruising and was diagnosed with [REDACTED]." On 3-4-14 at 10:30 a.m., the DON provided a copy of a follow up report of the "Incident Report Form" which was emailed to the ISDH on 2-12-14 at 8:30 p.m. The follow up report indicated the same information as the initial report and added the resident had been found lying on her right side with her right arm underneath her. It indicated a large hematoma was observed on the right side of her forehead. It indicated the CNA assigned to assist with Resident #A's care had taken her to her room to get her ready for bed at approximately 6:50 p.m. and had removed her shoes and the foot pedals and footboard from the wheelchair in preparation of going to bed. The resident had then indicated to the CNA that she was not ready to go to bed and wished to return to the activity room. The CNA then returned the resident to the activity room and informed the resident she would return later to get her ready for bed. It indicated at approximately 7:00 p.m., the charge nurse observed the resident in the activity room and the resident did not appear in any distress. It indicated at approximately 7:15 p.m., a visitor informed the nurse that a lady was lying on the floor of the activity room. It indicated, "The cause of the fall is undetermined. There were no witnesses...The resident's care plan called for foot pedals and foot board which were not put back on when taken back to the activity room. This may or may not have been the cause of the accident." It indicated all nursing staff were educated on the "importance of following care plan (for each resident) and on CNA assignment sheets." In an interview with the DON on 3-3-14 at 4:30 p.m., she indicated on the evening in which Resident #A fell from her wheelchair, CNA #1 was working with the resident. She indicated CNA #1 had forgotten to replace the resident's foot pedals and footboard onto the wheelchair prior to returning the resident to the activity room. In an interview with CNA #1 on 3-4-14 at 11:40 a.m., she indicated she was assigned to care for Resident #A on the evening shift of 2-7-14. She indicated after the resident had eaten supper, she took her down to her room to get her ready for bed as usual. She indicated she removed the resident's shoes and the foot pedals and footboard of the wheelchair. She indicated Resident #A told her she was not ready to go to bed yet and she returned her to the activity room. "I didn't get her shoes, foot pedals or footboard back on, just forgot." She indicated the resident was not toileted while she was in the resident's room, as she and the resident were in the room for approximately 2 minutes. She indicated she and CNA #3 had planned for her (CNA #1) to get the resident prepared for bed and for CNA #3 to meet her in Resident #A's room in order to transfer the resident from the wheelchair to the bed. She indicated, "It takes 2 people to transfer her." She indicated she and the resident met CNA #3 in the hallway as they returned to the activity room. She indicated she went to supper after assisting the resident into the activity room and had planned on assisting the resident with going to bed upon her return from her supper break. In an interview with CNA #1 on 3-4-14 at 11:40 a.m., she indicated she did have a CNA assignment sheet, "but did not look at it. I got written up for not following the assignment sheet." In an interview with CNA #3 on 3-4-14 at 2:03 p.m., she indicated she was assigned to the same hall on which Resident #A resided on 2-7-14, but was not assigned to Resident #A. She indicated that evening, CNA #1 was going to get Resident #A ready for bed and that she (CNA #3) was to meet CNA #1 in Resident #A's room in order for them to transfer the resident from her wheelchair, then into bed. She indicated that getting Resident #A ready for bed included removing the wheelchair's foot pedals and footboard. She indicated as she was exiting another resident's room and planning on going to Resident #A's room, she met CNA #1 and Resident #A in the hall. She indicated CNA #1 told her that Resident #A was not ready to lie down yet. She indicated over the next several minutes (time unspecified), she did observe the resident sitting in her wheelchair in the activity room and appeared to be sitting up in a normal manner for the resident. She indicated she did see the resident's 1/2 tray in place, but did not notice if the foot pedals or footboard were in place. She indicated she was sitting at the care station (nurse's station) when a family member of another resident told her and LPN #2 that a lady was in the floor. She indicated she did not recall hearing an alarm sound and did not think Resident #A had alarms on her wheelchair at that time. She indicated during the process of assisting LPN #2 with caring for Resident #A, she did note the resident's wheelchair was in an upright position with no foot pedals in place. She indicated the resident did not indicate what had happened, but complained of pain to her forehead where she noted a hematoma. She indicated she did not observe any bleeding. She indicated LPN #2 called for the emergency services (EMT's), which arrived very quickly . She indicated this was the resident's first fall that she was aware of since her admission. In an interview with LPN #2 on 3-4-14 at 1:30 p.m., she indicated she was working the evening of Resident #A's fall on 2-7-14. She indicated CNA #1 had informed her Resident #A was not ready to go to bed, so she (CNA #1) had returned her in her wheelchair to the activity room. She indicated she was seated in the nurse's station, charting (documenting written information in residents's clinical records) which is located across the hall from the activity room. She indicated at one point, a male resident had yelled, "hello," at her from the activity room. She estimated this occurred at 7:15 p.m. She indicated at that point, she walked over to one of the windows to the activity room and observed Resident #A in the activity room, along with several other residents. She indicated she did not notice anything unusual about Resident #A at that time. She indicated she estimated approximately 10 minutes later, CNA #5 and a visitor in the facility said a lady was on the floor in the activity room. She indicated she did not hear any alarms, but did not think Resident #A was care planned for any alarms at that time as this was the first fall she could recall the resident having since she was admitted . LPN #2 indicated she and CNA #3 immediately responded to assist Resident #A. She indicated she assessed the resident immediately and noted a hematoma to the right side of her forehead and the resident was complaining of pain to the right hip, shoulder and elbow. She indicated the resident did not lose consciousness. She indicated the resident was on Coumadin(an anti-coagulant), but she did not observe any bleeding. She indicated the EMS arrived in less than 5 minutes after they were contacted. She indicated she observed the wheelchair with the 1/2 tray was in an upright position, but the foot pedals and footboard were not in place. She indicated CNA #1 had been at supper break during this time. She indicated when CNA #1 returned to the floor, she questioned CNA #1 about the foot pedals and footboard. She indicated CNA #1 "started crying, said she forgot; had gotten in a hurry. She acknowledged the foot pedals and footboard should have been in place." In review of Resident #A's "CNA Assignment Sheet", identified by the DON for 2-7-14, it indicated "Supportive Devices" to include, "Wheelchair with cushion, 1/2 tray on right side of W/C (wheelchair), foot board on wheelchair." It indicated she required 2 persons to assist with transfers. 2. Resident #C's clinical record was reviewed on 3-4-14 at 1:15 p.m. Her [DIAGNOSES REDACTED]. In an interview with Resident #C on 3-4-14 at 1:15 p.m., she indicated she also had been diagnosed with [REDACTED]. In review of Resident #C's care plan related to potential for falls, dated 10-24-12 and updated on 9-4-13 and 12-30-13, it indicated the resident required 1 assist for transfers and 2 assists for toileting. In review of the Resident #C's "CNA Assignment Sheet", it indicated she required 2 persons to assist her with toileting needs. In review of the nursing notes, incidents were documented on 12-23-13 at 8:20 a.m. and on 2-20-13 at 8:15 a.m. in which the resident was assisted with toileting by CNA staff while in the resident's bathroom. The "Incident Report," dated 12-23-14 at 8:20 a.m., indicated the resident had a witnessed fall in the bathroom while toileting. It indicated the resident had no apparent injury. It indicated, "Resident assessed and assisted into her w/c (wheelchair) by staff x2 (2 staff persons). CNA educated to always follow CNA assignment sheet. Resident is to have assist of 2 for transfers for toilet use. CNA did not follow assignment sheet and used 1 assist for resident." The "Incident Report," dated 2-20-14 at 8:15 a.m., indicated the resident was lowered to the floor with no apparent injury. It indicated the resident was being transferred from the toilet to the wheelchair. It indicated, "Resident is to have assist of 2 (persons) for transfers on and off the toilet and CNA transferred her with assist of one." It indicated, "CNA educated on following CNA assignment sheet." Review of faxes sent to Resident #C's attending physician on 12-23-13 at 9:30 a.m. and on 2-20-14 at 8:15 a.m., indicated the resident had been lowered to the floor and sustained no apparent injuries. In an interview with CNA #4 on 3-5-14 at 10:00 a.m., she indicated she had been providing care to Resident #C both times in which she had the assisted falls to the floor. She indicated both times she was toileting the resident by herself. She indicated the resident was not injured in either assisted fall. She indicated after the first assisted fall, the nurse spoke to her about making sure she had the aide assignment sheet with her and checking it to make sure she was doing what it said. CNA #4 indicated she received a written counseling after the second assisted fall. She indicated, "The aide assignment sheet both times said she should have 2 people assisting her with toileting." On 3-3-14 at 4:30 p.m., the DON provided a copy of a policy entitled, "Fall Assessment & Prevention Protocol." This policy indicated, "All staff members are regularly inservices on resident fall prevention and safety, including proper placement of safety devices, use of different kinds of available safety equipment and daily surveillance of possible hazards." On 3-5-14 at 9:15 a.m., the DON provided a copy of a policy entitled, "Assignments, CNA." This policy indicated, "The C.N.A. assignments are part of resident's plan of care and are prepared and reviewed by a licensed nurse and are issued on a daily basis...C.N.A.'s are expected to carry out their daily assignments in a professional manner and in accordance with established nursing procedures. Teaming with other C.N.A.'s for rounds and care giving is acceptable, however, the individual assigned holds the responsibility for all residents on his/her assignment..." The ISDH "Division of Long Term Care Nurse Aide Training Program," (July 1998) indicated, under "Topic 2: Role of the Nurse Aide" the following: "...The CNA must exhibit ethical behavior...Perform to the best of your ability...Carry out your supervisor's instructions..." This Federal tag relates to Complaint IN 156. 3.1-45(a)(2)