Every finding on record at Forest Creek Village

Based on interview and record review, the facility failed to ensure resident care plans were revised to reflect only the accurate code status for 2 of 24 residents reviewed for care plan accuracy. (Resident 4, Resident 62)Findings include:1. The clinical record for Resident 4 was reviewed on 3/8/26 at 12:50 p.m. The diagnoses included, but were not limited to, dementia and type 2 diabetes.An active physician's order, with a start date of 7/1/25 and with no stop date, indicated that Resident 4's code status was DNR (Do Not Resuscitate).An Indiana Physician Orders for Scope of Treatment (POST) form, signed and dated by the resident's representative and the physician on 3/13/25, indicated Resident 4 had elected a DNR code status.A care plan, dated 6/25/25, regarding Resident 4 as a new admission to the facility included an approach with a start date of 6/25/25 which stated, Honor resident wishes including discharge goal: LTC, code status: full code.A care plan, dated 7/1/25, stated, Resident/legal representative has formulated an advanced directive: DNR.2. The clinical record for Resident 62 was reviewed on 3/8/26 at 12:10 p.m. The diagnoses included, but were not limited to, chronic kidney disease and transient ischemic attack.An active physician's order, with a start date of 12/3/25 and with no stop date, indicated that Resident 62's code status was DNR.An Indiana Physician Orders for Scope of Treatment (POST) form, signed and dated by the resident's representative on 12/2/25 and signed and dated by the physician on 12/3/25, indicated Resident 62 had elected a DNR code status.A care plan, dated 12/2/25, regarding Resident 62 as a new admission to the facility included an approach with a start date of 12/2/25 which stated, Honor resident wishes including discharge goal: home, code status: Full code.A care plan, dated 12/3/25, stated, Resident/legal representative has formulated an advanced directive: DNR.During an interview on 3/10/26 at 1:50 p.m., the Administrator indicated the care plans should have been revised to reflect only the current DNR code status preferences for both Resident 4 and Resident 62.On 3/10/26 at 2:10 pm., the DON (Director of Nursing) provided a copy of a policy titled IDT Baseline Care Plan, and indicated it was the policy currently in use by the facility. A review of the policy indicated, Baseline Care Plan is considered an updatable, working care plan; serving as a building block for the Comprehensive Care Plan. The problems, goals and interventions will be updated as needed based on assessment findings, changes in resident condition, and/or preferences.On 3/12/26 at 9:00 a.m., the Administrator provided a copy of a policy titled IDT Comprehensive Care Plan Policy, and indicated it was the policy currently in use by the facility. A review of the policy indicated, Care plan problems, goals, and interventions must be reviewed and revised by the interdisciplinary team periodically and following completion of each OBRA [Omnibus Budget Reconciliation Act] MDS [Minimum Data Set] assessment.410 IAC (Indiana Administrative Code) 16.2-3.1-35(d)(2)(B)

Based on observation, interview, and record review, the facility failed to ensure a resident was assessed to self-administer his own medications prior to leaving the resident's medication in his room unsupervised for 1 of 3 random observations. (Resident B) Findings include:On 1/15/26 at 8:08 a.m., observed two pill cups sitting on Resident B's dresser. One pill cup with Resident B's name written on the side contained an unmarked small white pill. The other pill cup was not labeled with a name and contained a large piece of candy, an unmarked small white pill, a yellow capsule, and a large white tablet. During an interview on 1/15/26 at 8:15 a.m., Licensed Practical Nurse (LPN) 1 opened the medication cart and compared the pills in the cups to Resident B's medications and indicated the medications belonged to Resident B. The small white pill was melatonin (prescription medication used to treat insomnia) 5 milligrams (mg), the yellow capsule was gabapentin (prescription medication used to treat nerve pain) 300 mg, and the large white tablet was gabapentin 600 mg. LPN 1 indicated the medication should not have been left in Resident B's room. The clinical record for Resident B was reviewed on 1/15/26 at 11:35 a.m. The diagnoses included, but were not limited to, chronic pain and neuropathy. An annual Minimum Data Set (MDS) assessment, dated 11/1/25, indicated Resident B was cognitively intact. The physician's orders indicated:- Gabapentin 300 mg capsule orally twice daily, initiated 1/22/25.- Gabapentin 600 mg tablet orally at bedtime, initiated 1/22/25.- Melatonin 5 mg tablet orally at bedtime, initiated 1/19/25. The clinical record for Resident B lacked a self-medication administration assessment and lacked a physician's order to self-administer his own medications. On 1/16/26 at 9:00 a.m., the Director of Nursing provided a copy of a facility policy, titled Self Administration of Medications, dated 01/2015, and indicated this was the current policy used by the facility. A review of the policy indicated if a resident desired to self-administer their own medications a self-administration of medication assessment would be completed and a physician's order would be obtained specifying the resident's ability to self-administer medications. 3.1-11(a)

Based on observation and interview, the facility failed to ensure a clean sanitary environment was provided for 3 of 3 random resident rooms observed. Urinals were left on the floor, soiled paper products were left in a trash can without a trash bag, toilets were dirty and leaking. (room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER]) Findings include: 1. On 1/15/26 at 8:08 a.m., room [ROOM NUMBER] was observed. A full closed urinal sitting on the floor with dark yellow urine inside was observed. The window side of the room was cluttered with personal belongings sitting along the wall. At that time, Resident B indicated the full urinal had been sitting on the floor for a couple days.During an interview on 1/15/26 at 8:15 a.m., Licensed Practical Nurse (LPN) 1 indicated Resident B's urinal should have been emptied and not left sitting on the floor. 2. On 1/15/26 at 8:25 a.m., room [ROOM NUMBER] was observed. In the bathroom, there was a strong odor of urine and feces. Dried feces on the rim of the toilet bowl and the toilet seat was observed. A trash can without a bag was almost full of toilet paper with dried feces on it and another trash can without a bag was observed to have a urine soiled brief in it. During an interview on 1/15/26 at 8:28 a.m., CNA 1 indicated the trash cans should have had bags in them and should have been emptied. The staff should have notified housekeeping to clean the toilet.3. On 1/15/26 at 8:30 a.m., room [ROOM NUMBER] was observed. In the bathroom, a white blanket folded over and sitting on the floor in front of Resident D's toilet was observed. The blanket was stained with dark brown on the top. At that time, Resident D indicated the blanket was stained brown from shoe and footprints. She had been folding a hospital blanket into four and placing it on the floor in front of the toilet because the toilet had a leak. The blanket had been changed out every week or two. During an interview on 1/15/26 at 8:32 a.m., CNA 2 indicated the blanket had been changed about every week. The blanket should not have been left on the floor. This citation relates to Intake 2711487. 3.1-19(f)

Based on observation, interview, and record review, the facility failed to maintain an effective pest control program when pests were observed in a residents rooms for 2 of 3 rooms observed. (room [ROOM NUMBER], room [ROOM NUMBER]) Findings include:1. On 1/15/26 at 8:08 a.m., inside room [ROOM NUMBER], observed a dresser with a meal tray sitting on top that had dried peas, potatoes, and an open chocolate pudding cup. A small roach-like insect was observed to be crawling out of the peas. At that time, Resident B indicated he hadn't seen a roach in his room in approximately a week, and the meal tray was from dinner the previous night. A Pest Control Report, dated 10/27/25 at 2:22 p.m., indicated cockroaches were noted during service in resident rooms and hallways. Access for service was limited due to clutter and stored items. Most resident rooms had too much clutter to actually service. Please remove or store items to allow access for service. 2. On 1/15/26 at 8:17 a.m., room [ROOM NUMBER] was observed. In the bathroom, a roach-like insect was observed crawling up the bathroom wall underneath the sink. On 1/16/26 at 9:00 a.m., the Director of Nursing provided a copy of a facility policy, titled Pest Control, dated 9/2023, and indicated this was the current policy used by the facility. A review of the policy indicated the facility will maintain an effective pest control program so that the facility is free of pests. This citation relates to Intake 2711487.3.1-19(f)(4)

Based on interview and record review, the facility failed to protect a resident's right to be free from mental abuse when a staff member took a picture of a cognitively impaired resident and posted the picture on a social media website for 1 of 3 residents reviewed for abuse. (Resident B, Activity Assistant) Findings include:On 12/16/25 at 8:48 a.m., the Administrator provided a copy of a facility reportable incident, dated 11/26/25 at 9:21 p.m. A review of the reportable incident indicated Resident B's picture had been posted online by an activity assistant that worked in the facility.During an interview on 12/16/25 at 10:40 a.m., the Administrator indicated an Activity Assistant posted a picture of Resident B online. The Activity Assistant was terminated because she violated a facility policy. The clinical record for Resident B was reviewed on 12/16/25 at 10:42 a.m. The diagnoses included, but were not limited to, Alzheimer's disease, delusional disorder, and cognitive communication deficit. Resident B was severely cognitively impaired and resided on the secured memory care unit.On 12/16/25 at 10:55 a.m., the Administrator provided a copy of the facility's investigation that occurred when she was made aware of Resident B's picture that had been posted online. The facility investigation included the following:- A copy of the picture that showed Resident B sitting up in her wheelchair holding a baby doll. Resident B was staring at the camera but did not have a smile on her face in the picture. There was a caption on the middle of the picture that indicated her an [sic] this f****** baby this baby not real.-An employee communication form, dated 12/1/25, indicated the Activity Assistant posted a picture of Resident B on a social media website without authorization from the family and facility. The Activity Assistant was terminated because she violated the facilities Health Insurance Portability and Accountability Act (HIPAA) and confidential information policies.On 12/16/25 at 8:48 a.m., the Administrator provided a copy of a facility policy, dated 2/2010, and indicated this was the current policy used by the facility. A review of the policy indicated it was the policy of the facility to provide an environment free of mental abuse.This deficient practice was corrected on 11/28/25 after the facility implemented a systemic plan of correction that included the following actions: all staff were educated on the use of cell phones and the prohibition of taking pictures, with ongoing monitoring.This citation relates to Intake 2682367.3.1-27(a)(1)

Based on observation, interview, and record review the facility failed to ensure food was served in a sanitary environment for 1 of 2 kitchen observations. The kitchen floors were dirty. Findings include: During the initial tour of the kitchen on 6/23/25 from 8:26 a.m. until 8:32 a.m., observed buildup of an unknown dark substance, dust, debris, a screwdriver, and several plastic lids under a freezer of the main kitchen area. A buildup of dust and debris under the shelves in the dry storage room was observed. At that time, the dietary supervisor indicated the floors under the freezer and in the dry storage room should have been cleaned. On 6/24/25 at 11:45 a.m., the Director of Nursing provided a copy of a facility policy, titled Cleaning Floors, Tables, and Chairs, dated 7/2015, and indicated this was the current policy used by the facility. A review of the policy indicated kitchen floors will be kept clean and sanitary. This citation relates to Complaint IN00461884. 3.1-21(i)(2) 3.1-21(i)(3)

Based on observation, interview, and record review, the facility failed to ensure person-centered care plan interventions were implemented for a resident with a high risk for a falls for 1 of 3 residents reviewed for falls. (Resident B) Findings include: On 6/23/25 at 11:08 a.m., observed Resident B's lying in bed. The bed was approximately two feet from the floor, not in the lowest position. At that time, Qualified Medication Aide (QMA) 1 entered Resident B's room and indicated the bed should not have been left that high. The clinical record for Resident B was reviewed on 6/23/25 at 9:29 a.m. The diagnoses included, but were not limited to, congestive heart failure, diabetes, and respiratory failure. A quarterly Minimum Data Set (MDS) assessment, dated 6/4/25, indicated Resident B was moderately cognitively impaired and had a history of two or more falls with one injury while a resident at the facility. A care plan, dated 3/6/25, indicated Resident B was at risk for falls. The interventions included, but were not limited to, bed in lowest position. A current physician's order, dated 3/17/25, indicated Resident B's bed was to be in the lowest position. On 6/24/25 at 8:32 a.m., the Director of Nursing provided a copy of a facility policy, titled Comprehensive Care Plan Policy, dated 8/2023, and indicated this was the current policy used by the facility. A review of the policy indicated it was the policy of the facility that every resident would have a person-centered care plan developed and implemented. This citation relates to Complaint IN00461240. 3.1-35(g)(2)

Based on observation, interview, and record review, the facility failed to ensure residents received meals that were palatable and at a proper temperature for 2 of 4 residents reviewed for palatability and proper temperature of food. (Resident C, Resident D) Findings include: On 6/23/25 at 8:35 a.m. until 8:45 a.m., observed a metal cart sitting in the hallway with a meal tray for Resident C. At that time, CNA 2 indicated the meal trays had been delivered to the hall at approximately 8:30 a.m. and then CNA 2 walked away from the cart. On 6/23/25 at 8:50 a.m., observed CNA 1 remove a meal tray for Resident C and deliver it to Resident C's room. CNA 1 removed the lid from the plate and asked Resident C to let him know if she needed anything else. CNA 1 left Resident C's room. On 6/23/25 at 8:51 a.m. observed Resident C try to cut a sausage link on her plate with a fork but was not able to do so. Resident C had a frustrated look on her face and tasted the scrambled eggs. At that time, Resident C indicated she rarely received hot food because the food sat in the hallway. Resident C indicated her food was cold and she couldn't cut the sausage because it was like rubber. On 6/23/25 at 8:54 a.m., observed Resident D sitting on her bed with her meal tray on her table sitting in front of her. Resident D ate approximately fifty percent of the meal and had a balled up napkin sitting on the food. At that time, Resident D indicated her food wasn't hot again and she didn't want to eat it. Resident D had not asked for her meal to be reheated because it took too long. On 6/24/25 at 8:32 a.m., the Director of Nursing provided a copy of a facility policy, titled Food Temperatures, dated 5/2025, and indicated this was the current policy used by the facility. A review of the policy indicated all hot and cold food would be served to the resident at a temperature that was considered palatable at the time the resident received the food. This citation relates to Complaint IN00461884. 1.3-21(a)(2)

Based on observation, interview, and record review, the facility failed to ensure enhanced barrier precautions (the use of gown and gloves during high contact resident care activities for residents that are at increased risk to transfer or become infected with multi-drug resistant organisms) were implemented for a resident with an indwelling urinary catheter for 1 of 3 residents reviewed for infection control. (Resident B) Findings include: On 6/23/25 at 8:58 a.m., observed Licensed Practical Nurse (LPN) 1 and CNA 1 transferring Resident B to the bed with a mechanical lift. Hanging on the door inside Resident B's room, personal protective equipment was observed with individually wrapped plastic gowns, gloves, and masks. Once Resident B was transferred to bed, observed LPN 1 hang Resident B's urinary catheter bag on the bed frame below the mattress. LPN 1 was wearing gloves but no gown and CNA 1 was not wearing gloves nor gown. During an interview on 6/23/25 at 9:14 a.m., CNA 1 indicated staff should have been wearing a gown and gloves when transferring Resident B. The clinical record for Resident B was reviewed on 6/23/25 at 9:29 a.m. The diagnosis included, but was not limited to, obstructive uropathy. A quarterly Minimum Data Set (MDS) assessment, dated 6/4/25, indicated Resident B had an indwelling urinary catheter. A Care Plan, dated 6/13/25, indicated Resident B was at risk of transferring or becoming colonized with a multi-drug resistant organism and required enhanced barrier precautions because Resident B had an indwelling urinary catheter. The interventions included, but were not limited to, enhanced barrier precautions. On 6/24/25 at 8:32 a.m., the Director of Nursing provided a copy of a facility policy, titled Enhanced Barrier Precautions, dated 3/2025, and indicated this was the current policy used by the facility. A review of the policy indicated wear gown and gloves for a resident with an indwelling urinary catheter during transfers. This citation relates to Complaints IN00461240 and IN00461884. 3.1-18(b)(1)

Based on observation and interview, the facility failed to ensure a sanitary environment for the residents for 1 of 1 random observations. Findings include: During the initial tour of the 100 Hall on 6/23/25 from 8:30 a.m. until 8:35 a.m., observed buildup of an unknown black substance along the floorboards and the floorboard trim throughout the 100 hall. On 6/23/25 at 11:30 a.m., observed approximately six inches of the black substance along the floorboards and the floor trim be scraped up. The substance was thick, black, and tar like with hair and other debris mixed with it. At that time the Director of Nursing indicated that should have been scraped up when the housekeeper cleaned the floor. During an interview on 6/23/25 at 11:41 a.m., the Housekeeping Supervisor indicated the floors are cleaned daily and the staff should be scraping the buildup off the floor at that time. On 6/24/25 at 12:10 p.m., the facility was unable to provide a policy by survey exit. This citation relates to Complaints IN00461884 and IN00461240. 3.1-19(f)

Based on observation, interview, and record review, the facility failed to ensure a self medication administration assessment was completed for 1 of 1 residents observed with medications at the bedside. (Resident C) Findings include: On 5/20/25 at 8:36 a.m., observed a small pill cup with a round brown tablet sitting on Resident C's bedside table. Resident C was resting in bed. During an interview on 5/20/25 at 8:37 a.m., LPN 2 indicated the brown tablet was senna (medication used to treat constipation) 8.6 milligrams (mg) and should not have been left in Resident C's room. The clinical record for Resident C was reviewed on 5/20/25 at 9:43 a.m. The diagnoses included, but were not limited to, diabetes and metabolic encephalopathy. A quarterly Minimum Data Set (MDS) assessment, dated 3/28/25, indicated Resident C had minimum cognitive impairment. The clinical record lacked a self medication administration assessment. During an interview on 5/21/25 at 12:45 p.m., the Director of Nursing (DON) indicated there was no self medication administration assessment completed for Resident C. On 5/21/25 at 8:17 a.m., the Director of Nursing (DON) provided a copy of a facility policy, titled Self Administration of Medications, dated 1/2015, and indicated this was the current policy used by the facility. A review of the policy indicated if a resident desires to participate in self-administration, the Interdisciplinary Team will assess the competence of the resident to participate by completing the Self-Administration of Medication Assessment observation. This citation relates to Complaint IN00458632 3.1-11(a)

Based on interview and record review, the facility failed to ensure an accurate Minimum Data Set (MDS) assessment was completed for a resident that was admitted with an indwelling urinary catheter for 1 of 3 residents reviewed for accuracy of the MDS assessment. (Resident F) Findings include: The clinical record was reviewed for Resident F on 5/20/25 at 11:50 a.m. The diagnoses included, but were not limited to, neurogenic bladder, severe morbid obesity, and diabetes. An admission Observation, dated 3/28/25, indicated Resident F was admitted with an indwelling urinary catheter An admission MDS assessment, dated 4/4/25, indicated Resident F did not have an indwelling urinary catheter when he was admitted . A physician's order, initiated on 3/28/25 and discontinued on 4/10/25, indicated Resident F had an indwelling urinary catheter. During an interview on 5/21/25 at 9:25 a.m., RN 1 indicated Resident F's MDS assessment should have indicated he had an indwelling urinary catheter. On 5/21/25 at 12:58 p.m., reviewed the Resident Assessment Instrument (RAI) Manual, dated 10/2023. A review of the RAI Manual indicated if a resident used an indwelling urinary catheter at any time in the seven days prior to the assessment date it should be documented on the MDS assessment. This citation relates to Complaint IN00458632. 3.1-31(d)

Based on observation, interview, and record review, the facility failed to ensure oxygen tubing had been changed, a nebulizer machine was cleaned, and the nebulizer tubing was changed for 3 of 3 residents reviewed. (Resident B, Resident D, Resident E) Findings include: 1. On 5/20/25 at 8:43 a.m., Resident B's nebulizer machine (small machine used to administer liquid inhalation medications) was observed to be stained a purplish color and dusty. The nebulizer machine was sitting on the floor next to the heating unit under the window. A clear tube extended from the nebulizer machine up and connected to a clear face mask shaped to fit over the nose and mouth with a small chamber to hold the liquid inhalation solution. The nebulizer face mask was not in a bag but was lying directly on the heating unit. The nebulizer face mask was dated 4/13/25. During an interview on 5/20/25 at 8:51 a.m., LPN 1 indicated a nebulizer machine should not have been placed on the floor and oxygen tubing, the nebulizer tubing, and mask should have been changed weekly. The clinical record for Resident B was reviewed on 5/20/25 at 10:37 a.m. The diagnoses included, but were not limited to, chronic obstructive pulmonary disorder, dementia, and morbid obesity. A current physician's order, intiated 4/30/25, indicated ipratropium-albuterol (prescription medication used to help breathe more easily) 0.5mg (milligrams)/3 ml (milliliter) inhalation solution administer one vial by nebulizer every four hours. 2. On 5/20/25 at 8:54 a.m., observed a blue oxygen concentrator sitting next to Resident D's bed. A clear tube connected to the oxygen concentrator extended to a clear plastic water bottle (humidity) with a green lid. The water bottle was dated 3/25/25. Another clear tube connected to the water bottle extended approximately 6 feet and then around Resident D's ears and into the nose (nasal canula). The nasal canula tubing was dated 3/20/25. The clinical record for Resident D was reviewed on 5/21/25 at 10:17 a.m. The diagnosis included, but was not limited to, chronic obstructive pulmonary disorder. A current physician's, initiated 12/6/24, indicated Oxygen 1 liter per minute every shift. 3. On 5/20/25 at 9:06 a.m., observed Resident E lying in bed with a nebulizer mask (a mask shaped to fit over the nose and mouth) placed over Resident E's mouth with mist of nebulizer solution spraying out into the open air. There was no staff present in Resident E's room for approximately one minute. The oxygen concentrator was sitting on the floor next to Resident E's bed. A clear tube connected to the oxygen concentrator extended to a clear plastic bottle (humidity) with a green lid. The water bottle was dated 4/21/25. The clinical record for Resident E was reviewed on 5/21/25 at 8:39 a.m. The diagnoses included, but were not limited to, encephalopathy, neurogenic bladder, and chronic obstructive pulmonary disease. The current physician's orders included, but were not limited to: - Change nebulizer tubing one time weekly, initiated 3/6/25. - Change oxygen tubing and humidity one time weekly, initiated 3/6/25. During an interview on 5/21/25 at 11:40 a.m., the Director of Nursing (DON) indicated she was unaware of a policy for changing the oxygen and nebulizer tubing and humidity, but the oxygen tubing, nebulizer tubing, and mask should have been changed weekly. On 5/21/25 at 1:00 p.m., the facility was unable to provide a policy regarding changing oxygen tubing, nebulizer tubing and nebulizer face mask. This citation relates to Complaint IN00458538. 3.1-47(a)(6)

Based on observation, interview, and record review, the facility failed to ensure prescription medications were secured for 2 of 2 random observations. Two prescription medications were sitting on top of an unlocked medication cart in a high traffic resident area unsupervised by staff; and two vials of a prescription aerosol medication were sitting in a resident's room who was not prescribed the aerosol medication. (Resident B) Findings include: 1. During an observation on 5/20/25 at 8:05 a.m., observed the west 200 hall medication cart to be unlocked and sitting against the wall near the nurses station. There was no staff supervising the medication cart. On top of the medication cart, observed a white plastic bottle labeled H-Chlor12 0.125% (prescription wound cleanser used to prevent infection) with approximately two ounces of solution remaining in the bottle and a full plastic bottle labeled lactulose (prescription medication used to treat hepatic encephalopathy and constipation) 10 grams (gm)/15 milliliters (ml) solution. During an interview on 5/20/25 at 8:07 a.m., LPN 1 indicated lactulose and H-chlor12 should have been secured and the medication cart should have been locked or supervised by staff. 2. On 5/20/25 at 8:43 a.m., observed two unopened clear plastic vials of albuterol inhalation solution (prescription aerosol medication to help breathe more easily) 0.63 milligrams (mg)/3 ml sitting next to Resident B's nebulizer mask on top of the heater unit under the window. During an interview on 5/20/25 at 8:51 a.m., LPN 1 indicated the albuterol inhalation solution should have been secured in the medication cart. The clinical record for Resident B was reviewed on 5/20/25 at 10:37 a.m. The diagnoses included, but were not limited to, chronic obstructive pulmonary disorder, dementia, and morbid obesity. A current physician's order, initiated 4/30/25, indicated ipratropium-albuterol (prescription medication used to help breathe more easily) 0.5 mg/3 ml inhalation solution administer one vial by nebulizer every four hours. The clinical record for Resident B lacked a physician's order for albuterol inhalation solution 0.63 mg/3 ml. On 5/21/25 at 8:17 a.m., the Director of Nursing (DON) provided a copy of a facility policy, titled Medication Storage and Expiration Policy, dated 11/2024, and indicated this was the current policy used by the facility. A review of the policy indicated medications including treatment items should be stored in a locked cabinet/cart or locked medication room that is inaccessible by residents and visitors. This citation relates to Complaint IN00458632. 3.1-25(m)

Based on interview and record review, the facility failed to ensure documentation was complete and accurate for 2 of 4 residents reviewed for documentation. (Resident B, Resident F) Findings include: 1. On 5/20/25 at 8:43 a.m., observed Resident B's dirty nebulizer machine (small machine used to administer liquid inhalation medications) sitting on the floor next to the heat unit under the window. A clear tube extended from the nebulizer machine up and connected to a clear face mask shaped to fit over the nose and mouth with a small chamber to hold the liquid inhalation solution. The nebulizer face mask was not in a bag but was lying directly on the heat unit. The nebulizer face mask was dated 4/13/25. The clinical record for Resident B was reviewed on 5/20/25 at 10:37 a.m. The diagnoses included, but were not limited to, chronic obstructive pulmonary disorder, dementia, and morbid obesity. The current physician's orders indicated: - Ipratropium-albuterol (prescription medication used to help breathe more easily) 0.5 milligrams (mg)/3 milliliters (ml) inhalation solution administer one vial by nebulizer every four hours, initiated 4/30/25. The Medication Administration Record (MAR), dated 5/1/25 at 12:00 a.m. through 5/20/25 at 8:00 a.m., indicated ipratropium-albuterol 0.5mg/3ml nebulizer solution, document pulse, respirations, and breath sounds before administration and breath sounds and minutes of therapy after administration. The MAR lacked completed documentation for the administrations of ipratropium-albuterol 0.5mg/3ml nebulizer solution as follows: - On 5/2/25 at 12:00 a.m., left blank. - On 5/2/25 at 4:00 p.m., pulse and respirations before administration were left blank. - On 5/9/25 at 12:00 a.m., breath sounds before administration, breath sounds after administration, and minutes of treatment were left blank. - On 5/11/25 at 8:00 a.m., left blank. - On 5/11/25 at 12:00 p.m., left blank. - On 5/12/25 at 12:00 a.m., left blank. - On 5/12/25 at 4:00 p.m., breath sounds after administration and minutes of treatment were left blank. - On 5/12/25 at 8:00 p.m., breath sounds after administration and minutes of treatment were left blank. - On 5/13/25 at 4:00 p.m., breath sounds after administration and minutes of treatment were left blank. - On 5/13/25 at 8:00 p.m., breath sounds after administration and minutes of treatment were left blank. - On 5/14/25 at 8:00 a.m., breath sounds after administration and minutes of treatment were left blank. - On 5/14/25 at 12:00 p.m., minutes of treatment was left blank. - On 5/14/25 at 4:00 p.m., breath sounds after administration and minutes of treatment were left blank. - On 5/14/25 at 8:00 p.m., breath sounds after administration and minutes of treatment were left blank. - On 5/16/25 at 8:00 a.m., minutes of treatment was left blank. - On 5/16/25 at 12:00 p.m., minutes of treatment was left blank. - On 5/16/25 at 4:00 p.m., minutes of treatment was left blank. - On 5/16/25 at 8:00 p.m., minutes of treatment was left blank. - On 5/17/25 at 8:00 a.m., minutes of treatment was left blank. - On 5/17/25 at 12:00 p.m., minutes of treatment was left blank. - On 5/17/25 at 8:00 p.m., minutes of treatment was left blank. - On 5/18/25 at 8:00 a.m., minutes of treatment was left blank. - On 5/19/25 at 8:00 a.m., left blank. 2. The clinical record for Resident F was reviewed on 5/20/25 at 11:50 a.m. The diagnoses included, but were not limited to, neurogenic bladder, severe morbid obesity, and diabetes. The physician's orders indicated: - Record urine output from urinary catheter every shift, initiated on 3/28/25 and discontinued on 4/10/25. The Treatment Administration Record (TAR), dated 4/1/25 at 7:00 a.m. through 4/10/25 at 3:00 p.m., lacked documentation that the urinary output was measured as follows: - On 4/3/25 there was no documentation for day shift. - On 4/4/25 there was no documentation for day shift. - On 4/9/25 there was no documentation for night shift. During an interview on 5/21/25 at 11:40 a.m., the Director of Nursing (DON) indicated the facility did not have a policy on documentation, but all documentation should have been completed. This citation relates to Complaint IN00458632 3.1-50(a)(1) 3.1-50(a)(2)

Based on observation, interview, and record review, the facility failed to implement infection control practices for 3 of 3 residents reviewed for infection control. A nebulizer machine and tubing were not maintained in a sanitary manner, a catheter bag was on the floor, and soiled linens, and a brief were not disposed of in a sanitary manner. (Resident B, Resident E, Resident F) Findings include: 1. On 5/20/25 at 8:43 a.m., observed Resident B's dirty nebulizer machine (small machine used to administer liquid inhalation medications) sitting on the floor next to the heat unit under the window. A clear tube extended from the nebulizer machine up and connected to a clear face mask shaped to fit over the nose and mouth with a small chamber to hold the liquid inhalation solution. The nebulizer face mask was not in a bag but was lying directly on the heat unit. The nebulizer face mask was dated 4/13/25. During an interview on 5/20/25 at 8:51 a.m., LPN 1 indicated Resident B's nebulizer machine should not have been placed on the floor and should have been cleaned. The nebulizer mask should have been placed in a bag not left lying out on the heat unit. The clinical record for Resident B was reviewed on 5/20/25 at 10:37 a.m. The diagnoses included, but were not limited to, chronic obstructive pulmonary disorder, dementia, and morbid obesity. A current physician's, initiated 4/30/25, indicated ipratropium-albuterol (prescription medication used to help breathe more easily) 0.5mg/3ml inhalation solution administer one vial by nebulizer every four hours. 2. On 5/20/25 at 9:06 a.m., observed Resident E's urinary catheter bag sitting directly on the floor with approximately 400 milliliters (ml) of yellow liquid inside. On 5/20/25 at 9:07 a.m., Qualified Medication Aide (QMA) 1 indicated Resident E's catheter bag should not have been left on the floor. The clinical record for Resident E was reviewed on 5/21/25 at 8:39 a.m. The diagnoses included, but were not limited to, encephalopathy and neurogenic bladder. An admission Minimum Data Set (MDS) assessment, dated 3/12/25, indicated Resident E was admitted with an indwelling urinary catheter. A current physician's order, initiated 3/6/25, indicated Foley catheter size 14 French scale (Fr) with 10 milliliter (ml) balloon. During an interview on 5/20/25 at 9:03 a.m., RN 1 indicated catheter bags should not be touching the floor. 3. On 5/20/25 at 8:11 a.m., observed a soiled brief, gown, and linen lying on the floor in Resident G's room. Resident G was not in his room. During an interview on 5/20/25 at 8:13 a.m., CNA 1 indicated Resident G's brief, gown, and linen were soiled with urine and should not have been left on the floor. The clinical record for Resident G was reviewed on 5/20/25 at 9:32 a.m. The diagnoses included, but were not limited to, lung cancer, dementia, and dysphagia. A quarterly MDS assessment, dated 4/4/25, indicated Resident G was always incontinent of bladder. On 5/21/25 at 12:35 p.m., the Director of Nursing (DON) provided a copy of a facility policy, titled Nursing Department Infection Control, dated 12/2024, and indicated this was the current policy used by the facility. A review of the policy indicated urinary drainage tubes and bags should not touch the floor. Bag/contain contaminated linen. Store equipment in a way that prevents contamination. Administer treatment according to professional standards. This citation relates to Complaint IN00458538. 3.1-18(b)(1)

Based on observation, interview, and record review, the facility failed to ensure the facility was free from roaches for 1 of 1 random observations. Finding includes: On 5/20/25 at 9:09 a.m., observed a brown cockroach crawling on the floor outside a resident's room. At that time, Resident H indicated he had seen a roach near his door. On 5/21/25 at 8:15 a.m., the Administrator provided a copy of a facility policy, titled Pest Control, dated 9/2023, and indicated this was the current policy used by the facility. A review of the policy indicated the facility will maintain an effective pest control program so that the facility is free from pests. This citation relates to Complaint IN00458615 3.1-19(f)(4)

Based on observation, interview, and record review, the facility failed to ensure residents were free of a medication error rate greater than 5 percent for 4 of 25 opportunities, resulting in a medication error rate of 16 percent. Resident B , Resident C) Findings include: 1. On 3/14/25 at 7:23 a.m., observed RN 1 administer Wixela 250/50 micrograms (mcg) (prescription metered dose inhaler used to treat asthma and chronic obstructive pulmonary disease) and Incruse Ellipta 62.5 mcg (prescription metered dose inhaler used to treat chronic obstructive pulmonary disease) to Resident B. RN 1 did not ask Resident B to rinse her mouth with water and spit the water out before RN 1 left Resident B's room. At that time, RN 1 indicated he had finished administering Resident B's medications. RN 1 didn't need to have Resident B rinse her mouth and spit after he administered Wixela nor Incruse. The instructions for use for Wixela 250/50 mcg were reviewed on 3/14/25 at 9:00 a.m. A review of the instructions indicated rinse mouth with water after breathing in the medicine. Spit out the water. Do not swallow. On 3/14/25 at 11:52 a.m., the Director of Nursing (DON) provided a copy of a skills competency, titled Meter Dose Inhaler Delivery, dated 9/2023, and indicated this was the current skills competency used by the facility. A review of the skills competency indicated once the medication is administered, have the resident wash their mouth out with water or mouthwash and spit it out. 2. On 3/14/25 at 7:45 a.m., observed RN 1 administer 34 units of Lantus Solostar 100 units/ml (milliliter) (prescription long acting insulin administered from an insulin pen) and 21 units of Humalog KwikPen 200 units/ml (prescription fast acting insulin administered from an insulin pen) to Resident C without priming either insulin pen. At that time, RN 1 indicated he did not need to prime the Lantus Solostar insulin pen nor the Humalog KwikPen before administering the insulin. The instructions for use of Lantus Solostar were reviewed on 3/14/25 at 9:09 a.m. A review of the instructions indicated dial a test dose of two units then press the injection button all the way in and check to see that insulin comes out of the needle. The instruction for use of Humalog KwikPen were reviewed on 3/14/25 at 9:10 a.m. A review of the instructions indicated prime before each injection. Priming the pen means removing the air from the needle and cartridge. If the pen is not primed the resident may receive too much or too little insulin. On 3/14/25 at 9:15 a.m., the DON provided a copy of a skills competency, titled Insulin Pen Administration, dated 10/2019, and indicated this was the current skills competency used by the facility. A review of the competency indicated prime the pen by dialing two units and push the end of the pen to push out the two units. A small drop of insulin should be visible. If insulin does not appear, repeat. This citation relates to Complaint IN00455414. 3.1-48(c)(1)

Based on observation, interview, and record review, the facility failed to ensure self-administration medication assessments were complete for 1 of 1 residents observed with medications at the bedside. (Resident E). Findings include: On 3/14/25 at 8:09 a.m., observed a small purple pill, a small white pill, and a yellow capsule sitting inside a small plastic medication cup on Resident E's bedside table. There was no staff in Resident E's room. During an interview on 3/14/25 at 8:25 a.m., LPN 1 indicated the three pills that were left in the plastic cup on Resident E's bedside table should not have been left in his room. On 3/14/25 at 9:29 a.m. Resident E's clinical record was reviewed. The diagnoses included, but were not limited to, diabetes and thyroid disorder. The clinical record lacked a self-administration medication assessment. On 3/14/25 at 12:10 p.m., the DON indicated Resident E did not have a self-administration medication assessment and the medications should not have been left at the bedside. On 3/14/25 at 9:15 a.m., the Director of Nursing (DON) provided a copy of a facility policy, titled Medication Storage and Expiration Policy, dated 11/2024, and indicated this was the current policy used by the facility. A review of the policy indicated medication should be stored in a locked cabinet/cart or locked medication room that is inaccessible by residents and visitors. This citation relates to Complaint IN00455414. 3.1-11(a)

Based on observation, interview, and record review the facility failed to ensure medications were dated when opened for 1 of 3 medication carts reviewed for medication storage. (200 Hall Medication Cart) Findings include: On 3/14/25 at 7:23 a.m., observed Wixela 250/50 mcg (micrograms) (prescription inhaler used for chronic obstructive pulmonary disease) sitting inside a clear baggy in the top drawer of the 200 hall medication cart. The label on the Wixela inhaler indicated Resident B, 60 doses were filled, on 1/22/25, and 47 doses remained. There was no opened date written anywhere on the inhaler package nor the inhaler itself. A Lantus Solostar 100 unit/ml (milliliter) insulin pen was observed sitting in the top drawer of the medication cart. The seal was broken on the Lantus Solostar insulin pen. There was no opened date written anywhere on the Lantus Solostar label nor on the insulin pen itself. During an interview on 3/14/25 at 7:47 a.m., RN (Registered Nurse) 1 indicated the Lantus Solostar insulin pen and the Wixela inhaler should have been dated when they were opened. On 3/14/25 at 9:15 a.m., the Director of Nursing provided a copy of a facility policy, titled Medication Storage and Expiration Policy, dated 11/2024, and indicated this was the current policy used by the facility. A review of the policy indicated the date opened should be documented on the primary medication container (vial, bottle, inhaler) when the medication had a shortened expiration date once opened. This citation relates to Complaint IN00455414. 3.1-25(j)

Based on record review and interview, the facility failed to ensure adequate supervision to prevent Resident [NAME] from having pushed Resident B, which resulted in a fall with a [MEDICAL CONDITION] and surgery to repair the injury for 1 of 3 residents reviewed for falls in a sample of 4 (Resident B). Findings include: The record for Resident [NAME] was reviewed on 8/8/19 at 9:07 a.m. [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS) assessment, dated 7/23/19, indicated Resident [NAME] had severe cognitive impairment and resided on the Memory Care Unit (secure dementia unit). Clinical record documentation, dated 1/16/19, indicated Resident [NAME] hit another resident with an open hand on the mouth, because the other resident was talking loudly. The record lacked documentation of care plans for behaviors or supervision to prevent recurrence of Resident [NAME] hitting other residents. The record for Resident B was reviewed on 8/8/19 at 10:37 a.m. [DIAGNOSES REDACTED]. The significant change in condition MDS assessment, dated 6/2/19, indicated Resident B had sever cognitive impairment and resided on the Memory Care Unit. A current Care plan, undated, indicated Resident B had repetitive verbal behaviors of saying, momma or I'm cold. The care plan lacked an intervention of staff supervision. A facility Event Report, dated 6/14/19 at 6:53 a.m., indicated Resident B had been pushed to the ground by Resident [NAME] on 6/14/19 at approximately 6:50 a.m. A Facility Reported Incident (FRI), dated 6/14/19, indicated Resident B had been pushed by another resident (Resident E) and had fallen to the floor. An assessment had been completed and no injuries were found. A second FRI, dated 6/14/19, indicated Resident B had been pushed to the floor by another resident (Resident E) earlier in the day. When the staff tried to assist the resident to bed, the resident began to complain of pain in the lower back and the left hip. The facility received orders for an X-ray and the results were positive for a left [MEDICAL CONDITION]. A hospital discharge note, dated 6/20/19, indicated Resident B's radiology (X-ray) report was positive for a left femoral neck (hip) fracture and surgical repair was completed. Interview, on 8/7/19 at 10:15 a.m., LPN 1 indicated there is usually two Certified Nursing Assistants (CNA) or a CNA and a Qualified Medication Assistant (QMA) on the night shift for the dementia unit. Interview, on 8/8/19 at 11:30 a.m., the Director of Nursing (DON) indicated Resident B would repeat things, such as, momma or I'm cold. The family refused multiple attempts to treat the resident with medication. Interview, on 8/8/19 at 11:40 a.m., CNA 2 indicated she had worked the night shift at the time of the incident, but had gone outside to dump the trash and had not seen Resident B pushed to the floor. Resident [NAME] was usually very quiet and stayed to herself. She has gotten upset sometimes if other residents make repetitive gestures or statements. Interview, on 8/8/19 at 2:20 p.m., QMA 3 indicated he had worked the night shift at the time of the incident, but was not on the unit at the time of the fall. He reported he had gone to the West Hall to check the schedule and thought CNA 2 had witnessed what happened. During a second interview, on 8/9/19 at 3:05 p.m., QMA 3 indicated he had not remembered the incident with Resident B correctly in his previous statement (8/8/19 at 2:20 p.m.). He remembered he had been at the opposite end of the unit passing medications and CNA 2 was down the hall assisting another resident. He heard a commotion and found Resident B on the floor of the dining room. No staff were present in the dining room. There were approximately 10 to 12 residents in the dining room and a couple of the residents had reported Resident B had been pushed to the floor by Resident E. Interview, on 8/8/19 at 2:30 p.m., the Administrator and DON indicated they were unable to find an investigation or any staff statements related to the incident. This Federal tag relates to Complaint IN 489. 3.1-45(a)(2)

Based on record review and interview, the facility failed to ensure staff followed the resident's plan of care which resulted in a fall with a forehead hematoma and fractured finger for 1 of 3 residents reviewed for falls in a sample of 6 (Resident # B and CNA #1). Findings include: The clinical record for Resident #B was reviewed on 12/30/13 at 10:30 A.M. [DIAGNOSES REDACTED]. A hospital note dated 12/1/13 indicated the resident was treated in the hospital emergency room for a left forehead hematoma and superficial abrasion above the left eye and for a left hand 3rd finger fracture related to a fall. A "Fall Event Report" dated 12/2/13 indicated the resident received 2 abrasions above the left eye and the 3rd finger on the left hand was out of alignment. The report also indicated CNA #1 had taken Resident #B to the bathroom by herself and she became combative and fell to the floor. The CNA was educated at that time to follow the CNA assignment sheet, as the resident was a 2 person assist with transfers. A care plan originally dated 6/13/12, indicated the resident was at risk for falls due to decreased strength and balance with a history of falls and required assistant with transfers. The care plan was updated on 11/8/13 (before the fall on 12/1/13) with an intervention of assistance of 2 for transfers. The current Quarterly Minimum Data Set (MDS assessment) dated 11/18/13 indicated the resident's cognitive status was severely impaired (BIMS - brief interview mental status "4") and she was an extensive assist of 2 staff members for transfers. During an interview with the Administrator on 12/30/13 at 4:00 P.M., he indicated the facility had done a lot of inservicing with the staff related to falls; but the resident was a 2 person assist, CNA #1 had assisted the resident by herself, and the resident fell . This Federal tag relates to complaint IN 641. 3.1-45(a)(2)

Based on record review and interview, the facility failed to ensure staff followed the facility protocol while transferring a resident in a hoyer lift and failed to follow the plan of care to prevent falls and injuries for 2 of 4 resident's reviewed for falls in a sample of 5 (Resident #B, Resident #E, CNA #1, CNA #2). Findings include: 1. The clinical record for Resident #B was reviewed on 11/12/13 at 10:55 A.M. [DIAGNOSES REDACTED]. A current quarterly MDS (Minimum Data Set) assessment dated [DATE], indicated an interview was not conducted with the resident due to the severe cognitive impairment related to Alzheimer's disease. The resident's functional status for transfers was total dependence with the assistance of 2 staff members and the use of a Hoyer lift. Resident #B's range of motion (ROM) was upper and lower impairments on both sides due to contractures. A nurses note dated 11/6/13 at 5:41 P.M., indicated the nurse was called to Resident #B's room at approximately 4:30 P.M., by CNA #1 and CNA #2. The nurse found Resident #B on the floor. A nurses note dated 11/6/13 at 5:45 P.M., indicated the Director of Nursing (DON) entered the room and found the resident lying on the floor. The resident was observed with bleeding from the nose and mouth and the nose appeared to be displaced and slight swelling to the bilateral (both) cheek bones. EMT's (Emergency Medical Technician) transported Resident #B to the hospital by ambulance. An IDT (interdisciplinary team) note dated 11/7/13 at 1:47 P.M., indicated through investigation, the strap to the lift had not been secured appropriately and slipped off allowing the resident to fall to the floor. A statement signed by CNA #2 on 11/6/13, after the incident indicated the hoyer sling came unhooked from the hoyer when they turned it. A hospital note dated 11/6/13 at 17:28:00 (5:28 P.M.), indicated the resident was assessed in the emergency department (ED) after sustaining a fall from a Hoyer lift. The resident sustained [REDACTED]. The radiology report also indicated the resident had a small amount of subarachnoid hemorrhage along the right temporal lobe and multiple facial fractures involving the bilateral nasal bones, nasal septum, bilateral maxillary sinuses, hard palate, inferior right orbit and nasal spine of the maxilla involving the roots of multiple teeth. During an interview with the Administrator on 11/12/13 at 9:25 A.M., he indicated CNA #1 and CNA #2 are currently suspended pending the completion of the investigation and will be terminated related to the resident being dropped from the Hoyer lift. During an interview with the DON on 11/12/13 at 12:15 P.M., she indicated maintenance checked all Hoyers and they were all working properly and the slings were checked and none were damaged. When I walked into the resident's room, one side of the sling was not attached to the lift. I believe it was not attached to the Hoyer correctly. During an interview with the LPN #3 on 11/12/13 at 3:10 P.M., she indicated one side of the sling was not attached to the hoyer, it wasn't broken so you have to assume the CNA's didn't attach it correctly. A current CNA-Skills Validation titled "Mechanical Lift" indicated " ... 11. Attach lift to sling using straps per manufacturer's guidelines. ... 14. Ensure that sling is securely attached to lift device ..." 2. The clinical record for Resident #E was reviewed on 11/12/13 at 3:25 P.M. [DIAGNOSES REDACTED]. A current Quarterly assessment dated [DATE], indicated the resident is severely cognitively impaired and is at risk for falls. A Fall Event Report dated 10/23/13 at 7:46 P.M., indicated the resident had an unwitnessed fall from the wheelchair. A nurses note dated 10/24/13 at 8:34 A.M., indicated the resident was found lying on the floor next to the bed. Resident #E had fallen from the wheelchair but could not explain how or why she fell due to cognitive deficits. Interventions put into place at that time, do not leave the resident in the room unattended in the wheelchair. The fall risk care plan for 8/25/10 and updated on 10/24/13, indicated the resident should not be left unattended in the wheelchair in the resident's room. A Fall Event Report dated 10/29/13 at 8:00 P.M., indicated the resident had an unwitnessed fall in the room from the wheelchair. CNA #1 had taken Resident #E back to the room and left the resident unattended in the wheelchair. The intervention at that time, CNA #1 was educated on the plan of care and given a written warning. Review of the CNA assignment sheets indicated the special needs of Resident #E included, do not leave the resident in the room alone in the wheelchair. A nurses note dated 10/29/13 at 9:20 A.M., indicated the resident was found lying on the floor from the wheelchair. The resident stated she fell out of bed but notes indicated she had not been in bed. An assessment was completed and could not complete passive range of motion to the upper right extremity. The resident also received an abrasion to the right shoulder (10.0 centimeters x 6.5 centimeters) and an abrasion to the right side of the face (4.5 cm x 1.0 cm). An order was received to send the resident to the hospital ER (no other injuries noted). During an interview with the Administrator and DON on 11/12/13 at 4:00 P.M., they indicated that CNA #1 had been given a written warning for the fall of Resident #E. This Federal tag relates to Complaint IN 559. 3.1-45(a)(2)

Based on observation, interview and record review, the facility failed to ensure residents were protected from injury and the potential for injury during transport: in that when cognitively impaired residents were transported via a wheelchair, the nursing staff failed to ensure the residents were moved safely throughout the unit and ancillary areas of the facility. This resulted in two residents falling forward from the wheelchair in which one resident's fall resulted in a head laceration which required emergency room intervention. In addition the nursing staff failed to provide supervision of a resident while toileting, which resulted in the resident falling to the floor. This deficient practice affected 3 of 5 sampled and 2 of 3 supplemental sampled residents. (Residents "F", "A", "C", "G", "H" and "D"). Findings include: 1. The record for Resident "F" was reviewed on 03-13-12 at 10:15 a.m. [DIAGNOSES REDACTED]. These [DIAGNOSES REDACTED]. The record indicated the resident fell from the wheelchair while being transported down the hallway and sustained a head laceration. During an observation on 03-13-12 at 9:45 a.m., Resident "F" was observed lying on a mattress which had been placed on the floor. During this observation the resident appeared to have bruising to bilateral eyes areas. Interview on 03-13-12 at 9:50 a.m., Licensed Practical Nurse,employee #4, verified the resident had bruising after falling from the wheelchair. When further interviewed, the employee indicated a "CNA (certified nurses aide) was pushing the resident, while seated in a wheelchair, down the hall and (resident) placed (resident) feet on the floor and went out the front of the wheelchair head first. (Resident) ended up with a laceration and a skin tear, we had to send (resident) to the hospital where they had to suture the laceration." The Licensed Nurse further indicated, the foot pedals were on the wheelchair but the CNA didn't place (resident's) feet on them, "they dangled in between them. Once (resident) feet hit the floor, that's all it took." Interview on 03-13-12 at 10:20 a.m., the Director of Nurses indicated "I reviewed the video and I could see that (name of resident) was fidgeting in the wheelchair and was kind of sitting on the edge of the seat. The CNA repositioned the resident but you could see (resident) was still fidgeting. The video showed the CNA pushing (resident) in the wheelchair, and then (the CNA) reaching forward. The video didn't show the fall and I couldn't really see what happened." Review of "Resident Progress Notes" indicated the following: "03-07-12 11:00 p.m. - Resident leaning forward in W/C (wheelchair) fell forward and hit forehead on W/C peddles (sic) while CNA was pushing resident down hallway to room. Noted resident had 2 cm laceration noted to forehead.""03-08-12 3:32 a.m. - Resident's (family member) arrived at facility prior to resident arrival. ER nurse called to give report, stated resident has 2 sutures to forehead. covered with dry dressing. Skin tear to resident's right arm, covered with dry dressing. ER nurse instructed this nurse to monitor both sites for s/s (signs and symptoms) of infection and any increased drainage. Resident's (family member) voiced frustration about fall." "03-09-12 10:52 p.m. - Continues with laceration on forehead and blue sutures intact. Nose is also scrapped alittle (sic). Several purple and blue discolorations on face." A review of the facility incident report, dated 03-07-12 at 10:30 p.m., indicated the following:"Witnessed fall, (location) hallway, non compliant resident, totally dependent. In wheelchair with CNA pushing res. (After fall) resident sitting on buttocks with back on wall. Resident hit head and noted to have 2 cm laceration to forehead. CNA stated resident was leaning forward and fell out of wheelchair when she (CNA) was pushing (resident) down the hallway. Resident was incontinent at the time of the fall. Resident leaning forward and hit forehead on wheelchair pedals while nursing CNA was pushing resident down the hallway to room." Review of additional information and documented by the Hospice nurse indicated the following in regard to the incident, and dated 03-10-12:"Pt. (patient) is a fall risk with a hx. (history) of falls. Pt. has fallen times 2 this past week. The first fall resulted in a trip to the ER (emergency room ). Pt. sustained a forehead skin tear requiring sutures...and has bruising surrounding the skin tear. Bruising is also present to both eyes. Pt. also sustained a skin tear to RFA (right forearm) requiring steristrips. Numerous large bruises noted to BLE's (bilateral lower extremities). Activity Mobility - wheelchair mobility assist, poor coordination and balance, bed or chair bound. Pt. is total care for ADL's (activities of daily living)." Review of CNA #9 employee's file indicated the following in regard to the circumstances with the fall which involved Resident "F." "On 03-07-12 employee was witnessed via facility camera sitting in dining room on her cell phone while a resident who was anxious and in need of attention sat nearby. This employee failed to provide the necessary attention to the resident. Shortly after this incident while pushing resident in (resident) wheelchair to room by this employee, resident fell forward out of wheelchair causing injury. This employee failed to prevent this fall by not addressing this resident timely. Employee did assist resident in positioning prior to transporting but at this point the assistance was not able to prevent the fall." During interview on 03-13-12 at 2:00 p.m., the Director of Nurses indicated the CNA should have requested assistance from other nursing staff to provide safety while transporting this resident. 2. The record for Resident "A" was reviewed on 03-12-12 at 9:15 a.m. [DIAGNOSES REDACTED]. These [DIAGNOSES REDACTED]. The record indicated the Resident had been admitted to the facility for Respite care on 02-20-12. The record indicated the resident required the use of nursing staff for ambulation on/off Unit as well as in room. Review of the Occupational Therapist Plan of Treatment, dated 02-21-12, indicated the resident has "low endurance - needs frequent rests. Fall risk. Patient presents with decreased functional mobility, balance, coordination, strength and endurance...." Review of the Progress Note, dated 02-24-12 at 7:22 p.m., indicated the following:"Res. was being pushed down the hall to be put to bed. CNA stated that resident planted foot on ground causing (resident) to fall forward out of chair. CNA stated resident did not hit head." "02-25-12 5:35 p.m. Care Plan meeting held with (family members). Discussed fall prevention efforts... ." "02-27-12 10:01 a.m., IDT (interdisciplinary team) fall review... resident landed on left side no injury noted. Family also requested footrests be placed on the wheelchair at this time. Res. has dx. (diagnosis) of Alzheimer's dementia and at time (sic) attempts to self transfer causing increased risk of falls if footrests in place. Staff attempted to explain risk to family. Family states they want footrests in place." A review of the employee file for CNA employee #5, who was identified by the Director of Nurses as the CNA who was involved with the fall for the resident, indicated the following: "On 02-24-12 this employee was transferring a resident down the hall when the resident planted feet in (sic) the floor and fell forward. By this employee's own admission she states that she was looking away at the time the incident occurred therefore playing part in the fall that occurred. Employee has been educated in the importance of giving resident her undivided attention when providing care and transportation. Also prior to transferring anyone, resident's positioning should be checked." During an interview on 03-12-12 at 11:43 a.m., a concerned family member indicated that when the family spoke with the Administrative staff at the facility "they made us feel as if (resident) was to blame for falling from the wheelchair. The foot rests should have been on the wheelchair." 3. The record for Resident "C" was reviewed on 03-12-12 at 10:40 a.m. [DIAGNOSES REDACTED]. These [DIAGNOSES REDACTED]. The record indicated the resident had no cognitive impairment, but required extensive assistance and 2 staff members with toileting. Review of the resident's plan of care indicated the resident was at high risk for falls due to decreased balance, need for assistance with transfers ...." Review of the "fall event," dated 03-09-12 at 1:07 a.m., indicated the following:"Found on floor next to wheelchair sitting on buttocks. States (resident) was trying to sit in wheelchair and didn't realize the wheelchair was turned around... Resident educated to use assistance when transferring. Resident states thought (resident) had gotten strong enough to walk alone." A review of the facility Incident Report, dated 03-09-12 at 1:15 a.m., indicated the resident was "found on the floor - non compliant resident - unwitnessed - sitting on bottom with knees bent trying to get up." During interview on 03-13-12 at 11:00 a.m. the Director of Nurses indicated CNA employee #6 had taken the resident "to the bathroom and left the resident unattended while answering another call light." Review of the employee file indicated the CNA "assisted resident into bathroom and didn't remain in the restroom. Resident had a fall that occurred due to the occurrence. Discussed importance of ensuring that resident when requiring assistance are not left unattended in restroom." 4. The record for Resident "G" was reviewed on 03-13-12 at 2:00 p.m. [DIAGNOSES REDACTED]. These [DIAGNOSES REDACTED]. During a review of CNA employee #7 file indicated the following "Resident/Family Concern/Grievance Form," dated 09-02-11, "Staff member (Name of employee #7) in dining room wheeling (name of resident) to table got resident foot caught under chair. Res. yelled out. Staff member still unaware foot was caught. Another CNA let (name of employee #7) know foot was caught. (Name of employee) stated 'I do not have time for this' grabbed res. shorts to hold legs up and as (name of employee #7) was pushing res. ran res. into another resident in dining room. CNA noted to have poor attitude." During interview on 03-13-12 at 2:00 p.m., the Director of Nurses indicated the CNA was a "really good CNA but just didn't have good customers service and came across as mean." The Director of Nurses indicated the CNA was also involved in another incident in which Resident "H" received a skin tear while providing care to the resident. "The family member indicated the CNA was rough with the resident." 5. The record for Resident "D" was reviewed on 03-13-12 at 9:35 a.m. [DIAGNOSES REDACTED]. These [DIAGNOSES REDACTED]. The record indicated the resident was severely cognitively impaired and required the assistance of the nursing staff for ambulation on and off the nursing unit. During an observation on 03-13-12 at 9:25 a.m., this resident was seated in a wheelchair and indicated a desire to go to the Activity area of the facility. Licensed Practical Nurse, employee #10, instructed the resident "Hold up your legs and I'll push you." The Licensed Nurse proceeded to push the resident down the hallway, and continued to instruct the resident "hold up your legs, remember what I said, hold your feet up (emphatic)." This dialog continued by the Licensed Nurse as she continued to push the resident down the hallway to the Activity area. During this observation, the resident did not have foot pedals on the wheelchair. 6. During an observation on 03-12-12 at 9:30 a.m., Resident "C" was being transported from the Therapy area adjacent to the Administrator's office to another section in the front of the facility. The therapist indicated the resident needed to have "blood drawn" and was being transported to another area. The therapist instructed the resident multiple times, "hold your feet up, hold your feet up," while transporting the resident. 7. During an interview on 03-13-12 at 10:00 a.m., the Therapy Director, employee #8, indicated "We don't ordinarily use foot pedals on the wheelchairs as they can cause a fall risk. If a resident has full range of the lower extremities we try to encourage them to continue to use the legs, but if a resident is cognitively impaired the pedals could increase the risk of falling." When further interviewed how an assessment was made for a resident who was admitted to the facility and was determined to be cognitively impaired, and received therapy for strengthening, and after a therapy session, was too tired to "hold up their legs or feet," and the reasoning why foot pedals could not be used for the transportation of the resident from one area of the facility to another, the Director indicated that upon admission the "Occupational Therapist" checks for the need of a cushion, leg pedals, a high back wheelchair or hemi height wheelchair for the resident. After that we (in reference to the therapy department staff) do the evaluation quarterly. The nurses need to let us know if there is a change or decline in the resident's condition." When interviewed about the fall in regard to Resident "F" and if the equipment had been checked or deemed appropriate for the resident, the Director indicated, "Oh (resident) Hospice, we just picked (resident) up after the fall." In regard to Resident "A" and the foot pedals, the Director indicated "we tried to educate the family that the pedals could cause a fall if the resident tried to get up independently." During interview on 03-13-12 at 10:20 a.m., the Director of Nurses verified the family for Resident "A" wanted the foot pedals on the wheelchair and were very upset that the resident had fallen forward from the wheelchair while being transported from the dining area to the resident room. The Director of Nurses further indicated that if foot pedals were placed on all wheelchairs, there would hardly be any room in the Activity area for the residents attending activities. This Federal tag relates to IN 667. 3.1-45(a)(2)