Every finding on record at Good Samaritan Home & Rehabilitative Center

Based on interview and record review, the facility failed to ensure newly admitted resident's had orders in place for ostomy and implanted port care, for 1 of 2 residents reviewed for ostomy and implanted port care. (Resident B) Finding includes: On 7/8/26 at 9:17 a.m., Resident B's clinical record was reviewed. Diagnoses included but were not limited to, other complications of enterostomy (Primary, Admission), dehydration, encounter for surgical aftercare following surgery on the digestive system. Resident B admitted to the facility on [DATE] and discharged to the hospital on 7/5/26. Care plans were reviewed and included but were not limited to: Resident has IV (intravenous) access; at risk for infection/complications: Implanted port, date initiated 6/30/26. Approach's included but were not limited to: change dressing as ordered, document abnormal findings and notify MD (medical doctor), flush as ordered, keep site clean and dry, observe insertion site for signs of infiltration (redness, swelling, tenderness, coolness, non-functioning access), start date 6/30/26. Resident has an ileostomy, date initiated 6/30/26. Approach's included but were not limited to: assist resident with stoma changes as needed, keep site clean and dry, monitor BM's (bowel movement), notify MD of abnormal findings, observe stoma site for excreations and irritation, start date 6/30/26. Resident is at risk for skin breakdown or further skin breakdown due to : incontinence, pain, weakness, ostomy .document abnormal findings and notify MD, date initiated 6/30/26, Approach treatments as ordered/indicated, start date 6/30/26. A progress note dated 6/29/26 at 1:34 p.m., indicated, Resident admitted to room [room number] per W/C (wheelchair), transferred to bed x 2 assist. Port in place left upper chest without s/s (signs and symptoms ) infection. Has illistomy (sic) in place . June and July 2026 physicians orders were reviewed and included but were not limited to: sodium chloride 0.9 % parenteral solution; amount to administer: 500 ml (milliliters) intravenous order once a day on Mon., Wed., Fri., frequency, indication: dehydration, rate 125/ml/hr (hour), special instructions, [DX( Diagnosis) encounter for other specified aftercare, date started 7/1/26- 7/4/26. There were no orders for care or monitoring of the implanted port or the ileostomy. On 7/9/26 11:37 a.m., the DON (Director of Nursing) indicated on admit, orders are supposed to be put in place for care and monitoring if a resident has an ostomy or implanted port. The floor nurse who admitted the resident should input the orders into the record, the IDT (Interdisciplinary team) follows up on the orders. On 7/9/26 at 12:37 p.m., the Regional Nurse Consultant provided the current policy on nursing admission/return with a revision date of 12/25. The policy included but was not limited to: It is the policy of [name of company] to provide baseline and accurate documentation of the mental and physical condition of each resident admitted or readmitted to the facility adn to assist the resident and family with adjusting to the facility. admission procedures will be followed for all new admissions including respite care. Procedure: .1. Physician orders: Upon admission, physician orders must be obtained. 2. Transcribe the admission orders from the original orders sent from the hospital or physician's office . On 7/9/26 at 9: 21 a.m., the Administrator provided the current policy implanted venous port accessing with revision date of 6/1/21. The policy included but was not limited to: .non-coring safety needles are changed every 7 days when the port is accessed and PRN (as needed). Needle change should correspond with dressing change .a dressing change is not required when the implanted venous port is accessed and then immediately deaccessed following blood sampling, monthly maintenance, or a one time IV push medication . This citation relates to Intake 3072064. 410 IAC (Indiana Administrative Code) 3.1-30(a)

Based on record review and interview, the facility failed to ensure the restorative services were provided for 1 of 1 residents reviewed for restorative and rehabilitation services. Restorative services were not initiated for a resident when discharged from rehabilitation services. (Resident 9)Finding includes: During an interview on 3/20/26 at 9:16 A.M., Resident 9 indicated that he had been cleared to walk for a while, but no one had been around to help him get started. On 3/23/26 at 8:46 A.M., Resident 9's clinical record was reviewed. Diagnoses included, but were not limited to, chronic obstructive pulmonary, unspecified fracture of left acetabulum, subsequent encounter for fracture with routine healing, and other specified fracture of left pubis.The current Quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident 9 was cognitively intact. Resident 9 was independent with eating, needed substantial to maximum assistance for dressing and lying to sitting at the bedside, and needed partial to substantial assistance for the following transfer modes sitting to standing from chair to bed, and walking 10 feet with a walker. Resident 9 required a walker and wheelchair for mobility during 7 day look back period and had a history of falls.Current physician orders included, but was limited to the following,A physician note dated 2/9/26, written by the Orthopedic physician indicated Options for treatment included living with symptoms trying to Weight Bearing as Tolerated (WBAT) and working with therapy. The other option is surgery to convert to a total hip replacement. Patient representative states his cardiologist did not recommend he undergo surgery. At that time the bone has healed enough he can WBAT with a walker. Return in 2 months for repeat x-rays.The current care plan for activities of daily living includes the following interventions but were not limited to:Activity Level: Up with assist of one to wheelchair (w/c), anti-rollbacks to w/c, equagel to w/c with dycem above and below, and Weight Bearing as Tolerated (WBAT) with walker dated 3/4/26.Nursing Progress Notes from 2/3/26 to 3/25/26 lacked any reference to therapy or to the implementation of a restorative plan.A physical therapy note dated 2/3/26, written by a Physical Therapist at facility indicated that the resident was to be discharged to restorative and nursing staff. During an interview on 3/19/26 at 9:00 A.M., a Therapy aide indicated he was assigned to residents with restorative care plans.During an interview on 3/23/26 at 2:15 P.M., an Occupational Therapist indicated there was no restorative services set up for the resident and was not aware of why the orders were missed.During an interview on 3/25/26 at 10:15 A.M., the Regional Physical Therapy Support person indicated that the order was missed from the physician treatment note and would be taken care of today. On 3/25/26 at 12:15 P.M., the Director of Nursing (DON) provided a Quarterly Therapy Screen Tool indicating that no evaluation was indicated for the resident. During this time the DON indicated that the resident refused therapy options. The document lacks the resident's response of refusal. On 3/25/26 at 11:30 A.M., the Administrator provided a current policy Restorative Nursing Program dated 4/2025. The policy indicated .recommendations for restorative nursing program can be made for the resident when preparing for discharge from a skilled program . 410 Indiana Administrative Code (IAC) 16.2-3.1-38(a)(2)(B)410 IAC 16.2-3.1-17(c)(4)

Based on observation, interview, and record review, the facility failed to store and prepare food under sanitary conditions during 2 of 2 kitchen observations. Food was not labeled correctly and expired food was not disposed of from the reach in refrigerator. (Kitchen, spice rack, reach-in refrigerator) Findings include: On [DATE] at 9:25 A.M., during the initial tour the following were observed in the reach in refrigerator: 1 container of sausage links prepared [DATE] with a discard date of [DATE] 2 containers of cheese with no open date 1 container of chicken soup with no open date 1 jar of grape jelly with no open date 1 container of pasta dated [DATE] with expiration date of [DATE] 1 bag of salad with no open date 1 bag of salad with use by dated of [DATE] On [DATE] at 9:40 A.M., the following were observed in the dry storage: 2 bags of dry noodles with no open date 1 box of potatoes with no open date 1 empty bread rack on the floor 1 moldy onion in a box with no open date On [DATE] at 9:50 A.M., the following was observed on a metal spice rack in the dry storage area: 1 bottle of Karo Syrup with no open date 1 bottle of Soy Sauce with no open date 1 container of Ground Mustard with a use by date of [DATE] 1 container of Lemon Pepper with no open date 1 jar of Pork Base with no open date 1 container of Basil with no open date 1 bottle of Honey with open date [DATE] 1 container of Sugar Sprinkles with no open date On [DATE] at 11:25 A.M., during a second kitchen observation the following were observed under the metal preparation table in the center of the kitchen: Flour bin with open date [DATE] and use by date of [DATE] 1 container of Leaf Basil with no open date During an interview on [DATE] at 9:40 A.M., the dietary manager indicated containers should be dated with open date and there should be no expired items in the refrigerator. On [DATE] at 10:30 A.M., the Administrator provided a current policy Food Storage revised ,d+[DATE]. The policy indicated .Left over prepared food .must clearly be labeled with the name of the product, the date prepare, and marked to indicate the date by which the food shall be consumed .left overs can be held .for no more than 3 days .Dry Storage containers should be labeled on and dated on both the container and the lid . 3XXX,d+[DATE](i)(2) 3XXX,d+[DATE](i)(3)

Based on record review and interview, the facility failed to follow pharmacy recommendations for 1 of 1 residents reviewed for hospice services. (Resident 58) Finding includes: On 1/3/25 at 2:53 P.M., Resident 58's clinical record was reviewed. Diagnoses included, but were not limited to, Alzheimer's disease. The most recent Significant Change Minimum Data Set (MDS) Assessment, dated 12/30/24, indicated Resident 58 was completely dependent on staff (staff do all of the work) for toileting, bathing, and transfers. Current physician orders included, but were not limited to: lorazepam (antianxiety medication) tablet; 0.5 mg (milligram) oral every 30 minutes as needed, Start date 11/28/24. hyoscyamine sulfate (muscle relaxant) tablet; 0.125 mg oral every two hours as needed, Start date 9/27/24. morphine concentrate (pain medication) solution 10 mg/0.5 mL (milliliter) every 15 minutes as needed, 9/30/24. A nursing progress note dated 12/19/24 at 2:40 P.M., indicated hospice services would be discontinued on 12/23/24. Resident 58 received the following medications after discharge from hospice on the following dates and times: 12/25/24 4:24 A.M. lorazepam tablet 0.5 mg 12/24/24 9:28 A.M. morphine concentrate 0.5 mL 12/26/24 5:05 A.M. morphine concentrate 0.5 mL A pharmacy consultation report, dated 12/24/24, indicated the pharmacist requested clarification on medications currently prescribed to Resident 58, stating if hospice had been discontinued to obtain orders to discontinue hospice related orders for lorazepam, hyoscamine, and morphine. The clinical record lacked physician review of the pharmacist recommendations. During an interview on 1/8/25 at 2:20 P.M., the Director of Nursing indicated Resident 58 no longer received hospice services. On 1/9/25 at 10:38 A.M., the Administrator provided a policy titled Medication Regimen Reviews and Pharmacy Recommendations, revised 10/2018, that indicated The consultant pharmacist recommendations will be reviewed by the Director of Nursing and the attending Physician will be notified promptly of any recommendations needing immediate attention. On 1/9/25 at 10:38 A.M., the Administrator provided a policy titled Psychotropic Management, revised 9/24, that indicated PRN (as needed) orders for psychotropic drugs are limited to 14 days unless it is deemed appropriate to use longer by the physician or prescribing practitioner. The prescriber must document their rationale in the medical record including the duration (this does not apply to PRN anypsychotic medication which must be evaluated every 14 days). 3.1-25(i)

Based on interview and record review, the facility failed to accommodate a resident's choice of funeral home for 1 of 1 residents reviewed for death (Resident 218). A resident's body was released to a funeral home that was not designated as the resident's choice. Finding includes: On [DATE] at 10:37 A.M., Resident 218's clinical record was reviewed. Diagnoses included, but were not limited to, intellectual disabilities. The Death in Facility Minimum Data Set (MDS) Assessment indicated Resident 218 died at the facility on [DATE]. Physician orders included, but were not limited to: May release remains to funeral home of choice, dated [DATE]. Resident 218's facesheet listed (name of Crematorium) as the resident's preferred funeral home. A nursing progress note, dated [DATE] at 5:24 P.M., indicated the resident was found without respirations or pulse in her room, and (name of Crematorium) would be called when the family was ready. A nursing progress note, dated [DATE] at 6:56 P.M., indicated (name of Crematorium) was called. A nursing progress note, dated [DATE] at 8:50 P.M., indicated (name of Crematorium) left the building with Resident 218. The Burial Transit Permit, dated [DATE], indicated authorization was granted to release the remains to (name of Crematorium). It indicated that the individual that picked up the remains at the facility was from (name of Funeral Home). During an interview on [DATE] at 9:20 A.M., Resident 218's Health Care Power of Attorney (POA) indicated that she left the faciity on [DATE] after Resident 218 died and before the resident's remains were picked up. On [DATE], she called (name of Crematorium) to make arrangements for the resident and was told they did not have Resident 218's body and had never received a phone call from the facility to pick up Resident 218's body. The POA called the facility to determine where Resident 218 had gone and they informed her that someone from (name of Crematorium) had picked up Resident 218 the night of [DATE], and they would need to investigate further. Resident 218's POA discovered where the resident had been taken when (name of Funeral Home) called later to make arrangements for Resident 218's body. The POA indicated the facility never noticed or caught that they allowed an unauthorized person to enter the building and to take Resident 218's body to an unapproved location. During an interview on [DATE] at 1:16 P.M., Registered Nurse (RN) 5 indicated that when a resident died , the nurse in charge got the preferred funeral home from the resident's facesheet or from the POA. Staff could look in a binder that contained all the funeral home numbers or search for the funeral home's phone number on the internet. During an interview on [DATE] at 2:51 P.M., the Director of Nursing (DON) indicated that the facility called (name of Crematorium) to pick up Resident 218, but (name of Funeral Home) picked up Resident 218. She indicated staff didn't look to confirm if the person picking up the body was the same person the body was authorized to be released to because Burial Transit Permits got signed as the body was leaving the facility. During an interview on [DATE] at 3:03 P.M., the general manager from (name of Crematorium) indicated they never received a phone call from the facility regarding Resident 218. She also indicated they do not share staff or an answering service with (name of Funeral Home). During an interview on [DATE] at 3:20 P.M., the general manager from (name of Funeral Home) indicated someone from the facility called their after-hours answering service on [DATE] to pick up Resident 218's body. She indicated they do not share staff or an answering service with (name of Crematorium). On [DATE] at 1:19 P.M., the Administrator provided a statement signed by the Administrator, dated [DATE], that indicated The paperwork our team filled out also showed [name of Crematorium] is the funeral home [name of facility] was releasing the body too [sic] and signed off by one of my RN's . The signature of the funeral home that picked up the resident did state he was from [name of Funeral Home] once he signed the paperwork and left with the resident. Our records show [name of Funeral Home] was never contacted nor even part of the resident's face sheet. On [DATE] at 10:40 A.M., the Administrator provided a Resident's Rights policy, dated ,d+[DATE], that indicated The Resident has a right to a dignified existence, self-determination and communication with, and access to, persons and services inside and outside the Facility . 3XXX,d+[DATE](u)(3)

Based on interview and record review, the facility failed to ensure notification to family or physician was provided for changes in condition for 2 of 3 residents reviewed for notification of change. (Resident 58 and Resident 218) Findings include: 1. On 1/3/25 at 2:53 P.M., Resident 58's clinical record was reviewed. Diagnoses included, but were not limited to, Alzheimer's disease. The most recent Significant Change Minimum Data Set (MDS) Assessment, dated 12/30/24, indicated Resident 58's cognition was too low to assess and was completely dependent on staff (staff do all of the work) for toileting, bathing, and transfers. A nursing progress note, dated 12/31/24 5:50 A.M., indicated staff found a 12 inch piece of cloth in Resident 58's stool while performing incontinence care, that Resident 58 had been eating pieces of his blanket. An Interdisciplinary Team (IDT) Behavior Review Note, dated 12/31/2024 09:22 A.M., indicated the root cause of Resident 58 eating his blanket was possible urinary tract infection (UTI) with increased confusion and labs were to be ordered. The clinical record, including progress notes, events, observations, and documents, from 12/31/24 at 9:22 A.M. until 1/8/24 at 3:15 P.M., lacked notification to family or physician regarding Resident 58 eating his blanket and pieces of blanket found in his stool, and lacked labs completed to rule out a urinary tract infection or intestinal blockage. During an interview on 1/8/25 at 2:20 P.M., the Director of Nursing (DON) indicated a urinalysis was not performed and no further follow up was documented because the blanket was removed from the resident's room. A nursing progress note, dated 1/6/25 at 4:10 A.M., indicated Resident 58 had congested coughing with coarse bilateral breath sounds in the upper lobes, oxygen saturation 90% on room air, and was afebrile. The clinical record, including progress notes, events, observations, and documents, 1/6/24 at 4:10 A.M. to 1/9/24 at 9:30 A.M., lacked notification to family or physician or follow up documented regarding Resident 58's change in condition. 48147 2. On 1/8/25 at 10:37 A.M., Resident 218's clinical record was reviewed. Diagnoses included, but were not limited to, intellectual disabilities. The most recent Quarterly Minimum Data Set (MDS) Assessment, dated 10/16/24, indicated Resident 218 was cognitively intact and required supervision of staff for transferring and toileting and setup assistance for eating. Care plans included, but were not limited to: Resident has been determined to be Intellectually Disabled, dated 5/8/24, with an intervention to involve family in care. Resident experiences short memory deficit with impaired decision making ability. Brief Interview for Mental Status (BIMS) score fluctuates, dated 5/12/24 A New Order Event Report, dated 8/5/24 at 2:20 P.M., indicated a new appointment with (name of Doctor) had been made for 8/19/24 at 9:00 A.M. to evaluate a probable cyst on Resident 218's left armpit. Resident 218's representative was notified of the appointment. A nursing progress note, dated 8/19/24 at 8:20 A.M., indicated the mass on Resident 218's left armpit had popped and was gone. The appointment scheduled for that morning was canceled. The clinical record lacked a progress note or event to indicate Resident 218's representative was notified of the canceled appointment or the change with the resident's mass in the armpit. During an interview on 1/3/25 at 9:20 A.M., Resident 218's representative indicated the facility did not notify her that the cyst in the resident's armpit had ruptured and the appointment was canceled. The representative indicated she found out about the missed appointment when she received a no show message from the Doctor. At that time, she indicated Resident 218 had an intellectual disability that caused the resident to be mentally equivalent to a five-year-old. During an interview on 1/8/25 at 1:16 P.M., Registered Nurse (RN) 5 indicated the nurse in charge would notify families about falls, change in condition, new orders, weight changes, wounds, new roommates, room changes, new appointments, and canceled appointments. All notifications to family were documented in the progress notes. During an interview on 1/9/25 at 1:19 P.M., the Administrator indicated staff would not notify a resident representative about an appointment cancellation if the resident's BIMS score was a 13 or higher (indicating no cognitive impairment) even if the resident's BIMS score fluctuated or the resident had an intellectual disability that hindered the resident's cognitive ability. On 1/9/25 at 10:40 A.M., the Administrator provided a Resident Change of Condition policy, dated 11/2015, that indicated It is the policy of this Community that changes in resident condition will be communicated to the physician and family/responsible party, and that appropriate, timely, and effective intervention occurs . The nurse in charge is responsible for notification of physician and family/responsible party prior to end of assigned shift when a significant change in the resident's condition is noted. If unable to reach the physician or family/responsible party, all calls to physicians or exchanges and family/responsible party requesting callbacks will be documented in the resident care notes. Document resident change of condition and response on the resident care notes and continue in the nursing progress notes if necessary. Documentation will include time and family/physician response. On 1/9/25 at 10:40 A.M., the Administrator provided a Resident's Rights policy, dated 11/2015, that indicated Every resident and the responsible party of his responsible family member of his guardian has the right to be fully informed of the resident's medical condition unless medically contraindicated and documented by a physician in the resident's medical record . The resident's responsible party or family member or his guardian shall be notified immediately of any accident, sudden illness, disease, unexplained absence, or anything unusual involving the resident . 3.1-5(a)(3)

Based on observation and record review, the facility failed to ensure infection control procedures were followed for hand washing technique for 1 of 1 observations of wound care. (Resident 13) Finding includes: On 1/3/25 at 2:16 P.M., Resident 13's clinical record was reviewed. The most recent Quarterly Minimum Data Set (MDS) Assessment, dated 11/22/24, indicated Resident 13 had one stage four pressure ulcer (full-thickness tissue loss with exposed bone, tendon, or muscle). Current physician orders included, but were not limited to: Coccyx Pressure Cleanse with wound cleanser, apply Hydrofera Blue (an antibacterial foam dressing used to pack deep wounds), Leave Hydrofera Blue to wound base for seven days, secure with bordered foam dressing. change foam dressing daily and as needed. Start date 1/3/25 During an observation on 1/8/25 at 9:15 A.M., Licensed Practical Nurse (LPN) 12 entered Resident 13's room and put a protective gown on. LPN 12 washed her hands for nine seconds, and put gloves on. Qualified Medication Aide (QMA) 7 was in room with gown on assisting Resident 13 rolled on her left side. LPN 12 opened packs of gauze and a dressing, sprayed wound cleanser to the coccyx wound, applied the dressing over the coccyx wound, and dated the dressing with a marker. LPN 12 removed her gloves, and washed her hands for seven seconds. QMA 7 removed her gloves and gown, and washed her hands for ten seconds. During an interview on 1/9/25 at 8:59 A.M., the Infection Prevention RN indicated hand hygiene should be performed for at least 20 seconds. On 1/9/25 at 10:38 A.M., the Administrator provided a policy titled Hand Hygiene Policy, revised 12/2021, that indicated American Senior Communities will follow the Center for Disease and Prevention (CDC) guidelines for the standards of hand hygiene. (Scrub your hands for at least 20 seconds) Five moments of hand hygiene - a term that describes the hand hygiene opportunities that prevent infection transmission linked to healthcare activities. Before touching a resident, before clean/aseptic procedure, after body fluid exposure risk, after touching a resident, after touching resident surroundings. 3.1-18(l)

Based on observation, record review, and interview, the facility failed to ensure that food was served at palatable temperatures for 1 of 1 trays tested for food temperature. Finding includes: On 11/15/23 at 11:56 A.M., the Regional Registered Dietician (RRD) checked the temperatures of the lunch food items that were on the holding table ready to be served. The following temperatures were recorded: Chicken salad sandwich - 32.4 F (Fahrenheit) Pureed chicken salad - 58 F Mashed potatoes - 143.5 F Burgers - 148.6 F Tomatoes - 42.4 F Lettuce - 51.5 F Tomato juice - 40.3 F Cucumber salad - 59.4 F Pudding - 48.2 F At that time, the pureed chicken salad, tomatoes, lettuce, tomato juice, cucumber salad, and pudding were put back in the refrigerator to chill. At 11/15/23 at 12:15 P.M., the RRD re-tested the following foods for temperature: Pureed chicken salad - 36.5 F Tomatoes - 40.8 F Lettuce - 40.4 F Cucumber salad - 40.2 F At that time, the pudding was not re-tested for temperature. At 11/15/23 at 12:33 P.M., Cook 3 started plating food to be served to the residents for lunch. At that time, none of the foods were re-tested for temperature. On 11/16/23 at 12:32 P.M., a test tray was obtained. Food temperatures for that meal were: Patty melt - 116.3 F Potato wedges - 108.2 F Watermelon - 62.4 F A filed resident grievance, dated 10/28/23, indicated breakfast was ice cold. On 11/16/23 at 2:00 P.M., Resident S, Resident L, Resident W, and Resident B indicated meals did not come on time and foods were not always hot. On 11/15/23 at 12:45 P.M., the RRD indicated the temperature for food should be below 41 F for cold foods and above 135 F for hot foods when plated. On 11/16/23 at 1:05 P.M., the Administrator provided a current Food Temperatures policy, revised 6/2023, that indicated hot foods that are potentially hazardous will be held for service at or above 135 F, and cold foods at or below 41 F . All hot and cold food items will be served to the residents at a temperature that is considered palatable at the time the resident receives the food. This citation relates to complaint IN00418254. 3.1-21(a)(2)

Based on observation, interview, and record review, the facility failed to ensure resident dignity was respected during a random dining observation for 1 of 2 dining rooms in use at the time of the survey. Findings include: 1. During a random lunchtime observation beginning at 12:10 P.M. in the Chandelier dining room on 11/13/23, Certified Nurse Aide (CNA) 6 placed a clothing protector on a resident and referred to it as your bib. 2. During a random lunchtime observation beginning at 12:10 P.M. in the Chandelier dining room on 11/13/23, CNA 6 stood while she assisted a resident sitting in a regular sized wheelchair to eat. 3. During a random lunchtime observation beginning at 12:10 P.M. in the Chandelier dining room on 11/13/23, CNA 6 answered her personal cell phone while assisting a resident to eat. On 11/16/23 at 10:19 A.M., the Administrator indicated staff should not refer to clothing protectors as a bib due to resident dignity. At that time, she indicated that staff should sit while assisting residents to eat, and that staff should not have their phones out or answer them while caring for residents. On 11/16/23 at 10:41 A.M., the Administrator provided a current Resident Rights, Privacy, Photographs, Cell Phone Usage and Investigation Cooperation policy, undated, that indicated to avoid disruptions and ensure productivity and focus on serving our residents, our facilities' employees are not to use their personal cellular telephone and other communications [sic] devices during working time for non-work purposes unless for emergency reason . Do not have your phone visible or headphones in resident care areas . This further includes .while in dining areas. 3.1-3(a)

Based on observation, interview, and record review, the facility failed to ensure posted nurse staffing sheets contained the correct information daily for 5 of 5 days reviewed during the survey. (11/13/23, 11/14/23, 11/15/23, 11/16/23, 11/17/23) Findings include: On 11/13/23 at 10:30 A.M., the Posted Nurse Staffing form was observed on Station One's nurse's desk dated 11/13/23. The sheet included, but was not limited to, the following information: Shift hours for RN (Registered Nurse), LPN (Licensed Practical Nurse), and CNA (Certified Nursing Assistant). Total number of RN, LPN, and CNA for each shift. Total hours of RN, LPN, and CNA for each shift The sheet did not specify which actual hours were worked by each discipline during the specified shift when the total hours were not equal to the number of staff or to which station they were assigned. On 11/15/23 at 8:28 A.M., the Administrator provided Daily Staffing Sheets dated 11/13/23, 11/14/23 and 11/15/23. The sheets included, but were not limited to, the following information: Shift hours for RN, LPN, and CNA. Total number of RN, LPN, and CNA for each shift. Total hours of RN, LPN, and CNA for each shift. The sheets did not specify which actual hours were worked by each discipline during the specified shift when the total hours were not equal to the number of staff or to which station they were assigned. During an interview on 11/15/23 at 10:30 A.M., the DON (Director of Nursing) and Scheduler indicated the Home Office will have to update the form since was created by them. It was filled out with the information that was listed on the form. At that time, new Daily Staffing Sheets were provided for 11/13/23, 11/14/23 and 11/15/23. The Daily Staffing Sheet was updated for 11/14/23 to include CNA working 10 A.M. to 2 P.M. on day shift and CNA working 2 P.M. to 6 P.M. on evening shift to explain the 12.5 listed under the Total Number of Unlicensed Nursing Staff on days and the 9.5 on evenings. The Daily Staffing Sheet was not updated to include if an RN or LPN worked a partial shift on evening shift to explain the 3.5 listed under the Total Number of Licensed Nursing Staff. The night shift was not updated to include if an RN or LPN worked a partial shift to explain the 2.5 listed under the Total Number of Licensed Nursing Staff. Daily Staffing Sheets for 11/13/23 and 11/15/23 were not updated. On 11/17/23 at 8:52 A.M., the Administrator provided Daily Staffing Sheets dated 11/16/23 and 11/17/23. The sheets included, but were not limited to, the following information: Shift hours for RN, LPN, and CNA. Total number of RN, LPN, and CNA for each shift. Total hours of RN, LPN, and CNA for each shift. The sheets did not specify which actual hours were worked by each discipline during the specified shift when the total hours were not equal to the number of staff or to which station they were assigned. During an interview on 11/17/23 at 9:06 A.M., the Administrator indicated the Daily Staffing Sheet comes from the Corporate Office and was the form they used. On 11/17/23 at 8:52 A.M., the Administrator provided a Posted Nurse Staffing policy, revised on 7/2023, which indicated .10. The nurse staffing data should be in a clear and readable format .

Based on observation, interview, and record review, the facility failed to ensure staff posting was accurate for 2 of 2 days observed during the survey. Finding includes: During an observation on 6/7/23 at 2:00 p.m., the daily staffing schedule observed at the nurses station, reflected the number of staff members and hours worked, but lacked the resident census. During an observation on 6/8/23 at 2:00 p.m., the daily staffing schedule observed at the nurses station, reflected the number of staff members and hours worked, but lacked the resident census. On 6/8/23 at 11:36 a.m., QMA 1 indicated the daily staff posting is put out every morning, it has how many nurses and CNA's are working and how many hours they are working that day. QMA 1 indicated she did not know the resident census was supposed to be included, she was just told it needed to be included. On 6/8/23 at 11:38 a.m., the Administrator provided the current policy on posted nurse staffing requirements with an original date of 7/2019. The policy included, but was not limited to: 1. The facility must post the following information at the beginning of each shift. b. Resident census. This Federal tag relates to Complaint IN00409945 and IN00405313.

Based on observation, interview, and record review, the facility failed to ensure a safe, comfortable, and sanitary environment was maintained in 7 of 7 resident halls/rooms. Bedside tables and walls were scratched and scuffed, debris was on the floor of resident rooms, water was observed in a resident bathroom floor, resident bathrooms observed with uncovered briefs and toothbrushes, and paper towels were observed sitting on a sink. (Room 304, Room 305, Room 303, Room 306, Room 223, Room 110, Room 221) Findings include: 1. On 4/4/22 at 10:05 A.M., Room 304 was observed with a bedside table that was scuffed and rough on two of four side edges. Another bedside table was observed with cup marks and a sticky substance on the surface. A baseboard was observed on the floor behind the beds, and a glove was observed wadded up on the floor in between the two beds. On 4/5/22 at 9:34 A.M., Room 304 was observed with bedside tables and baseboard in the same condition as the day prior. A wadded up glove was observed again on the floor in between the two beds. On 4/6/22 at 12:24 P.M., Room 304 was observed with the same bedside table that was scuffed and rough on two of the four side edges. The baseboard was observed still on the floor behind the beds, and a wadded up glove was on the floor in between the two beds. 2. On 4/4/22 at 9:07 A.M., Room 305 was observed with the bed unmade, and a yellow substance on the sheet. The wall rail behind the bed was observed with chipping in three places. The bathroom was observed with paper towels sitting on the sink and the paper towel holder was empty. The toilet base was observed with a thick black substance around it, and a puddle of water was observed behind the right side of the toilet. On 4/6/22 at 12:21 P.M., Room 305 was observed with the same chipping of the wall rail, and the bathroom was observed with paper towels still sitting on the sink with an empty paper towel holder. The toilet base was observed with the same thick black substance around it, and a larger puddle of water was observed behind the toilet on the right side. 3. On 4/4/22 at 9:28 A.M. Room 303 was observed with an uncovered and unlabeled toothbrush on the sink in the bathroom. A small hole (about the side of an eraser) was observed in the wall under the toilet paper holder, and the bottom of the bathroom door was scuffed. A handrail in the room was observed with the end covers hanging off, and not attached. On 4/6/22 at 12:23 P.M., Room 303 was observed with the same hold in the bathroom wall, and the bathroom doors were still scuffed at the bottom. The handrail in the room was still observed with the end covers not attached and hanging. 4. On 4/4/22 at 9:23 A.M., Room 306 was observed with scuff marks on the bottom of the bathroom doors. On 4/6/22 at 12:22 P.M., Room 306 was observed with the same scuff marks on the bottom of the bathroom doors. 5. On 4/4/22 at 9:47 A.M., Room 223 was observed with an incontinence brief sitting on the back of the toilet. Several scratches with pieces of the wall missing were observed behind the recliner. On 4/6/22 at 12:27 P.M., Room 223 was observed with the same scratches and pieces of wall missing. An incontinence brief was observed sitting on the bathroom sink, as well as an open pack of wipes. On 4/6/22 at 2:40 P.M., Resident Council meeting minutes were provided with the following concerns: 10/7/21: Rooms not getting cleaned on weekends or cleaned good when they do clean them 12/9/21: Resident state their rooms are not getting cleaned 1/6/22: Rooms not getting cleaned or cleaned good During an interview on 4/7/22 at 10:57 A.M., HK 15 (housekeeper) indicated the messiest resident rooms were cleaned every day, and all other rooms were cleaned every other day. She indicated when cleaning the rooms, the trash was emptied, all surfaces wiped down, and floors cleaned. She indicated the bathrooms were wiped down as well, and the bathroom floors swept and mopped as needed. During an interview on 4/7/22 at 11:02 A.M., the Maintenance Supervisor indicated he looked for repairs several times a day. He indicated any time something needed repair, staff filled out a maintenance slip and brought to him. He further indicated he was unaware of any room concerns listed above. During an interview on 4/7/22 at 11:09 A.M., RN 7 (registered nurse) indicated all resident toothbrushes should have been kept in totes in the resident rooms, and should not have been in the bathroom. 6. During an observation on 4/5/22 at 8:15 A.M., in Room 110, the privacy curtain track was loose and hanging down from the ceiling, the track had a build up of dust, the ceiling vent had a build up of dust, walls were chipped and scuffed next the to bed and near the room doorway, one light was missing a pull chain and did not function, the other light above the bed had one bulb not functioning, and the restroom floor was spotted with small white paper flecks. During in interview on 4/5/22 at 8:05 A.M., Resident 221 indicated the first evening they were in the room (4/1/22), the commode overflowed and that maintenance had not been in to inspect it. During an observation on 4/7/22 11:27 A.M., in room 110, the privacy curtain track was loose and hanging down from the ceiling, the track had a build up of dust, the ceiling vent had a build up of dust, walls were chipped and scuffed next the to bed and near the room doorway, one light was missing a pull chain and did not function, the other light above the bed had one bulb not functioning, and the restroom floor had small white paper flecks remaining. During an interview on 4/7/22 at 2:30 P.M., the Maintenance Director indicated not being aware of every issue in room 110, but had a stack of work orders to get to and that they were behind on repairs. On 4/7/22 at 11:13 A.M., a current non-dated cleaning guideline was provided and indicated DAILY Resident rooms: Clean and disinfect restroom, replenish soap paper towels and toilet tissue, clean/disinfect horizontal surfaces including commonly touch items, clean over bed light and bedside table, remove refuse/clean container/replace liner, sweep and mop floor vacuum carpet if applicable On 4/7/22 at 2:39 P.M., a current Maintenance Work Orders policy, dated 11/15, was provided and indicated Work orders for maintenance needs shall be used to maintain effective communication and tracking 3.1-19(f)

Based on observation, interview, and record review, the facility failed to ensure MDS (Minimum Data Set) assessments were accurate for 1 of 5 residents reviewed for accidents. A significant change MDS was not completed for a resident who had a significant change after a fall with fracture. (Resident 21) Finding includes: On 4/4/22 at 9:21 A.M., Resident 21 was observed sitting in the common area in a wheelchair. On 4/4/22 at 9:27 A.M., Resident 21 was observed sitting in the common area in a wheelchair. On 4/5/22 at 11:20 A.M., Resident 21's clinical record was reviewed. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The most recent MDS (Minimum Data Set) Assessment, dated 1/20/22, was a quarterly assessment and indicated Resident 21 required limited assistance of one (1) staff for bed mobility, transfers, eating, toileting, and bathing. A fall on 2/12/22 resulting in a femoral fracture included, but was not limited to, the following notes: 2/12/22 2:01 PM Resident yelling for help when staff entered room resident sitting propped against bathroom door. External rotation right leg noted. Resident reported she fell and her right leg hurt. Unable to move resident r/t [related to] to pain. Vitals obtained, physician notified and order gave to send out. [ambulance] transporting to [hospital] 2/14/22 8:46 AM Spoke with family regarding her fall over the weekend. She had surgery yesterday and had been up and walking yesterday. Daughter said they may discharge her Tuesday at the earliest back to the facility. They will keep us updated Resident 21 was readmitted to facility 2/16/22. The admission observation assessment, dated 2/16/22, indicated Resident 21 required a 2 person facility staff assist for transfers, and pain limits independence with at least one (1) ADL (activities of daily living), as well as limits day to to day activities. A functional assessment 5 day, completed 2/22/22, indicated Resident 21 required assist of 2 for toileting and bathing. Progress notes included, but were not limited to, the following: 2/17/22 5:30 AM Resident requires assist of 2 for ADLs/transferring/bathing/grooming/hygiene . Resident was in moderate pain throughout the shift, due to right hip fracture/surgery, especially when moved/moving for care 2/19/22 9:33 AM Resident requires assistance x2 [two person] for ADLs/transferring/bathing/grooming/hygiene . 2/20/22 9:35 AM Resident requires assistance x2 for ADLs/transferring/bathing/grooming/hygiene . 2/23/22 12:33 AM Resident x2 assist for ADLs/transferring/bathing/grooming/hygiene . 3/26/22 04:54 AM Resident requires maximum assist X 2 with transfers and toileting; up in w/c and requires staff to propel w/c [wheelchair] . On 4/6/22 at 8:32 A.M., LPN 4 and RN 9 were observed to assist Resident 21 with toileting. When assisted up from the wheelchair, Resident 21 did not attempt to bear weight on or move the right leg. During an interview on 4/6/22 at 8:43 A.M., LPN 9 indicated Resident 21 wandered a lot before her fall on 2/12/22. She indicated Resident 21 was up by herself all the time walking around. During an interview via phone on 4/7/22 at 9:52 A.M., the Regional Consultant indicated a significant change MDS should be completed after a return from the hospital with a fracture if that resident were to have a decline in two (2) or more areas of functional status such as bed mobility, transfers, or toileting. She indicated the IDT (interdisciplinary team) would determine if there were a change in status, then trigger a significant change MDS to be completed. During an interview on 4/8/22 at 6:25 A.M., the DON (Director of Nursing) indicated a significant change MDS should have been completed for Resident 21 after the fall on 2/12/22. On 4/7/22 at 11:38 A.M., a current Significant Change in Status Assessment policy, dated 10/2019, was provided, and indicated a significant change assessment should be completed by the IDT for any resident that returns from the hospital to establish a new baseline, and may take up to 14 days to determine if criteria are met for a decline in status. 3.1-31(d)(3)

Based on observation, interview, and record review, the facility failed to ensure treatment and care were provided in accordance with professional standards for 1 of 2 residents reviewed for skin conditions. A resident's dressing was not changed per physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . (Resident 21) Finding includes: On 4/4/22 at 9:21 A.M., Resident 21 was observed sitting in a common area in a wheelchair, wearing a shirt that exposed the arms. A bandage was observed on the left elbow, dated 3/30/22. On 4/5/22 at 9:27 A.M., Resident 21 was observed sitting in a common area in a wheelchair. With the assistance of RN 3, a bandage was observed on the left elbow, dated 4/4/22. At that time, RN 3 indicated she had changed it the previous day. On 4/6/22 at 10:00 A.M., Resident 21's clinical record was reviewed. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The most recent quarterly MDS (Minimum Data Set) Assessment, dated 1/20/22, indicated Resident 21 was severely cognitively impaired, and required limited assistance of one (1) staff for bed mobility, transfers, eating, and toileting, and required physical help with part of bathing of one (1) staff. Progress notes included, but were not limited to, the following: 3/30/22 12:01 PM Resident scratched self on the arm inflicting a skin tear inferior to left elbow while in the shower. Area cleansed with wc and covered with opti foam until healed. 4/5/22 9:38 PM This skin tear has healed. A skin event, dated 3/30/22, indicated Resident 21 had a left lateral inferior elbow skin tear that was noticed 3/30/22 when the resident scratched self in shower. The area measured 1.3 cm (centimeters) x 0.06 cm. Current physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] Cleanse with wound cleaner, apply opti foam q [every] 3 days until healed dated 3/30/22. Cleanse with wound cleaner, apply opti foam if soiled/dislodged PRN [as needed] until healed dated 3/30/22. A current care plan for impaired skin integrity: skin tear to left elbow, dated 3/30/22, indicated, but was not limited to, the following interventions: Assess for pain, treat as ordered. Notify MD of unrelieved/worsening pain Long sleeves Resident 21's MAR (medication administration record) and TAR (treatment administration record) for 3/2022 and 4/2022 indicated the left elbow dressing was changed on 4/2/22 and 4/5/22. No other dressing changes for the left elbow were documented. On 4/6/22 at 8:32 A.M., RN 9 was observed to change Resident 21's dressing on the left elbow. Prior to removing, the dressing was dated 4/4/22. When the dressing was removed, a clear, yellowish drainage was observed on the area surrounding the skin tear. At that time, RN 9 measured the skin tear at 1.9 cm x 0.6 cm [larger than original size]. The area was cleaned with wound cleanser, allowed to dry, and a clean foam dressing was placed. RN 9 dated the dressing 4/6/22. At that time, RN 9 indicated Resident 21's skin was fragile, and staff was supposed to encourage to wear long sleeve sweaters as to not further damage the skin. On 4/8/22 at 6:57 A.M., a current Dressing Change Clean Technique policy, dated 6/2021, was provided and indicated Verify resident and physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] 3.1-37(a)

Based on observation, interview, and record review the facility failed to ensure residents received necessary respiratory care and services in accordance with professional standards of practice for 1 of 1 residents reviewed for respiratory care. The facility failed to obtain an oxygen order, date tubing, and routinely service the oxygen concentrator for a resident on oxygen. (Resident 57). Finding includes: On 4/4/22 at 9:10 A.M., Resident 57 was observed sleeping in bed with oxygen on via nasal cannula. On 4/5/22 at 9:03 A.M., Resident 57 was observed in bed with oxygen on at 3 LPM (liters per minute) via nasal cannula. There were no visible dates on the tubing. At that time, the filter on the back of the oxygen concentrator was observed with a layer of dust. The oxygen concentrator lacked a date indicating the last time it was serviced. On 4/6/22 at 8:32 A.M., Resident 57 was observed in bed with oxygen on at 2LPM. On 4/7/22 at 7:11 A.M., Resident 57 was observed in bed with oxygen on at 2LPM, humidification on and dated 4/6, and O2 tubing dated 4/6/22. On 4/5/22 at 11:01 A.M., Resident 57's clinical record was reviewed. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The most recent admission MDS (minimum data set) Assessment, dated 3/17/22, indicated Resident 57 was severely cognitively impaired, and was not on oxygen. Current physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] May wear oxygen at 2 liter per NC to keep O2 sats above 90%. dated 4/5/22. Change oxygen tubing and humidity. Clean concentrator and filter. Once A Day on Sun. dated 04/6/22. Resident 57's clinical record lacked a care plan related to oxygen use. Progress notes included, but were not limited to, the following: 3/11/22 2:22 PM res [resident] arrived to facility [sic] via facility transport. res was oriented to room, staff, and cottage. family present. water at bedside. call light within reach. currently sitting in recliner. O2 on at 2L via n/c [nasal cannula]. initial assesments [sic] done. orders confirmed. skin check done. dietary notified of new res. therapy notified of n.o. [new order] to eval [evaluate] and tx [treat]. will cont [continue] to monitor 3/30/22 6:25 PM . Resident SOB [shortness of breath] noted, S O2 [oxygen saturation] 88, PRN verbal order for O2 2L [liters] nasal canula [sic] . 3/31/22 1:32 AM . SpO2 remains in the mid- to upper-nineties on 2L of supplemental O2. Will continue to monitor 4/1/22 12:41 PM .Continues supplemental oxygen at 2LPM per nasal cannula with oxygen saturation 92-95% . 4/2/22 08:14 PM .On supplemental o2 with sats 90-94% . 4/3/22 08:21 AM Upon room entry, pt found lying on his side, awake and talking. Oxygen was not turned off, not using at this time . Resident 57's vitals for oxygen use from 4/4/22 to 4/6/22 included the following: 4/4/22 6:00 AM oxygen in use at 3LPM. 4/4/22 7:54 PM oxygen in use at 3LPM. 4/5/22 3:10 PM oxygen in use at 2LPM. 4/6/22 7:42 PM oxygen in use at 2LPM. Resident 57's MAR (medication administration record) and TAR (treatment administration record) for 3/2022 and 4/2022 lacked documentation that oxygen was received. During an interview on 4/5/22 at 12:47 P.M., RN 3 (Registered Nurse) indicated an order was required for oxygen use. During an interview on 4/5/22 at 12:43 P.M., Resident 57 indicated had been using oxygen for more than one week. During an interview on 4/6/22 at 8:42 A.M., RN 5 indicated something had happened last Thursday (3/31/22) to require oxygen use for Resident 57. RN 5 further indicated oxygen concentrators were cleaned on night shift and nasal cannulas should be dated. RN 5 also indicated oxygen tubing was changed on Thursday nights and PRN, and those changes should have been documented in the resident's medical record. During an interview on 4/7/22 at 8:08 A.M., the Administrator indicated unsure of how often the oxygen concentrators were cleaned and serviced. During an interview on 4/7/22 at 8:37 A.M., the DON (Director of Nursing) indicated night shift cleaned and changed oxygen concentrator filters weekly and charted that in the resident's medical record. The DON further indicated an outside source serviced the oxygen concentrators weekly. On 4/7/22 at 1:15 P.M., an oxygen concentrator maintenance log from (outside source) was provided and indicated it was last serviced on 6/23/21. On 4/8/22 at 8:13 A.M., Resident 57's care plans were provided. A risk for ineffective tissue perfusion related to hypertension and [CONDITION(S)] careplan was revised on 4/6/22 to include PRN oxygen use. On 4/6/22 at 2:38 P.M., a current, undated, Oxygen Therapy and Devices policy was provided and indicated Oxygen is a drug which must be ordered by a physician .nasal cannula tubing should be changed out weekly and prn. On 4/8/22 at 6:57 A.M., a current General Dose Preparation and Medication Administration policy, dated on 1/1/13, was provided and indicated Document necessary medication administration/ treatment information on appropriate forms. On 4/8/22 at 6:57 A.M., a current Documentation Guidelines for Nursing policy, dated on 7/20, was provided and indicated Nursing to develop a care plan with new physician orders. 3.1-47(a)(6)

Based on observation, interview, and record review, the facility failed to ensure it was free from a medication error rate greater than 5% for 3 of 26 opportunities observed to administer medications correctly, resulting in an error rate of 11.54%. This affected 1 of 6 residents observed during medication administration. (Resident 35) Finding included: On 4/7/22 at 1:52 P.M., LPN 11 (licensed practical nurse) was observed to administer the following medications to Resident 35: [MEDICATION(S)] 7.5/325mg (milligram), 1 tablet [MEDICATION(S)] 20mg, 1 tablet [MEDICATION(S)] 20mg, 1 tablet The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] [MEDICATION(S)] ([MEDICATION(S)]-acetaminophen) tablet; 7.5-325 mg; amt: 7.5-325 mg; oral, three times a day at 5:00 AM, 12:00 PM, 8:00 PM, starting 5/23/19 [MEDICATION(S)] tablet; 20 mg; amt: 20 mg; oral, three times a day at 5:00 AM, 12:00 PM, 8:00 PM, starting 10/26/20 [MEDICATION(S)] tablet; 20 mg; amt: 20 mg; oral, twice a day at 5:00 AM, 12:00 PM, starting 4/25/18 During an interview on 4/7/22 at 2:06 P.M., RN 7 (registered nurse) indicated medications were allowed to be given one (1) hour prior to, and one (1) hour after administration times. On 4/8/22 at 6:47 A.M., a current General Dose Preparation and Medication Administration policy, dated 1/1/13, indicated Verify each time a medication is administered that it is the correct medication, at the correct dose, at the correct route, at the correct rate, at the correct time, for the correct resident . 3.1-48(c)(1)

Based on observation, interview, and record review, the facility failed to ensure food was stored, and served in a sanitary manner for 3 of 3 kitchen observations. Floors were sticky and had debris build up, equipment had debris build up. (Kitchen) Finding includes: On 4/4/22 at 9:03 a.m. during the initial observation of the kitchen, floors were sticky, had debris build up, the dry pantry storage room floor had debris build up, the top of the stove had food and grease build up, the stand ovens and steamer had debris build up around the doors and sides. The stairs leading to the kitchen had debris build up. On 4/6/22 at 11:24 a.m., the same was observed. On 4/7/22 at 10:40 a.m., the same was observed. On 4/7/22 at 10:42 a.m., the Assistant Dietary Manager indicated the kitchen floors are mopped daily, scrubbed once a week. On 4/7/22 at 11:01 a.m., the Assistant Dietary Manager provided the daily kitchen cleaning schedule. The daily schedule included, not limited to, stove/range- burner grates, and plates, surfaces, drip pans, Ovens- steamer wipe exterior, dry store room- sweep & mop floor, kitchen floors-sweep and mop. On 4/8/22 at 8:34 a.m., the Administrator provided the current policy for cleaning and sanitizing with a revision date of 10/17. The policy included, not limited to, cleanliness of kitchen is of utmost importance to ensure safe food handling and meal services. Work areas and floors will be kept clean and orderly. Each person will be responsible for what he or she uses. The food service manager shall post a cleaning schedule in the kitchen and assign cleaning responsibilities to assure timely cleaning of all areas and equipment. The majority of cleaning tasks will be completed by the cooks and food service staff. 3.1-21(i)(2) 3.1-21(i)(3)

Based on observation, interview, and record review, the facility failed to ensure infection control practices were maintained to mitigate the spread of COVID-19 for 1 of 2 new admissions reviewed observed in Transmission Based Precautions (TBP). A resident was not initially in isolation precautions according to the facility policy and staff failed to donn required PPE (personal protective equipment) before entering a resident's room on transmission based precautions. (Resident 221) Findings include: 1. During an observation on 4/4/22 at 9:30 A.M., Resident 221's room door was closed and had signage indicating the resident was in isolation and required Transmission Based Precautions (TBP). During an interview on 4/4/22 at 9:35 A.M., RN 16 indicated Resident 221 was in isolation due to being recently admitted and being unvaccinated against COVID-19. During an interview on 4/ 5/22 at 9:05 A.M., Resident 221 indicated they admitted to the facility on [DATE] (Friday) but were not put in isolation until 4/4/22 (Monday). During an interview on 4/6/22 at 11:28 A.M., LPN 11 indicated they worked over the weekend of 4/2/22 and 4/3/22 and that Resident 221 was not in isolation. During an interview on 4/7/22 at 2:30 P.M., the Facility Administrator indicated there was some miscommunication that lead to Resident 221 not initially being placed in isolation with transmission-based precautions. During record review on 4/5/22 at 11:22 A.M., Resident 221's Admission Observation, dated 4/1/22, indicated Resident 221 was alert and oriented. Resident 221's vaccination status indicated the resident had refused the COVID-19 vaccine. Resident 221's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 2. On 4/6/22 at 8:40 a.m., CNA 1 was observed to put on a gown and gloves before entering Resident 221's room which was on droplet transmission based precautions for new admit unvaccinated for COVID-19. CNA 1 had on a surgical mask and face shield. On 4/6/22 at 8:50 a.m., CNA 1 indicated when entering a transmission based precaution yellow room for COVID-19 the required PPE (personal protection equipment), is a face shield, mask, gown and gloves. CNA 1 was queried on what type of mask should be worn. CNA 1 hesitated, looked at the stop sign hanging on the door of Resident 221, and indicated It says N95. On 4/7/22 at 10:00 A.M., the Facility Administrator supplied a facility policy title, COVID-19 Resident Policy, dated 3/23/22. The policy included, 1. New Admissions or Re-admissions to facility . i. New admissions/re-admissions that are not up to date should be observed in TBP, yellow zone for full 10 days even if they have negative test . On 4/7/22 at 10:51 a.m., the Administrator provided the current policy on transmission based precautions with a revision date of February 2022. The policy included, not limited to, droplet/contact precautions (formally known as droplet plus precautions): is used to designate transmission-based precautions beyond droplet precautions for residents who meet the criteria for transmission based precautions associated with COVID-19, which includes the use of N-95 respirator. 3.1-18(b)(1)

Based on observation, record review and interview, the facility failed to ensure residents received showers as scheduled for 3 of 3 residents reviewed for showers. ( Resident B, Resident C, Resident D) Findings include: 1. During a review of Resident B's clinical record on 5/10/21 at 9:16 a.m., it indicated Resident B was cognitively intact. Resident B's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A discharge, return not anticipated MDS (Minimum Data Set Assessment), dated 4/23/21, indicated Resident B required supervision with bed mobility and limited assistance of 1 with transfers, dressing, toileting, and hygiene. It further indicated bathing had not occurred. Resident B was always continent of bowel and bladder. Resident B's care plans included, but were not limited to, Resident requires assistance with toileting due to: frequent falls, impaired vision, weakness, fatigue, unsteady gait, and [CONDITION(S)]. Interventions included, but were not limited to, assess and document skin condition weekly and as needed, assist with elimination, observe for signs of urinary tract infection. Start date: 4/19/21 Resident requires assistance with ADLs including bed mobility, transfers, eating and toileting related to: hepatic [CONDITION(S)], Type 2 diabetes mellitus, intervertebral disc degeneration, depression, [CONDITION(S)] of liver, [CONDITION(S)], and [CONDITION(S)]. Interventions included, but were not limited to, assist with ambulation as needed, assist with bathing as needed per resident preference, offer showers two times a week, partial bath in between. Start date: 4/19/21. Reviewed Resident B's showers for 4/19/21- 4/23/21. Resident B was discharged on [DATE]. 4/19- nothing 4/20- nothing 4/21- nothing 4/22- nothing 4/23- nothing The clinical record lacked documentation of refusals of showers or bed baths. During an interview on 5/10/21 at 8:50 a.m., Resident B's family indicated they had been visiting with the resident daily from 8 a.m.- 6:30 p.m., and the resident had never been approached by staff for a shower. They further indicated they had asked for her to have a shower and had spoken with the Administrator and were told she had refused showers. 2. During a review of the clinical record for Resident C on 5/10/21 at 9:56 a.m., it indicated Resident C was cognitively intact. Resident C's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An Admission MDS, dated [DATE], indicated Resident C required limited assistance of 1 for ADLs (activities of daily living) and physical help in part of bathing. Resident C was continent of bowel and bladder. Resident C's care plans included, but were not limited to, Resident requires assistance with ADLs including bed mobility, transfers, eating and toileting related to: weakness, limited mobility, recent hospitalization , urinary tract infection, generalized [CONDITION(S)]. Interventions included, but were not limited to, assist with ambulation as needed, assist with bathing as needed per resident preference. Offer showers 2 times per week, partial bath in between. Start date: 4/28/21. Resident C was scheduled for showers on Tuesdays and Fridays. A review of Resident C's showers from 4/27/21- 5/9/21 indicated, 4/27 partial bed bath Shower day 4/28 partial bed bath 4/29 partial bed bath 4/30 shower Shower day 5/1 partial bed bath 5/2 partial bed bath 5/3 nothing Mon 5/4 partial bed bath Shower day 5/5 partial bed bath 5/6 partial bed bath 5/7 shower Shower day 5/8 partial bed bath 5/9 partial bed bath Resident C received two showers during the time period. Did not receive showers on her scheduled Tuesday shower day. Resident C did not receive a partial bath on 5/3/21. Resident C's clinical record lacked refusals for showers or bed baths. 3. During a review of Resident D's clinical record on 5/10/21 at 10:38 a.m., it indicated Resident D was cognitively intact. Resident D's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An annual MDS, dated [DATE] indicated Resident D required extensive assistance of 1 for bed mobility, transfers, and toileting and limited assistance of 1 for dressing, and physical help in part of bathing. Resident D was frequently incontinent of bowel and bladder. Resident D's care plans included, but were not limited to, Resident requires assistance with ADLs including bed mobility, transfers, eating and toileting related to: [CONDITION(S)], [CONDITION(S)], depression, GERD, weakness, [CONDITION(S)]. Interventions included, but were not limited to, assist with ambulation as needed, assist with bathing as needed per resident preference. Offer showers 2 times a week with a partial bath in between. Start date: 4/5/19, revised 4/12/21. Resident D was scheduled for shower days on Sundays and Wednesdays. A review of Resident D's showers from 4/10/21- 5/9/21 indicated, 4/10 partial bed bath 4/11 partial bed bath Shower day 4/12 partial 4/13 nothing 4/14 partial bed bath Shower day 4/15 nothing 4/16 partial bed bath 4/17 partial bed bath 4/18 partial bed bath Shower day 4/19 partial bed bath 4/20 partial bed bath 4/21 partial Shower day 4/22 shower 4/23 nothing 4/24 partial bed bath 4/25 nothing Shower day 4/26 partial bed bath 4/27 partial bed bath 4/28 partial bed bath Shower day 4/29 partial bed bath 4/30 nothing 5/1 partial bed bath 5/2 partial bed bath Shower day 5/3 nothing 5/4 partial bed bath 5/5 shower Shower day 5/6 partial bed bath 5/7 nothing 5/8 nothing 5/9 nothing Shower day Resident D received a shower on only one of his shower days. During an interview on 5/10/21 at 9:10 a.m., CNA 1 indicated showers usually get done on her shift, unless it is a really busy day then it rolls to the next shift. There is plenty of staff to complete tasks. If a resident refuses a shower, staff goes back up to 5 times during the shift to ask again. If the resident still refuses they have them sign a shower sheet that is kept in a shower binder, but it is not scanned into the clinical record. They document the type of bath and if it was given or refused in the point of care in the clinical record. During an interview on 5/11/21 at 7:50 a.m., the Director of Nursing indicated staff was to document in the electronic health record the type of bath/shower given. They also fill out shower sheets that are kept in a binder at the nurses' station and at the end of the month they are placed into a file. They are not scanned into the clinical record or kept with the individual resident's clinical record. During an interview on 5/11/21 at 9:00 a.m., the Director of Nursing staff was to give partial baths with a.m. care every day the resident does not receive a shower/bath. This should be documented in the electronic health record. During a review of the current policy, Resident Rights, updated 3/15/17, provided by the Director of Nursing on 5/11/21 at 9:05 a.m., indicated, .You have the right to be informed, and participate in your treatment. This includes the right to: .Participate in the development of your person-centered plan of care .receive the services and/or items included in the plan of care. The facility lacked a specific written policy related to showers. This Federal tag relates to Complaint IN 463. 3.1-38(a)(3)

Based on observation, interview, and record review, the facility failed to provide supervision to prevent intrusive wandering on a dementia unit, resulting in resident to resident altercations. (Resident B) wandered into (Resident C's) room, urinating on the resident and causing bruising.; and wandered into (Resident D's) room, grabbing the hair and breast, and causing fear. Resident F repeatedly wandered into other residents' rooms, resulting in a co-resident grabbing her arm. This deficiency resulted in an Immediate Jeopardy. The Immediate Jeopardy began on 8/9/19 when Resident B wandered into Resident C's room, and urinated on the resident and grabbed the resident. The Administrator and Corporate Nurse were notified of the Immediate Jeopardy on 9/5/19 at 11:05 [NAME]M. The Immediate Jeopardy was removed on (MONTH) 9, 2019 but noncompliance remained at the lower scope and severity level of isolated, no actual harm with potential for more than minimal harm that is not Immediate Jeopardy. Findings include: 1. On 9/4/19 at 4:45 [NAME]M., during the initial tour, LPN 2 indicated there were 2 staff members working on the dementia unit, plus CNA 2 was providing 1:1 observation for a resident. On 9/4/19 at 4:50 [NAME]M., during the initial observation of the dementia unit, RN 2 and CNA 2 were observed at the nursing station. RN 2 indicated Resident B was requiring 1:1 observation, due to intrusive wandering. RN 2 added Resident B was challenging, and we needed an extra pair of eyes. RN 2 added that Resident D was alert and oriented, but that the facility did not know if she was mixed up at that time, and so added the 1:1 observation as a precaution. On 9/4/19 at 4:55 [NAME]M., Resident B's door was opened, and a door alarm sounded. CNA 2 responded from the nursing station, and indicated, There is a sensor at the door, and it will sound if he goes through the door. Resident B was asleep in bed at that time. On 9/4/19 at 6:35 [NAME]M., Resident D was interviewed. Resident D indicated, Last week, around 3:00 [NAME]M., he (Resident B) came in my room. He woke me up, and scared me. He grabbed my hair, and then he grabbed my breast. I told him to get out, but he wouldn't listen. So I grabbed my cane and told him to get out and he did. Resident D indicated she informed a staff member following the incident. Resident D indicated, I was pretty scared. But I think they handled it well. They have someone sitting with him all the time now. Resident D added that Resident B would periodically come into her room, and she would tell him to leave, but that he just couldn't remember and would do it again. On 9/4/19 at 6:55 [NAME]M., CNA 3 was interviewed. CNA 3 indicated there had been a staff member providing 1:1 care for Resident B, but that she had not seen anyone that morning yet. CNA 3 went to the resident's door, knocked on the door, and went into the room. No alarm sounded. CNA 3 indicated she did not know why an alarm didn't sound. On 9/4/19 at that same time, RN 3 indicated that Resident B had been on 1:1, but that he had been changed to 15 minute checks. While standing in the hallway, Resident B's door alarm sounded, and Resident B was observed to come out of his room. RN 3 indicated, Let's get your glasses, and went into Resident B's room alone. While she was in the room, Resident B opened Resident D's door and entered. Resident D was overheard to yell at the resident to Get Out. Resident B then went to the next room, and opened the door, and started to enter. RN 3 then came out of Resident B's bedroom, and escorted Resident B down the hall. On 9/4/19 at 7:20 [NAME]M., the Director of Nursing (DON) provided a facility room list, highlighting those residents considered interviewable. Resident D was considered interviewable. The clinical record of Resident B was reviewed on 9/4/19 at 7:30 [NAME]M. [DIAGNOSES REDACTED]. A Care Plan, initially dated 8/9/18 and updated 9/4/19 at 8:18 [NAME]M., indicated, Resident intrusively wanders into other residents (sic) rooms. The Approaches included: 8/30/19 Motion sensor to the entry door of the rooms. 8/28/19: Resident 1:1 from 6pm to 6am. 15 min checks 6am to 6pm. 8/28/19 wellness program such as take for a walk daily, active range of motion. 8/20/19 Offer resident math worksheet due to resident was a math teacher .8/20/19 Offer resident to watch sports on TV. 8/9/19 Toileted every 2 hours while awake and before bed. 8/9/19 Visual cues placed for bathroom and bedroom. Progress Notes included the following notations: 7/18/19 at 10:23 P.M.: .Oriented to person, confused to time, place and situation .Resident goes to doors that exit to other units, easily redirected. Requires limited assist x 1 per staff with ADLs (activities of daily living). 7/20/19 at 12:13 P.M.: Resident toileting in other residents' bathrooms, trash cans, an (sic) in bedrooms. Will continue redirection attempts. 7/28/19 at 3:13 [NAME]M.: Res (resident) easily redirected, wondering (sic) noted. 8/5/19 at 2:45 P.M.: .Resident has a BIMS (brief interview of mental status) of 6 which indicates resident is severely impaired .Resident often walks around looking for his wife 8/9/19 at 2:16 [NAME]M.: Resident had wandered into (Resident C's room), and (Resident C) came out into hallway yelling for staff, 'There is someone in my room.' Staff immediately entered room, and resident was laying in (Resident C's) bed. (Resident C) stated resident had 'Peed' on her and open handedly made contact to her left arm. (Resident C's) left arm is red, and upper gown wet with urine. (Resident B) was assist (sic) up out of (Resident C's) bed and returned to his room. Resident started on 15 minute checks 8/11/19 at 4:12 [NAME]M.: Res has been in and out of room, difficult to redirect. Gave snack and drink. Cont (continue) to walk floor .Will cont to monitor. On 9/4/19 at 9:15 [NAME]M., CNA 6 was interviewed. CNA 6 indicated on 8/11/19 at 12:00 [NAME]M.-12:30 [NAME]M., she was working on the dementia unit. Resident B needed to go to the restroom, so she helped him to the restroom and stood outside the room to provide privacy. She heard something in Resident C's room, which was next to Resident B's room. She entered Resident C's room, and saw Resident B standing next to Resident C, naked except for his pull-up. She could tell Resident C was upset, and escorted Resident B back to his room and got him dressed. Then she checked on Resident C; she indicated Resident C was agitated, and started swinging at her. She told Resident C, It's okay, he won't come back. 8/12/19 at 1:00 [NAME]M.: Res wandering aimless in and out of others room (sic), on call notified and stated put on 15 min (minute) checks. 8/13/19 at 1:33 P.M.: Spoke with wife at this time. Wife is agreeable to sending resident to (a behavioral health center). The resident was transferred to a behavioral health center on that date, and returned on 8/19/19. Progress Notes continued: 8/22/19 at 12:18 P.M.: Resident noted to have increased agitation and confusion. Resident verbally aggressive at this time toward staff .Contacted resident's wife, wife is coming in to visit with resident .Remains on 15 minute checks. 8/26/19 at 3:11 [NAME]M.: Res needs redirection often 8/27/19 at 5:16 [NAME]M.: 15 minute checks continue .Intrusive wandering easily redirected 8/28/19 at 5:53 [NAME]M.: Co-resident made allegations toward resident. Co-resident unable to stated (sic) exact time of incident. Resident noted to be sleeping in common area at approximate time of allegation and for approximately one hour prior On 9/6/19 at 9:15 [NAME]M., CNA 6 indicated on 8/28/19 she was getting ready to check Resident D's roommate, when Resident D stated, I'm scared. CNA 6 questioned the resident, and the resident told her Resident B had come into her room and he touched me. He touched my breast. CNA 6 indicated Resident D was alert and oriented, and had told her in the past that she was afraid of Resident B. And Resident D had peppermint candy in her room, and she had seen Resident B with peppermints in his mouth. CNA 6 indicated Resident B wandered into rooms during evening shift, and he was hard to watch. It was difficult to watch so many residents with behaviors. A Functional Maintenance Program Recommendation, dated 9/3/19 at 11:09 [NAME]M., included: Pt (patient) pleasant and agreeable most often but consistently confused. Pt demonstrates sundowning symptoms such as increased confusion, intrusive wandering, and combativeness with residents/staff .Pt requires nearly constant activity to decrease intrusive wandering and anxiety A Therapy Dementia Stages document, dated 9/3/19 at 11:09 [NAME]M., included: Environmental orientation: Poor. Pt unable to find room from dining room, unless cued from caregiver .Pt often intrusively wanders into others rooms. Resident does not cognitively comprehend the implications of this. REDIRECT RESIDENT IF HE ENTERS ANOTHER PERSONS ROOM. Progress Notes continued: 9/3/19 at 3:00 P.M.: (Recorded as Late Entry on 09/04/2019, 07:19 AM) IDT (interdisciplinary team) discussed residents (sic) 1:1 status and determined resident could be on 15 minute checks from 6a-6p and continue with 1:1 from 6p-6a due to resident is easily redirected throughout the day. On 9/4/19 at 9:20 [NAME]M., Resident B's room was observed to be located between Resident C and Resident D's room. Resident B's room had a private bathroom, and the bathroom was not accessible to Resident C or Resident D. Resident B would have to physically exit his room to the hallway, and then enter into the other residents' rooms. In a confidential interview, the interviewee indicated they had seen Resident B's hat in Resident D's room after the incident on 8/28/19, so they knew he had been in Resident D's room. 2. On 9/4/19 at 4:50 [NAME]M., during the initial tour of the locked dementia unit, RN 2 indicated Resident F had a behavior of wandering. Resident F was observed asleep in bed at that time. The clinical record of Resident F was reviewed on 9/4/19 at 1:15 P.M. [DIAGNOSES REDACTED]. A Care Plan, initially dated 4/22/19 and updated 9/4/19 at 8:22 [NAME]M., indicated, Resident intrusively wanders. Res becomes confused. The Approaches included: Assess for pain. Offer neck massage prior to res walking around looking confused. Offer to do residents (sic) hair when res appears lost or confused. Review expression with IDT for other possible contributing factors. Offer resident a snack or drink for redirection if res appears lost or confused. Progress Notes included the following notations: 6/2/19 at 4:42 [NAME]M.: Wandering up and down hallways, attempting to enter other residents (sic) rooms while they are sleeping, difficult to redirect. 6/9/19 at 3:00 [NAME]M.: Resident up multiple times during night. Wandering hallways, and attempting to enter other resident's room. Attempted to redirect, resident will stop and verbally say 'OK' when asking her not to enter other resident's room. Resident will then turn around and continue to wander down to rooms. Resident continues to wander after multiple interventions attempted and unsuccessful. 6/18/19 at 3:21 P.M.: Resident wandering in and out of rooms. Wandering in hall with pants dragging on floor on one ankle and panties on 6/22/19 at 2:44 [NAME]M.: .wandering the hallways attempting to go into other residents (sic) room. Redirected back to her room. 6/23/19 at 3:47 [NAME]M.: Resident up multiple times during the night, wandering up and down hallways. When staff attempts to redirect resident back to her room, resident .will continue to wander hallway. Resident attempted to enter other resident's room , and difficult to redirect 6/23/19 at 3:57 P.M.: .Pacing unit halls, in and out of other resident rooms .Attempts to redirect unsuccessful at this time. 6/23/19 at 8:18 P.M.: Resident continues to pace hallway, and in and out of other resident's room 6/24/19 at 8:37 P.M.: She has been pacing hallways, going in an (sic) out of other residents (sic) rooms .Attempts to eat other residents food/snacks that are sitting on table by them 6/27/19 at 7:28 P.M.: .Resident continues to wander hallway at this time, and enter into other resident's (sic) rooms. Resident difficult to redirect at times. 6/28/19 at 2:38 [NAME]M.: Resident up multiple times .Pacing hallways without cause, and entering other resident's rooms Resident difficult to redirect .began entering co-joining room, waking up residents that reside in room .Resident left alone at this time, and is in room. 7/1/19 at 4:36 P.M.: Currently going up and down hallways, going into other residents rooms, difficult to redirect at times 7/8/19 at 4:01 [NAME]M.: Resident up multiple times throughout the night. Entering other resident's rooms, and waking resident's up. Resident difficult to redirect at times .Interventions unsuccessful 7/9/19 at 10:30 P.M.: .Resident was wandering about unit into others rooms, but was easily redirected 7/18/19 at 5:21 [NAME]M.: Resident has been wandering intrusively, multiple times, this shift Resident wandered intrusively, and entering other residents room. Went into room [ROOM NUMBER], 304, and 308 and woke residents up .Interventions unsuccessful. Resident up at this time, wandering up and down hallway. Difficulty to redirect at time. 7/20/19 at 5:10 [NAME]M.: Resident has been wandering most of this shift .no interventions effective 7/22/19 at 5:25 P.M.: Resident continues to wonder (sic) into other rooms, redirection works only for a few minutes, then resident starts wondering (sic) in rooms again. 7/25/19 at 4:03 [NAME]M.: Resident has been wandering intrusively, multiple times, this shift .Went into other resident's room and woke residents up .Difficulty to redirect at time. An Incident Report, dated 7/28/19 at 5:20 P.M. and faxed to the Indiana State Department of Health, included: Brief Description of Incident: (Resident G) grabbed right wrist of (Resident F) during verbal altercation .Immediate Action Taken: Residents were separated. (Resident F), who had been wandering intrusively during the afternoon (sic). Interventions tried earlier .were not successful .Preventive Measures Taken: (Resident F) was placed on schedule for frequent check by staff 8/30/19 at 4:17 [NAME]M.: Resident up multiple times during N[NAME] (night) .Interventions non-successful The Immediate Jeopardy that began on 8/9/19 was removed on (MONTH) 9, 2019 when the facility completed staff education/inservices on 1:1 and wandering behaviors, created specific assignment sheets, and updated care plans. The Immediate Jeopardy was removed on (MONTH) 9, 2019 , but noncompliance remained at the lower scope and severity of isolated, no actual harm with potential for more than minimal harm that is not Immediate Jeopardy, because monitoring and inservicing would be ongoing. This Federal tag relates to Complaint IN 386. 3.1-45(a)(2)

Based on observation, record review, and interview, the facility failed to prevent an unstageable pressure ulcer for 1 of 3 residents reviewed for wounds. A resident was found to have an unstageable pressure ulcer on the posterior right heel. (Resident D) Findings include: On 6/28/18 at 10:05 a.m., Resident D was observed to be assisted into bed with the use of a Hoyer lift (a mechanical lift). After placing Resident D into bed, the CNAs were observed to place pressure relieving boots to the resident's bilateral feet, leaving the resident's socks on. The CNAs placed the resident's feet onto a wedge device. The CNAs then removed the resident's boots and socks and the resident's feet were observed. An area of black eschar (unstageable pressure ulcer (full thickness tissue loss in which the base of the ulcers were covered by slough (yellow, tan, green or brown) and /or eschar-tan, brown or black in the wound bed) was observed to be on the posterior side of the resident's right heel. The CNAs indicated the area was new and they would be alerting the nurse on the unit. The CNAs reapplied the resident's socks and pressure relieving boots back on and placed the resident's lower legs and feet back onto the wedge device. On 7/2/18 at 10:01 a.m., Resident D was observed to be lying in bed with socks and pressure relieving boots to the bilateral feet and calf areas. Upon removal of the resident's socks, an area of eschar was observed on the right heel. The Director of Nursing indicated she was not aware of the resident having the area and applied skin prep to the area. The clinical record for Resident D was reviewed on 7/2/18 at 8:12 a.m., Resident D had [DIAGNOSES REDACTED]. A significant change MDS (Minimum Data Set), dated 5/4/18, indicated the resident had severe cognitive impairment. The MDS indicated the resident was an extensive assist of 2 persons for bed mobility, totally dependent on 2 persons for transfers, and was total dependent of 1 (one) person for locomotion on and off the unit. The MDS indicated the resident was at risk for developing pressure ulcers. The MDS further indicated the resident used a pressure reducing device for bed, pressure ulcer care was provided, and an application of dressings were applied to the feet. A care plan, dated 1/2/18 and reviewed on 6/29/18, indicated the resident had skin impairment - Stage 2 (partial thickness loss of dermis presenting as a shallow open ulcer with a red pink ulcer bed without slough) to coccyx, left medial buttock and left buttock. Interventions included, but were not limited to, resident to wear pressure relieving boots while in bed to bilateral feet and assess wound weekly documenting measurements and description. A care plan, dated 8/22/12 and reviewed 6/14/18, indicated the resident was a risk for further skin impairment related to diabetes, extensive assist with bed mobility, incontinence of urine, and history of diabetic ulcer left calcareous, healed 7/5/17. Current wounds 3/18/18: readmitted with unstageable 2 Pressure area to coccyx area. Interventions included, but were not limited to, Low air loss mattress with settings per resident comfort, start date 4/3/18. Pressure relieving boots on feet while in bed, start date 3/22/18. Diabetic shoes, start date 1/18/18. CNA to do skin checks with showers and notify LN (licensed nurse) of abnormals, start date 8/22/12. Weekly skin check by LN, start date 8/22/12. A weekly skin assessment, dated 6/25/18 at 11:12 a.m., indicated the resident's bilateral feet were warm and dry with intact skin. No reddened or discolored areas were noted. A progress note, dated 6/30/18 at 12:12 p.m., indicated the resident was checked by the weekend wound round staff and pericare was provided. Resident turned side-to-side . Dressing to coccyx and adjacent area confirmed to be clean, dry, and intact. Would continue to monitor. A progress note, dated 7/1/18 at 1:08 p.m., indicated the dressing to the coccyx and adjacent area was confirmed to be clean, dry, and intact by the weekend facility wound care team. Nail care was provided and the resident would continued to be monitored. A progress note, dated 7/2/18 at 12:00 p.m., indicated an area was noted to the right heel. Skin prep and pressure reducing boots applied. The note indicated the physician was notified and new orders received. A Wound Management form, dated 6/28/18 at 2:38 p.m., indicated the resident had a Stage 2 pressure ulcer to the left buttock, a Stage 2 pressure ulcer to the left medial buttock, and a Stage 3 (full thickness tissue loss; subcutaneous fat may be visible but bone, tendon or muscle were not exposed, slough could be present but would not obscure the depth of tissue loss, and it could include undermining and tunneling) pressure ulcer to the coccyx. The clinical record lacked documentation of a wound to the right heel. On 7/2/18 at 10:15 a.m., the Director of Nursing indicated she oversaw all the wounds in the facility, but the resident's weekly skin checks were done by the nursing staff. She indicated the nursing staff should be notified if a new area was found by the CNAs. The current facility policy, dated 4/2018, and obtained from the Administrator on 7/2/18 at 3:30 p.m., indicated each resident would receive care, consistent with professional standards of practice to prevent pressure ulcers. The policy indicated any skin alterations noted by the direct care givers during daily care and/or shower days must be reported to the licensed nurse for further assessment. The Federal tag relates to Complaint IN 228. 3.1-40(a)(1) 3.1-40(a)(2)

Based on interview and record review, the facility failed to ensure complete assessments of wounds were completed, and dressing changes were completed as ordered to wounds on toes, resulting in hospitalization and treatment of [REDACTED]. Resident C Findings include: The clinical record of Resident C was reviewed on 11/6/17 at 9:50 A.M. [DIAGNOSES REDACTED]. A quarterly Minimum Data Set (MDS) assessment, dated 8/8/17, indicated Resident C scored an 11 out of 15 for cognition, with 15 indicative of no memory impairment. Resident C required extensive assistance of two+ staff for transfer, and did not ambulate. Resident C had no pressure or vascular wounds. A Care Plan, initially dated and revised 10/25/17, indicated, Problem, Resident is at risk for skin breakdown r/t (related to) decreased mobility, incontinent, extensive assist with bed mobility. The Approaches included: Assess and document skin condition weekly and as needed. Notify MD of abnormal findings. Nurses Notes included the following notations: 10/25/17 at 11:32 A.M.: Resident called this nurse to his room stating that he needed me to look at his toes. Res (resident) noted to have scraped his right foot, 2, 3, and 4th toes on the shower room wall. Res has a scab on each toe. Res states that they do not hurt, res foot noted to be slightly swollen, no warmth and no redness noted. Pedal pulses are present and strong at all points. MD notified by this nurse at this time, awaiting further orders. 10/25/17 at 5:50 P.M.: (Recorded as Late Entry on 10/26/2017 01:03 PM) Resident came to this nurse and stated the scab had partially came off his second toe and was bleeding. Area cleansed with WC (wound cleanser) and dry bandage applied 10/26/17 at 11:32 A.M.: (Recorded as Late Entry on 10/30/2017 01:38 PM) Scabs to right toes 2, 3, 4 examined and tx (treatment) applied to 2nd digit. Wound is moist with character change noted. Unit manager advised and in contact with physician with physician to review wound and examine resident later in shift with new orders pending examination. Resident denies pain to area but states area was dry yesterday. Resident continues [MEDICAL TREATMENT] and diabetic mgt (management). Resident had [MEDICAL TREATMENT] appointment earlier in shift and wearing his shoe to right foot. Unknown if this may account for excess moisture present r/t sweating .Will continue to monitor. 10/26/17 at 11:32 A.M.: Edited By: (RN 1) on 10/26/17 11:49 A.M. Reason: More data available. Resident (sic) 2nd toe very moist with sock and shoe removed and area cleaned. Scabs to other 2 toes cleaned .Will continue to monitor 10/26/17 at 12:00 P.M.: This nurse was called to res room by staff to look at his toes again, scab has came off the second toe completely, moderate amount of green drainage noted on toe, toe is also noted to be warm, red and swollen this am. Call placed to MD at this time, awaiting call back at this time 10/26/17 at 1:19 P.M.: (Recorded as Late Entry on 10/29/2017 01:22 AM) IDT (Interdisciplinary Team) Not (sic) for scabs on right foot 2, 3, 4, toes: Resident stated that he scuffed his toes in the shower room. Resident stated they do not hurt. Scabs dry and intact at this time. Resident transfers self in the shower room. Resident stated his foot slipped and hit the wall 10/26/17 at 1:22 P.M.: (Recorded as Late Entry on 10/29/2017 01:24 AM) Called into the room to look at residents (sic) 3rd toe. The scab has come off the toe part way and there is some drainage from it. His toe is also swollen at this time and warm to the touch. Unit manager was calling doctor. (Name of physician) was coming to see resident. 10/26/17 at 5:14 P.M.: (Recorded as Late Entry on 10/30/2017 11:24 AM) Resident examined by physician with new treatment orders. Physician did remove dressing for exam and resident currently eating and says he will let dressing be re-applied before bed. Next shift nurse advised .Resident reminded to elevate foot often as possible. 2nd digit to right foot wound moist from tx. Will continue to monitor. A Physician's note, dated 10/26/17 and untimed, indicated, This patient is seen, at the request of nursing, because of his right 2nd and 3rd toes. He apparently has had an abrasion to the dorsal (top) aspect at some undetermined time. There is now an eschar (black tissue), largest on the 2nd toe, but a smaller area noted to .the 3rd toe. There is no drainage at this time, it does appear to be clean. It looks as though nursing has applied [MEDICATION NAME]. I will ask them to cleanse the area with peroxide daily and then to use [MEDICATION NAME] (ointment) and to keep the area dressed. He does have shoes that may be a bit tight fitting. I am going to suggest that he wear socks and have the area dressed .I suspect that he is really not able to feel his feet. He does have pulses, but they are rather weak A physician's orders [REDACTED]. He should use socks rather than tight fitting shoes to avoid abrasion. A Treatment Administration Record (TAR), dated October 2017, was reviewed. The TAR indicated, Clean 2nd (and) 3rd toe (with) soap (and) water; pat dry, apply scant [MEDICATION NAME]/cover (with) 4 x 4 [MEDICATION NAME] and prn (as needed) soiling. The TAR indicated the treatment was to be performed daily. The TAR indicated the treatment was not performed on 10/26/17, 10/27/17, or 10/28/17. Documentation on 10/27 or 10/28 regarding the appearance of the resident's toes was not found in the clinical record. Th next documentation of the resident's wounds was not recorded until 10/29/17 at 7:29 P.M. Nurses Notes indicated: 10/29/17 at 7:29 P.M.: Residents (sic) toe found to be black and swollen during treatment to right foot. Scab noted on top of toe. Toe is blanchable. No drainage or odor noted from toe. Foot has +2 [MEDICAL CONDITION] (swelling) and is red. Resident denies hitting or injuring this toe recently. Resident is shaking and face appears flushed. Temperature is taken and is 101.2 .(Name of physician) notified of condition and new orders received to start [MEDICATION NAME] (an antibiotic) 750 mg x 7 days, XRAY of right foot and cbc (lab work) in am 10/30/17 at 3:25 A.M.: [MEDICATION NAME] 750 mg started at HS (bedtime) 10/30/17 at 7:39 A.M.: Resident found to be running a fever this am and upon attempting to examine foot dark skin noted to surrounding wound bed. Resident asked to elevate his foot as much as possible r/t poor circulation and change in wound character reported by night shift nurse .Resident transferred to ER and report called in. Will continue to monitor. A hospital history and physical, dated 10/30/17 at 12:52 P.M., indicated, Chief Complaint: Toe infection and fever. History: .past medical history notable for [MEDICAL CONDITION], end stage kidney disease on [MEDICAL TREATMENT], [MEDICAL CONDITION] .presents to the ED (emergency department) with complaints of fever and his toe being infected. He states about a month ago he was taking a shower and his (sic) started to bleed, once he looked at the toe he seen it had a sore on it. He lives at (name of nursing home) and his PCP (primary care physician) had given orders to monitor the area. Then last night he started to have chills and a fever. When asked the patient when he first noticed that his foot was red, he stated 'I don't know. I don't ever look at my feet.' He was started on [MEDICATION NAME] last night after his daughter called his doctor .He had his left foot removed in April of 2017 due to osteo[DIAGNOSES REDACTED] and had to be hospitalized in May due to the stump being infected. ER (emergency room ) MD noted dry Gangrene of toe .BKA ([MEDICAL CONDITION]) to LLE (left lower extremity), redness and warmth to left (sic) foot. Necrosis (dead tissue) to right second toe .Assessment/Plan: [MEDICAL CONDITION] (infection) of Right foot with gangrene in distal part of the right 2nd toe. Started on [MEDICATION NAME] (IV antibiotic) in the ED .consulted Vascular Surgeon On 11/8/17 at 9:00 A.M., during an interview with the Administrator and Interim Director of Nursing (IDON), the IDON indicated the resident requested to take showers by himself, and that is why he was in the shower room by himself. The IDON indicated they recognized that the treatments ordered by the physician for Resident C did not appear to be done for at least 3 days. They indicated they had done an investigation, and had inserviced staff regarding documentation of wounds and wound care. On 11/8/17 at 9:25 A.M., the Administrator provided the current facility policy, Skin Management Program, updated 9/2016. The policy included: 1. Alterations in skin integrity will be reported to the physician .2. Treatment order will be obtained. 3. All alterations in skin integrity will be documented in the medical record .All newly identified area (sic( after admission will be documented on the New Skin Event .The facility assigned wound nurse will complete further evaluation of the wounds identified and complete the appropriate skin evaluation on the next business day .5. Direct care givers will be notified of skin alterations and specific care needs. 6. IDT and/or designated wound nurse will review and document on any new alterations in skin integrity the following business day to determine root cause and implement wound/skin integrity healing interventions This Federal tag relates to Complaint IN 171. 3.1-37(a)

Based on observation, interview, and record review, the facility failed to ensure adequate supervision was provided to prevent falls; failed to ensure a gait belt was utilized to assist a resident with ambulation; utilized alarms in place of supervision, resulting in falls with head lacerations, cerebral bleeding, and a hip fracture, for 3 of 7 residents reviewed for falls, in a sample of 10. (Resident A, Resident D, Resident F) Findings include: 1. The closed clinical record of Resident A was reviewed on 6/1/16 at 9:50 A.M. [DIAGNOSES REDACTED]. A Significant Change Minimum Data Set (MDS) assessment, dated 12/3/15, indicated the resident scored a 9 out of 15 for cognition, with 15 indicating no memory impairment. The MDS assessment indicated Resident A required extensive assistance of two+ staff for bed mobility and transfer, and did not ambulate. A test for balance indicated the resident was Not steady, only able to stabilize with staff assistance while moving from a seated to standing position, moving on and off the toilet, and surface-to-surface transfer. Resident Progress Notes included the following notations: 12/5/15 at 3:13 A.M.: .Confusion at times. Assist of one with ADL's (activities of daily living) and transfers .Resident non compliant in calling for assistance. Pad alarm in place in bed and w/c (wheelchair) 12/7/15 at 4:25 A.M.: Resident attempting to get from bed to w/c without calling for assistance. Staff entered room upon hearing alarm and witnessed resident fall to bottom in a sitting position .Resident now up in w/c with pad alarm in place and 15 min checks .will continue to monitor. 12/7/15 at 10:05 A.M.: IDT (interdisciplinary team) met to review fall event .Prior to fall, resident was in bed .Spoke to resident this morning who stated he was trying to go to the bathroom .IDT recommend to continue pad alarm to bed and w/c along with floor mat at bedside. Encourage resident to call staff for assistance 12/11/15 at 2:30 A.M.: .Confusion increasing as witnessed by staff and family. Heavy Assist of one with ADL's and transfers. Resident transfer ability has declined .non compliant with calling for assistance. Pad alarm in place in bed and w/c. Resident has been folding pad alarm into side of w/c so it will not alarm and getting up without assistance 12/23/15 at 12:58 P.M.: .Decision making markedly impaired r/t (related to) disease process. Resident remains on fall precautions including pad alarm to w/c and bed .often non-complaint with safety instructions and often attempts to defeat his pad alarm 12/24/15 at 7:00 P.M.: .Resident continues to fold alarm in corner of w/c so it does not alarm when he tries to get up. Pad alarm to floor in place at bedside. Will continue to monitor. 12/25/15 at 7:00 P.M.: Fall in room. Resident found sitting at side of bed on buttocks leaning back against bed with pad alarm sounding .Stated he was trying to get extension cord off the end of the bed .Resident has dementia and is confused 12/25/15 at 9:55 P.M.: Resident has fallen attempting to get from his bed to his w/c. Has been confused today per previous RN. This is his second fall today .Has been anxious. Transferring to ER for laceration to back of his head and will move resident back to his old room by the nurses station upon return to facility. A Fall Event dated 12/25/15 at 9:55 P.M., indicated, Was fall witnessed, No .States he was getting up to his w/c from the bed and lost his balance. Supposed to call for help but is confused at times .Describe injuries .laceration to back of head approx 3.5 cm in length Documentation that an alarm was sounding was not found in the clinical record. Resident Progress Notes continued: 12/26/15 at 1:00 A.M.: Resident has returned from ER .He has staples in place to wound he received from falling. Resident has been moved back to his old room by the nurses station .Daughter is happy .states she was worried that he was too far away from nurses station. Pad alarm and floor alarm in place .Explained call light and instructed him to push his button if needing anything and especially if he needs to get up for any reason. States he understands but is forgetful and mostly pleasantly confused A Fall Event, dated 12/28/15 at 10:20 A.M., indicated, Was fall witnessed, No .Resident last seen in w/c. Describe the position of the resident when first observed after fall, Face down on floor .Describe location of the fall, In Resident room near heating unit .no difficulty in movement but does state he hurts unable to explain to the nurse due to impaired cognition. Did the resident hit his/her head, Yes .Laceration to R (right) eyebrow 4 cm laceration to R face 3 cm both approximated with steri strips. Knot noted to R forehead raised. Resident sent to ER for Eval (evaluation) and TX (treatment). Resident states I don't know when asked what happened A Hospital History and Physical, dated 12/28/15, indicated, Admitting Chief Complaint: Repetitive falls, weakness. History of Present Illness: The patient had a fall at the nursing home, was trying to get to the wheelchair, and he turned it over and hit the back of his head on Friday, December 25th. Was transported to the emergency room where a wound on the back of his head was closed with staples, cleaned up, and went back to the nursing home .The patient then again had another fall at the nursing home had a laceration of the right forehead 3 to 4 cm on right brow. Has had a change in his mental status .He has had recurrent falls over the last several months, but his recent falls have been more intense and more injurious .CT of the head did show a new hematoma (raised bruise) .to the right orbit, acute hemorrhage filling much of the left lateral ventricle with additional hemorrhage in the third and right lateral ventricle .Assessment: Recurrent falls; cerebral bleed inner ventricular; large hematoma of the right periorbital region with laceration; intraventricular hemorrhage .Multiple contusions secondary to his fall, laceration posterior occiput (back of head) On 6/2/16 at 10:50 A.M., during an interview with the Director of Nursing (DON), she indicated she was not employed by the facility during this resident's falls. She indicated she did not locate further documentation which indicated if the resident's alarm was sounding or not during the resident's falls. 2. The closed clinical record of Resident D was reviewed on 6/1/16 at 1:20 P.M. [DIAGNOSES REDACTED]. An annual MDS assessment, dated 4/13/16, indicated the resident scored a 10 out of 15 for cognition. The resident required extensive assistance of two+ staff for transfer, and extensive assistance of one staff for ambulation in room. A test for balance during transitions and walking indicated Not steady, only able to stabilize with staff assistance while moving from seated to standing position, walking, turning around, and surface-to-surface transfer. The resident had a history of [REDACTED]. Resident Progress Notes included the following notations: 4/12/16 at 4:10 A.M.: This nurse was at med cart, when I heard resident walker bumping into objects in room. Went to see what resident was doing, when out of corner of my eye saw resident going down. Resident landed on buttocks near bathroom. Asked resident if he need (sic) to go to restroom, when resident said yes .Resident did receive skin tear to left elbow region 4/13/16 at 11:33 A.M.: Resident found sitting on floor in room in front of restroom door with walker in front of him. When asked what happened resident stated he was trying to open the bathroom door. 1 skin tear noted to left thumb area cleaned and band aid applied 4/28/16 at 11:30 A.M.: Witnessed Fall: Resident observed by another nurse trying to transfer from bed to w/c and slipped forward landing on coccyx seated on floor in front of w/c .resident states his feet slipped The resident was transferred to the hospital on [DATE] and was admitted with a [DIAGNOSES REDACTED]. A Readmission Assessment, dated 5/5/16 at 6:30 P.M., indicated, .Balance:walking, Not steady, only able to stabilize with human assistance .Upper body weakness, Lower body weakness .Fall history: Has res (resident) had a fall any time in the last month, Yes .Does the resident express a fear of falling , Yes A Fall Event, dated 5/5/16 at 7:25 P.M., indicated, Resident was taken to the bathroom by CNA and on the way back to bed he was using his walker and the CNA was straightening his O2 (oxygen) tubing and she said his non-slip socks were not on properly and caused him to slip and he fell backward and hit his head on his roommates (sic) W/C .C/O (complains of) pain to right hip .Small open area to back of his head that had slight bleeding but has since stopped .He was just released from the hospital today and has been on IV fluids and antibiotics. Document any environmental factors observed in area of fall, non-slip socks not on properly. What intervention(s) was put into place to prevent another fall? new socks on, staff to use gait belt and stay behind resident when out of bed Progress Notes continued: 5/6/16 at 6:00 P.M.: (Recorded as Late Entry on 05/08/2016 06:45 PM) Witnessed Fall Follow Up: Resident neuro checks per baseline but resident is very fatigued and still complaining of moderate pain to right hip .X-ray ordered for resident with negative results 5/9/16 at 10:11 A.M.: Res still c/o R (right) hip. MD notified. CT scan ordered 5/10/16 at 10:57 A.M.: CT scan showed right hip fracture. Resident being admitted to (name of hospital). for surgery A hospital History and Physical, dated 5/11/16, indicated, .presented with a history of FALL AT TRHE (sic) NURSING HOME .He is being admitted for surgical management of this condition. The indications for this procedure included displaced IT (intertrochanteric) femur (hip) fracture On 6/2/16 at 10:50 A.M., during an interview with the Administrator and Director of Nursing (DON), the Administrator indicated that a gait belt was not used on Resident D during his transfer and ambulation. The DON and Administrator indicated that staff should utilize gait belts during transfers. The Administrator indicated Resident D had been fairly independent prior to his hospitalization for pneumonia. 3. On 6/1/16 at 8:35 A.M., during the initial tour of the locked Alzheimer's Unit, the DON indicated Resident F had a history of [REDACTED]. Resident F was laying in bed at that time. Documentation indicated the resident was treated for [REDACTED]. A Significant Change MDS assessment, dated 2/24/16, indicated Resident F was unable to complete a brief interview for memory, exhibited inattention and disorganized thinking, and required extensive assistance of two+ staff for bed mobility and transfer. The MDS assessment indicated the resident did not ambulate, and a test for balance during transitions indicated, Not steady, only able to stabilize with staff assistance. The resident had fallen since the previous assessment; 2 or more falls with no injury, 2 or more falls with injury, and 1 fall with a major injury. Progress Notes included the following notations: 3/2/16 at 10:25 A.M.: IDT met to review res fall from 03/01/16 at 3:58 pm. Res was sitting in her w/c following another res down the hall, res slid out of w/c landing on the floor, sitting on her buttocks .IDT recommends to sandwich dysom (sic) around pad alarm in w/c 3/3/16 at 5:44 A.M.: Res fell attempting to transfer self from bed to bathroom. Res found on buttocks .Res stated ' Bumped head and have to pee.' Generalized redness noted to right side of head 3/3/16 at 9:37 A.M.: IDT met to review fall event .Interventions at time of fall were scoop mattress, pad alarm to bed, and toileting program every hour .IDT recommends staff education to review fall prevention interventions 3/4/16 at 3:40 P.M.: Resident was in common area. RN was assisting another resident in restroom. CNA was with another RN in a different residents (sic) room. Resident was trying to stand. Pad alarm sounded alerting RN but I did not get here in time and she was on the floor 3/7/16 at 10:55 A.M.: IDT met to review res falls from 03/4/16 .and second fall at 03/06/16 at 3:22 pm .Second fall res noted to be sitting in her w/c in the dinning (sic) room. Second resident stated that she slipped out of her chair, res was noted to be laying on her back .IDT recommends to continue PT (physical therapy) .and keep resident busy while res friend is smoking. 3/12/16 at 6:49 A.M.: Heard resident yell out - found resident on floor by nurses station laying on her right side. Two other residents were standing by her - all they could say was that she just fell .Resident alert with confusion. 3/14/16 at 10:00 A.M.: IDT met to review unwitnessed fall event .Pad alarm to bed had sounded .determined that resident had ambulated from her room to the nurse's station with another resident .X-ray results dated 3/12/16 indicated no evidence of fracture or dislocation to right wrist and pelvis/hips An Fall Event, dated 3/16/16 at 5:13 P.M., indicated, .Resident was in dining room and was attempting to stand. NA was in dining area and RN was next to far hall when alarm sounded. We were unable to get to resident in time. Resident fell to floor 3/17/16 at 10:26 A.M.: IDT met for fall review dated on 03/16/16 at 513 pm. Resident was in dining room attempting to stand, when her alarm sounded. Staff attempted to get to the resident but was unable to get to resident in time. Resident fell to the floor no injuries noted .IDT recommends to continue with anti rollbacks and anti tippers. 4/8/16 at 10:27 A.M.: Resident was standing up from wheelchair and fell on right side. Alarm on but did not sound. Resident alert with confusion .Hospice to replace alarm and wheel chair to be lowered 4/12/16 at 8:27 P.M.: Resident was sitting in hallway in front of nurses station. Resident was wearing her gown, gripper socks, and hipsters. Pad alarm was in chair and working properly .Resident attempted to stand from w/c to place plate on desk when she lost her balance and fell to the floor . Resident did hit her head. Landed on Left side. Left shoulder had some redness noted but faded quickly. Small knot noted to Left side of head .Resident alert with confusion 4/21/16 at 5:15 A.M.: Resident was laying in bed resting. Staff in hallway heard a bang come from residents (sic) room. Resident was found sitting in middle of floor. Pad alarm was in bed and on but sound was muffled .Fall was unwitnessed .Dark purple bruising noted to posterior left upper arm. 4 1 cm skin tears and 1 .5 skin tear all on posterior left alarm .New Pad alarm applied under resident in bed. 4/21/16 at 9:12 A.M.: IDT met to review res falls from 04/20/16 and 04/21/16. At the time of first fall res was resting in her bed and then was noted to be laying on the floor on her right side next to her bed .During the second fall res was also laying in bed prior to fall and then was noted to be sitting in the floor in the middle of her room 5/2/16 at 12:47 P.M.: IDT Fall Review: Resident noted to have an unwitnessed fall on 5/01/16 at 2:15 PM. Prior to fall, resident was lying in bed. Resident was found fully clothed with hipsters in place on the floor next to the bed 5/2/16 at 2:19 P.M.: Resident had a witnessed fall at 1110 am (11:10 A.M.). Resident was seen sitting in her wheel chair a sleep (sic), when she fell forward out of the chair onto the floor. Resident was laying/sitting on her left side On 6/2/16 at 10:50 A.M., during an interview with the DON, she indicated she had only been at the facility for approximately 1 1/2 months. She indicated she realized the facility had numerous falls, and that staff had recently been inserviced. The DON indicated she was trying to decrease the number of alarms used in the facility. On 6/2/16 at 1:00 P.M., the DON provided a Record of Facility Inservices. An inservice, dated 3/16, indicated, Discussed (with) staff about making sure alarms and all fall prevention items are in place at the start of each shift. An additional inservice, dated 5/18/16, indicated, Please please start checking the profiles of each resident, we have had way too many falls because a pad alarm wasn't on, someone transferred someone alone, make sure furniture is where is (sic) should be placed in the room for the safety of the resident, make sure that call lights are in reach. On 6/2/16 at 1:10 P.M., the Director of Nursing provided the current facility Fall Management Program, revised 2/2015. The policy included: It is the policy .to ensure residents residing within the facility will maintain maximum physical functioning through the establishment of physical, environmental, and psychosocial guidelines to prevent injury related to falls .A care plan will be developed at time of admission specific to each resident's fall risk factors. The resident specific care requirements will be communicated to the assigned caregiver utilizing resident profile or CNA assignment sheet .The care plan will be reviewed and updated, as necessary. This Federal tag relates to Complaint IN 738, Complaint IN 242, and Complaint IN 368. 3.1-45(a)(1) 3.1-45(a)(2)

Based on observation, interview, and record review, the facility failed to ensure a resident at risk for dehydration, received adequate fluids to prevent dehydration, in that, a resident with impaired cognition and decreased fluid intake and output, was not monitored adequately and the physician was not notified. This deficient practice resulted in a resident being hospitalized with severe dehydration, acute [MEDICAL CONDITION], and [MEDICAL CONDITION]. (Resident A) Findings include: On 12/22/2014 at 9:25 a.m., Resident A was observed lying in bed with her eyes closed. The clinical record for Resident A was reviewed on 12/22/14 at 9:50 a.m., [DIAGNOSES REDACTED]. A hospital history and physical dated 12/6/14 included, Reason for admission: "Acute toxic metabolic [MEDICAL CONDITION], acute [MEDICAL CONDITION]". The hospital report also included lab results that included, but were not limited to, BUN 50, Creatinine 3.21. Another section titled "ASSESSMENT AND PLAN " included, but was not limited to: "1. Acute [MEDICAL CONDITION], prerenal (sic), from severe dehydration. The patient's renal function was normal just 2 weeks ago and now comes with a creatinine of 3.21 and BUN of 50 as well as [MEDICAL CONDITION] (high potassium). She has been on [MEDICATION NAME], lethargic for over 2 weeks and has not been drinking enough or eating and all this leading to prerenal (sic) azotemia (high BUN) At this time will put in a Foley catheter, aggressively will hydrate with IV fluids, monitor urine output and BMP (basic metabolic profile)". Also included in the hospital history and physical was,"4. Acute [MEDICAL CONDITION] with hypoxemia secondary to altered mental status (lethargy). The patient also has underlying [MEDICAL CONDITION]. Will continue with [MEDICATION NAME][MEDICATION NAME] treatment every 6 hours, supplemental oxygen as needed to maintain her oxygen saturation between 89% and 92%". The care plans included, but were not limited to, dehydration and fluid maintenance initiated 2/19/14, the interventions included: provide nectar thick liquids added on 10/14/14, document and notify MD of signs and symptoms of fluid volume deficit: dry mucous membranes, thirst, weight loss, decrease blood pressure, weak rapid pulse, change in mental status, decreased urine output, abnormal labs and poor skin turgor, encourage fluids, labs as ordered and record intake initiated on 2/13/14. A nutritional risk assessment completed by the Registered Dietician dated 8/27/14 included, but was not limited to, "Estimated fluid needs >(more than) 1610 cc/d (cubic centimeters daily)". The labs for Resident A were reviewed and included, but were not limited to, 11/7/14 BUN (blood urea nitrogen) 22 reference range (normal level) listed as 8-23, creatinine 0.8 and the reference range (normal level) listed as 0.4-1.1. Labs dated 11/24/14 included, BUN 29<H> (high) reference range (normal levels) listed as 8-23, Creatinine 0.9 reference range (normal levels) 0.4-1.1. Resident A's fluid intake was reviewed and were as follows: 11/21/14 fluid intake was 720ml, 890ml less than suggested intake. 11/22/14 fluid intake was 840ml, 770ml less than suggestion intake. 11/23/14 fluid intake was 1080ml, 530 ml less than suggested intake. 11/24/14 fluid intake was 710ml, 900 ml less than suggested fluid intake. 11/25/14 fluid intake was 600ml, 1010ml less than suggested fluid intake. 11/26/14 fluid intake was 900 ml, 710ml less than suggested fluid intake. 11/27/14 fluid intake was 1080ml, 530 ml less than suggested fluid intake. 11/28/14 fluid intake was 1080ml, 530 ml less than suggested fluid intake. 11/29/14 fluid intake was 1080ml, 530 ml less than suggested fluid intake. 11/30/14 fluid intake was 600ml, 1000 ml less than suggested fluid intake. 12/1/14 fluid intake was 840ml, 770ml less than suggested fluid intake. 12/2/14 fluid intake was 1680ml, resident met suggested fluid intake. 12/3/14 fluid intake was 1320ml, 280 ml less than suggested fluid intake. 12/4/14 fluid intake was 1440 ml, 170 ml less than suggested fluid intake. 12/5/14 fluid intake was 960ml, 650ml less than suggested fluid intake. The record lacked documentation the resident refused fluids when offered. Resident A's urine output record was reviewed and included: 11/21/14 medium urine output documented at 9:24 p.m., 11/22/14 no documented urine output 11/23/14 no documented urine output 11/24/14 medium urine output at 4:23 p.m. 11/25/14 medium urine output at 10:31 p.m. 11/26/14 medium urine output at 12:03 a.m. 11/27/14 medium urine output at 4:44 p.m. 11/28/14 no urine output documented 11/29/14 no urine output documented 11/30/14 large urine output documented at 4:20 p.m., 12/1/14 medium urine output documented at 12:52 a.m. and a Large Urine output at 10:03 p.m. 12/2/14 medium urine output documented at 4:37 p.m. 12/3/14 no documented urine output 12/4/14 medium urine output at 4:12 p.m. 12/5/14 medium urine output at 3:59 p.m. During an interview on 12/23/13 at 8:37 a.m., the Director of Nursing (DON) indicated all residents fluid intakes were tracked in the matrix system. She further indicated they would monitor residents for decreased fluid intake and notify the physician as necessary. The DON was unable to provide documentation that the physician for Resident A had been notified of her decreased fluid intake. A policy titled "Hydration Management" dated June 2014 was on 12/23/14 at 3:49 p.m., it included, but was not limited to, "1. Resident's Hydration status will be assessed upon admission or readmission, with significant change and quarterly utilizing the IDT Hydration Review. Any resident with identified risk factors will be assessed by the IDT and documentation will be placed in the EMAR IDT hydration review observation to include but not limited to: a. Resident's risk factors for dehydration, b. resident ' s current fluid intake, c. resident's self performance with fluids, d. physical assessment including mucous membranes, skin turgor, and f. plan for hydration. " This Federal tag relates to complaint IN 822. 3.1-46(b)

Based on observation, interview, and record review, the facility failed to ensure 1 of 5 residents reviewed for falls, in the sample of 5 who met the criteria, had fall preventions in place at the time of a fall. The resident fell walking to the bathroom resulting in a fractured hip. (Resident B) Finding includes: Resident B clinical record was reviewed on 12/18/14 at 9:19 a.m. The resident was originally admitted to the facility 10/30/14 with [DIAGNOSES REDACTED]. Progress notes included, but were not limited to, the following: 10/30/14 11:32 p.m. "Resident on pad alarm to bed and chair r/t (related to) fall history. Resident alert and oriented to person,place, and time...resident utilizing of w/c (wheelchair) and rolling walker along with staff assist as weakness to lower limbs and stooped over gait observed during toileting..." 11/1/2014 8:55 a.m., indicated, "CNA reported to this nurse that resident was found sitting on floor. Upon entering resident's room this nurse noted that resident was seated on her buttocks next to her bed. Resident stated that she had gotten up to go to the restroom and got light headed and fell . Resident denied hitting her head; however, examination revealed a small laceration to back of resident's head. Blood also found on the floor next to the resident's bed. Resident stated that her hip was 'sore.' Upon assessment external rotation to right leg; altered range of motion. MD notified....Transfer to (hospital)..." 11/3/14 11:36 a.m. "IDT (interdisciplinary team) met to review res fall on 11/1/14. Res was found on floor next to bed c/o hip pain et bleeding from head. Upon assessment res had external rotation of R (right) leg et altered ROM (range of motion). Res stated when she got up to go to restroom she got up et became light headed et fell . Resident is new to facility et was not yet acclimated to surroundings et routine. Resident does have dx (diagnosis) of syncope. Family et doctor notified. Resident was sent to (hospital) for further treatment. IDT feels root cause is resident attempted to take self to restroom with out calling for assistance to restroom. Intervention put in place is awaken at night et toilet resident. Therapy to evaluate upon return. Other interventions in place are call light in reach floors clean et clutter free non skid foot wear pad alarm in bed et chair therapy to screen..." The admission history and physical from the hospital, dated 11/1/14, indicated the resident was admitted for treatment of [REDACTED]. Fall event documentation included the following: 11/1/14 05:10 a.m. Unwitnessed fall Had been in bed with oxygen (O2) 2 liters per nasal cannula Found on floor on buttocks beside bed Pajamas on, bare feet, O2 off-laying on bed Pain right hip and leg Hit head On anticoagulant History of orthostatic hypotension Head pressure dressing, immobilized hip Resident stated that she got up to go to the bathroom and got light headed and fell Was incontinent at time of fall Intervention put in place to prevent another fall: "Night shift to toilet resident more often. Therapy to screen when resident returns." The resident had a care plan, initiated on 10/30/14, for being at risk for falls. The care plan was current as of 12/18/14. Interventions included, but were not limited to, the following: 10/30/14 call light in reach 10/30/14 Environmental changes: floors clean and clutter free 10/30/14 Non skid footwear 10/30/14 at risk for fall care plan 10/30/14 personal items in reach 10/30/14 Therapy screen as ordered 11/1/14 Staff will toilet resident before meals or after meals upon rising at bedtime et through the night every 4 hours. 11/10/14 Alarming floor mat at bedside. physician's orders [REDACTED]. On 12/18/2014 at 10:56 a.m., Resident B was observed to be seated on the side of her bed. The floor pad alarm was in place and working. On 12/18/2014 at 3:29 p.m., the Director of Nurses (DON) was interviewed about falls. She indicated she couldn't find any reference to the alarm. Doesn't remember if that was looked at or not. She indicated if a resident was known to turn off an alarm, they usually added an alarm or put the alarm box out of reach. On 12/18/14 at 4:16 p.m., the DON provided an in-house fall review tool. The documentation indicated the resident was noncompliant with asking for assistance and was known to turn alarms off. The DON indicated that was why they added the alarming mat at the bedside when the resident returned from the hospital. On 12/22/14 at 3:10 p.m., the DON provided the Fall Management Program policy, dated 7/01, revised 9/2013. She indicated the pad alarms were being used as an intervention for new admissions, but Resident B had been noncoompliant and turned the alarm off. The policy included, but was not limited to, the following: "All new admissions will be considered at fall risk based upon his/her new living arrangements, and his/her reasons for being admitted in to the nursing facility. -All staff members will be notified of new admissions per facility specific policy. -Nursing staff will assess the resident and environmental conditions every shift for the 1st 3 days and/or as directed by the DNS (Director of Nursing Services) /designee..." This Federal tag relates to complaint IN 822. 3.1-45(a)(2)

Based on record review and interview, the facility failed to ensure complications from a urinary catheter were noted and acted upon, for 1 of 2 sampled residents reviewed with a urinary catheter, in the total sample of 17, in that the resident was sent to the hospital with the catheter lodged in the urethra and [MEDICAL CONDITION]. (Resident #82 ) Findings include: During the initial tour on 10/19/11 at 10:35 a.m., the Assistant Director of Nursing indicated Resident #82 had been hospitalized recently with pneumonia. She indicated the resident had a urinary catheter due to retention. Resident #82 clinical record was reviewed on 10/21/11 at 2:30 p.m. The resident's [DIAGNOSES REDACTED]. Nurses' notes indicated, on 10/3/11, Resident #82's urinary catheter had been replaced. Urinary outputs for the night shifts 10/4/11 through 10/9/11, ranged from 350 cubic centimeters (ccs) to 550 ccs. Intakes on night shifts for the same dates ranged from 120 ccs to 240 ccs. On 10/10/11 night shift, the resident refused any intake and had only 125 ccs output. Nurses' notes, dated 10/10/11 at 8:00 a.m., indicated Resident #82 had a right sided bulge in the lower abdomen that was tender. The note indicated the physician had been notified at that time. It was not until 3:00 p.m., that nurses' notes indicated an order was obtained to send the resident to the hospital. The hospital history and physical, dated 10/11/11, indicated the resident was admitted for lower abdominal pain and distention. The history and physical indicated the urinary catheter had been dislodged upon admission, was repositioned and the resident had 1700 cubic centimeters (cc's) of urine out at that time, and relief of the distention. A CT scan done on admission indicated the urinary catheter balloon was inflated in the urethra causing severe urinary distention and bilateral moderate [DIAGNOSES REDACTED]. The policy and procedure for Resident Change of Condition, dated 8/98 and revised 3/10, included, but was not limited to, the following: "Acute Medical Change Any sudden or serious change in a resident's condition manifested by a marked change in physical or mental behavior will be communicated to the physician with a request for physician visit promptly and/or acute care evaluation..." 3.1-41(a)(1)

Based on observation, interview and record review, the facility failed to ensure 1 of 8 residents reviewed for falls, in the total sample of 17, was provided supervision and assistance devices to prevent falls, in that the resident suffered numerous falls with inconsistent use of interventions, with injuries including a laceration requiring sutures and a fractured radius. (Resident C) Findings include: During the initial tour, on 10/19/11 at 10:44 a.m., the Assistant Director of Nurses indicated Resident C had Alzheimer's Disease, had recent falls, including one resulting in a fractured left radius. She further indicated the resident had taken off her self release velcro belt on 10/18/11 in the parking lot when returning from a doctor's appointment, and fallen. She indicated they were changing the velcro seat belt to a click type seat belt due to the fall. Resident C was observed in a wheelchair with a seat belt in place on 10/19/11 at 1:35 p.m., 10/20/11 at 9:20 a.m., 11:20 a.m., and 12:55 p.m. Resident C's clinical record was reviewed on 10/20/11 at 10:30 a.m. The resident's [DIAGNOSES REDACTED]. The resident had a care plan, dated 7/18/11, for being at risk for falls related to medication, decreased mobility, incontinence of urine and bowels. "Freq. (frequently) observed easing self to floor et will crawl in hallway or lays on floor." Approaches included, but were not limited to, the following: Hi-low bed alarm in bed concave matress (sic) mat on floor beside bed 8/29/11 seat belt in w/c (wheelchair) eyeglasses are clean and in good repair Keep call light in reach Provide proper, well-maintained footwear Provide toileting assistance every 2 hours and as needed 7/18/11 re-arrange furniture - place mattress on floor beside bed - bed against wall 7/18/11 body pillow in bed 10/19/11 click seat belt while in w/c Nurses' notes included, but were not limited to, the following: 8/26/11 1930 (7:30 p.m.) "Skin pink/warm et dry. (No) c/o (complaints) voiced. Res. (Resident) has been getting out of w/c (wheelchair) tonight et crawling on the floor 3X (three times). She doesn't fall. She just gets on the floor et falls (sic)." 8/26/11 2040 (8:40 p.m.) "Res. was found on floor by this nurse. Res. was sitting on floor. Res. had 2 different skin tears on (lower) (L) (left) arm. 1 was .8 cm (centimeters) the other was 2.5 cm X 4.0 cm. This nurse called (family member) et advised (family member) of fall out of bed et skin tears...Neuro (check) started @ this X (time)..." 8/26/11 2245 (10:45 p.m.) "CNA called this nurse to another res's room where this res's wheelchair was stopped at door with resident lying face down in front of it. (No) shortening or rotation of extremities, laceration to (R) (right) brow noted with small amount of bleeding, laceration size 3 cm long by 0.5 cm wide, (no) other injuries noted, pull alarm on resident at 2230 (10:30 p.m.) as checked by nursing, pull alarm did not sound when res. fell , VS (vital signs): 118/68 (blood pressure) - 118 (pulse) - 18 (respirations) 98% (oxygen saturation) - 97.8 (degrees) (temperature)." The resident was sent to the hospital for sutures. 8/28/11 1505 (3:00 p.m.) "This res. was found lying in blood (with) head in bathroom floor. Res. tried to get to bathroom. Urinated on floor et fell in urine hitting her head on door frame of bathroom. Res. has a 1 cm gash in middle of forehead. Another 1 cm V shaped gash on bridge of nose. Neuro (check) started @ this X..." The family, physician, and Director of Nursing were notified. 8/28/11 1505 "Fall Circumstance Report" indicated the resident had been in bed prior to the fall. The resident statement of how the fall occurred indicated, "Res. wanted to go to bathroom. She said she slipped (there was urine on the floor where she tried to go to bathroom). She hit head on door facing going into bathroom." The interventions put in place to prevent further falls indicated, "Res. pad alarm was checked. It was turned on but didn't go off till body pillow was moved (after) fall. We place res. in w/c, put her in w/c. Then put (a high-low) bed in res. room." 9/4/11 1330 (1:30 p.m.) "Res. was found sitting on floor in lobby. She stated that she was trying to scoot over to the couch, so she sat on floor to get there. (No) injuries noted..." 9/4/11 1330 Fall Circumstance Report indicated, "Res. said she sat on floor to scoot herself to the couch." Interventions to prevent another fall indicated, "Changed pull alarm to a pad alarm in chair d/t (due to) res. took off her pull alarm." 9/8/11 1300 (1:00 p.m.) "Resident (up) in w/c propelling self...alarming SRSB (self release seat belt) intact to w/c..." 9/10/11 2210 (10:10 p.m.) "...Frequent unsafe transfers from w/c. Pad alarm/pull alarms all in place and working..." 9/11/11 12:40 p.m. "Res. came into nursing office, promptly lowered self to floor onto her knees then crawled to middle of room et laid herself down, stating 'I'm going to rest.' Pillow et cover provided." 9/11/11 1330 (1:30 p.m.) "Res. requesting to get up. Assisted per ii (two) staff to standing position et amb (ambulated) 3 feet to w/c. Personal alarm attached to sweater..." 9/15/11 1710 (5:10 p.m.) "Res. up in w/c propelling self. Heard a loud thump noise come from hallway down toward station 2. Saw res. on floor on her (R) side in front of linen closet. Pad alarm on et functioning properly. Res. was assessed. Noticed red area to (L) side of forehead. Res. was placed on her back. ROM (range of motion) performed...Neuro (checks) initiated..." 10/13/11 0700 (7:00 a.m.) "When getting res. up from bed this morning, swelling (and) bruising were noted to (L) (left) forearm (and) fingers of unknown origin at this time. Investigation started. Dr. notified (and) NOs (new orders) for x-ray received. Family notified. Res. c/o (complaint of) pain..." 10/12/11 2040 (8:40 p.m.) Fall Circumstance Report "Found on floor crawling on hands (and) knees but had been in w/c with safety belt in place." First observed "crawling in hallway" "near room 303-305." "Found no abrasions or bruising when examined on floor. When first seen she was crawling on hands (and) knees towards 305 where I was taking care of resident. Belt alarm in place on chair (and) sounding." The x-ray done on 10/13/11 indicated a fractured distal radius. Resident C had a pre-physical restraint assessment form, dated 8/29/11, indicating the need for a self release belt. Alternatives tried were pad alarm, personal alarm, and hi/low bed. [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. A restraint review, completed 10/6/11, indicated the continued need for a self release seat belt. Another physician's orders [REDACTED]. Documentation in the nurses' notes indicated inconsistent use of the self release seat belt, i.e. 9/4, 9/10, 9/11, and 9/15/11 notes above. During interview with the Administrator on 10/24/11 at 4:30 p.m., she indicated the Fall Circumstance Report had been completed after investigating the bruising that appeared on 10/13/11 at 7:00 a.m. The nurse from the evening before indicated the resident had been crawling around on the floor, but they didn't think she had fallen, but had lowered herself to the floor. According to the Administrator, the nurse was educated about considering it as a fall anytime a resident was found on the floor. During the investigation, she indicated the night shift 10/12 to 10/13/11 had been interviewed and had not noticed any bruising or pain. The policy and procedure for Fall Management, dated 7/01 and revised 3/10, was provided by the Director of Nursing on 10/31/11 at 12:00 noon. The policy and procedure included, but was not limited to, the following: "Charge nurses will communicate the specific care required for each resident to the assigned caregiver on each shift." "Any resident experiencing a fall will be assessed immediately by the charge nurse for possible injuries and provide necessary treatment." "A fall circumstance report will be initiated as soon as the resident has been assessed and cared for. The report must be completed in full in order to identify possible root causes of the fall and provide immediate interventions. An entry will be completed in the nurses' notes addressing the fall, any injuries, physician and family notification, and interventions initiated." "All falls will be discussed by the interdisciplinary team the 1st morning after the day of the fall to determine other possible interventions to prevent future falls...The care plan will be reviewed and updated, as necessary." This federal tag relates to complaint number IN 540. 3.1-45(a)(2)

Based on observation, interview, and record review, the facility failed to ensure a resident at risk for elopement was supervised to prevent elopement. The deficient practice affected 1 of 3 residents reviewed for elopement risk and the use of Wanderguard alarms in a sample of 5. (Resident G) The deficient practice had the potential to affect 15 other residents using Wanderguards among the 81 residents residing at the facility. (Residents E, I, J, K, L, M, N, O, P, Q, R, S, T, U, and V) Resident G eloped from the facility when a visitor held the door open for her. The Wanderguard alarm sounded, and staff failed to ensure no resident had eloped from the building. Resident G wandered away from the building and was picked up in an automobile by an unidentified passerby. The passerby took Resident G to the local police, who returned her to the facility. The immediate jeopardy began on 7/1/11 when Resident G eloped from the facility. The Administrator, Assistant Director of Nursing Services, Staff Development Coordinator, and Memory Care Director were notified of the immediate jeopardy at 6:00 p.m. on 8/5/11. The immediate jeopardy was removed 7/2/2011 with the placement of the resident in the secured unit of the facility and staff monitoring of doors pending repairs by the security company. The deficient practice was corrected as of 7/27/2011 after two visits by the security company confirmed the alarms had been adjusted to the appropriate sensitivity and all staff had been inserviced on the importance of responding to alarms, the actions to be taken when responding to alarms, and the consequences for not responding to alarms. Findings include: During interview at the Entrance Conference on 8/4/11 at 2:00 p.m., the Administrator indicated she had expected an investigation into her report of a resident's elopement from the facility, which she had sent to the Indiana State Department of Health. Documentation related to the facility's report was requested. During the Initial Tour completed on 8/4/11 at 2:45 p.m., the Staff Development Coordinator (SDC) indicated residents assessed as "exit seekers" are provided a Wanderguard Code Alert bracelet that is worn on the wrist or ankle. The SDC also indicated the facility's secured unit has a locking system that requires a code for opening the secured unit doors into the remainder of the facility, but these doors are not related to the Wanderguard Code Alert system. The SDC indicated if a resident wearing a Wanderguard Code Alert bracelet nears an exit door to the outside of the building, the door locks down, and if the resident exits the door, an alarm sounds. The SDC indicated the Maintenance Supervisor checks the facility's exit doors for functioning of the Wanderguard system. During interview on 8/4/11 at 3:00 p.m., the Administrator indicated on 7/1/11, a visitor opened the door and allowed Resident G, who was wearing a Wanderguard, to leave the facility. The Administrator indicated the alarm sounded, a nurse looked out the door, saw no one, and turned the alarms off. On 8/4/11 at 3:40 p.m., the Administrator provided a packet of paperwork indicating her investigation into the elopement of Resident G. Review of the paperwork indicated the following: An Incident/Investigation Report from the Oakland City Police Department, dated 7/2/11 at 10:19 Saturday, indicated, "On the 1st of July 2011, Oakland City Police Department brought back an elderly woman that had left the Good Samaritan Nursing Home without permission," and "...This affiant then spoke with (name of police officer) who was on shift at that time and he stated that he was at the (name of service station) in Oakland City when a male in his 30's drove up and stated to him that he saw an elderly female walking and she seemed confused so he asked her if she needed a ride and she said yes and asked him to take her to (name of street). The male instead took her to the police and that is when she got into (name of police officer's) police vehicle and she told him that she wanted to go home on (name of street). (Name of police officer) stated that when he was speaking with her she could not tell him exactly where her house was and that is when he received a dispatch from a 911 call from Good Samaritan of a missing resident. (Name of police officer) stated that he then took (name of Resident G) to the Nursing Home and released her to them." An unsigned notation, handwritten on a plain sheet of paper and dated 7/2/11, indicated, "(Name of visitor) came into facility he noticed a lady stand (sic) by front entrance & held door for her to leave facility. (Name of Resident G's spouse, also a resident at the facility) came to nurses station stated his wife & he argued & she said she was going home. Staff immediately started to look for (name of Resident G). Staff paged her name overhead & (name of visitor) went to nurses station and informed staff he held door for a woman. Showed him picture of (name of Resident G) he concurred that it was her. Staff called 911 - police brought (name of Resident G) back to facility. Per police (name of Resident G) got a ride from a gentleman he quickly realized she was confused so he took her to police at (service station) & police brought her to facility." Another notation, handwritten on a plain sheet of paper, undated, with the name of the visitor with the visitor's phone numbers in the lower corner of the paper indicated, "When I walked up to the door and a lady carrying her purse wearing a sweater was approaching the door I opened the door & let her out the door. She thanked me and left outside. Sometime later I noticed staff walked to (name of resident) door then I hear a page that staff was looking for someone so I then ask a nurse what the lady looked like & I realized she was the lady I opened the door (sic). Nurse she (sic) got a picture of the lady - so we (illegible word) right away it was her." A type-written statement on a plain piece of paper, dated 7/5/11, indicated, "On July 1st, 2011, the date (name of resident G) eloped, I heard the alarm sound on the front door. I went to the front door to observe the interior and exterior surroundings of the entrance. I did not see anyone, so I entered the code and reset the alarm." Typed at the end of the statement was the name of LPN #9. Handwritten on the paper was "Interviewed by" followed by an illegible signature. During interview on 8/5/11 at 3:20 p.m., the Administrator indicated, "(Name of alarm services company) redid the (alarm) system" since the facility was purchased by American Senior Communities. The Administrator indicated the alarms, especially at the ambulance and front doors, alarmed frequently, even when caught by the wind. The Administrator indicated the alarms sounded "all the time" when people came in and out the front door and staff "got conditioned." The Administrator summoned LPN #9 for interview. During interview with LPN #9 and the Administrator, LPN #9 indicated she was not the nurse responsible for Resident G on July 1 at the time of the elopement, but she was working Station 1, near the front door. LPN #9 indicated the event happened about 8:00 p.m., and she thought the resident was gone about 20 minutes. LPN #9 indicated she "went outside to look, but saw no one, and came back" into the facility. LPN #9 indicated Resident G and her husband "stayed in their room most of the time." LPN #9 indicated at the time of the elopement, the door alarms were "constantly going off." During interview on 8/5/11 at 5:15 p.m., LPN #13 indicated that until recently the facility's exit doors, especially the front door and ambulance doors, alarmed frequently. LPN #13 indicated when the door alarmed, an indicator light at the nurse's station indicated which door was alarming. She indicated from her unit she most frequently attended to the ambulance door. LPN #13 indicated she would check the door, reset the alarm, and often it would immediately sound again, especially if it was storming. Review of the American Senior Communities policy for "Missing Resident/Resident Elopement," with most recent revision date of 1/06, provided on the work table on 8/5/11 at 1:00 p.m., indicated, "It is the policy of this facility that personnel who have residents under their care are responsible for knowing the location of those residents...." Resident G's clinical record was reviewed on 8/4/11 at 4:15 p.m. The record indicated the resident was admitted to the facility on [DATE]. Nurse's Notes, dated 6/21/11 at 4:30 p.m., indicated, "Res (resident) was brought in the facility @ this time by nephew in auto. Res in satisfactory condition. Res restless wanting to go back home. Redirected easily. Placed wander guard to L (left) ankle...." A Care Plan with Problem Start Date of 6/24/11, indicated, "Problem: Resident is at risk for elopement due to: resident states she wants to go home. Goal: Resident will not leave the facility unattended." Approaches included, but were not limited to, "...Electronic monitoring bracelet, check function/placement every shift....Observe whereabouts....Walk with resident...." During observation of testing of the facility's exit door alarm system completed with the Maintenance Supervisor on 8/4/11 at 3:50 p.m., the facility was observed to have six exit doors connected to the Wanderguard system. Using a Wanderguard Code Alert, the Maintenance Supervisor demonstrated how he checked the doors' functioning, and all doors were functioning at the time. On 8/5/11 at 5:10 p.m., the Administrator provided a list of all residents in the facility who were monitored using the Wanderguard Code Alert system. During interview at this time, the Administrator indicated all residents were re-assessed related to risk for elopement after Resident G eloped. The list indicated 16 residents, including Resident G, were wearing the Wanderguard bracelet to alert staff to their elopement from the facility. The residents other than Resident G were: Residents E, I, J, K, L, M, N, O, P, Q, R, S, T, U, and V. The immediate jeopardy that began on 7/1/11 was removed on 7/2/11 after the resident was placed in the facility ' s secured unit and staff provided monitoring of the facility doors. The deficient practice was a past noncompliance that was corrected as of 7/27/11, prior to the start of this survey, with the facility ' s implementation of a systemic plan that included the following: the door alarm company serviced the doors and adjusted the sensitivity settings; the Wanderguard Code Alert Monitoring for functionality was completed daily; and all staff were inserviced regarding each staff member ' s responsibility to respond to alarms and conduct a search until each resident ' s location and safety was assured. These corrections were verified by review of inservice sign-in sheets and training materials; review of invoices and description of service from alarm company; interviews with staff regarding knowledge of protocol to follow when a door alarm sounds; and observations on 8/4/11 between 2:00 p.m. and 5:45 p.m. and on 8/5/11 between 1:00 p.m. and 6:15 p.m. when a resident approached the door and/or the door ' s functioning was tested . During these observations, staff responded immediately to the appropriate door and conducted a search until the location of all residents was determined. This federal tag is related to Complaint IN 087. 3.1-45(a)(2)

Based on observation, interview, and record review, the facility failed to provide supervision to prevent falls and wandering off of a locked Alzheimer's unit, for cognitively impaired residents residing on the locked Alzheimer's unit, resulting in a fall with a resulting fractured hip (Resident B), for 3 of 4 residents reviewed for falls, in a sample of 4. Residents B, C, and D Findings include: 1. On 6/22/11 at 10:00 A.M., the Administrator indicated Resident B had fallen and was in the hospital. The clinical record of Resident B was reviewed on 6/22/11 at 10:10 A.M. [DIAGNOSES REDACTED]. The resident was admitted to the facility on [DATE] from a previous facility. A transfer sheet, dated 6/9/11, indicated, "...Able to walk (with) assist, Walks with aid of gait belt, walker...Wanders quickly, Keep within close view, High Fall Risk, Keep close contact...Therapies, Current Activity Level: Amb (ambulates) (with) hand held (assist) of 1. Very impulsive! Fall Risk!...Res. (resident) will require use of alarms to promote safety...." A Fall Risk Assessment, dated 6/9/11, indicated, "...Resident has had a history of [REDACTED].? Yes...Resident is incontinent of urine and or bowel? Yes...Resident is confused and/or disoriented? Yes. If any answer above is 'Yes,' the resident is at risk for experiencing a fall. Proceed to care plan with appropriate interventions based upon the risk factor(s)." A physician's orders [REDACTED]." An Interim/Admission Nursing Care Plan, dated 6/9/11, indicated, "Problem: Fall Risk related to: dementia, Hx (history) of falls, HTN (hypertension), medication, anemia...Interventions: Encourage and remind resident to use call light...Provide appropriate assistive devices such as walker, low bed, mats on floor, alarms on chairs/beds. Pad alarm in chair. Pad alarm in bed x 3 days et (and) reassess." A physician's orders [REDACTED]. An Occupational Therapy "Plan of Treatment," signed 6/12/11, indicated, "...Assessment: Patient presents with decreased attn (attention) to task, shuffled gait, behaviors at times, poor balance, muscle weakness influencing ability to complete functional transfers and ADL's (activities of daily living) safely...." A Physical Therapy Progress Report, dated "06/10/2011-06/16/2011," indicated, "...Current, Gait Tasks: Deviations, The patient demonstrates muscle weakness causing deficits during turning during gait training without assistive device and contact guard assist (contact with patient due to unsteadiness) /SBA (stand-by assist) for 300 feet...Target Goal: The patient will improve muscle weakness in order to improve deficits during turning and narrow base of support during gait training without assistive device and stand by assistance (close enough to reach patient if assist needed) in order to decrease risk of falls...Precautions: Fall risk, agitated behavior at times...." An admission Minimum Data Set (MDS) assessment, dated 6/15/11, indicated the resident scored a 3 out of a total 15 for cognitive impairment, with 15 indicating no impairment. The resident required limited assistance of one for transfer, bed mobility, toilet use, and personal hygiene, and was assessed as "Independent -no help or staff oversight at any time, No set-up or physical help from staff" for walking in room, and "Supervision -oversight, encouragement or cueing, No setup or physical help from staff" for walking in corridor. The MDS assessment indicated the resident had not fallen in the previous month, was "Unable to determine" if the resident had fallen in the previous 2-6 months prior to admission, and had not fallen since admission. A Care Plan, dated 6/17/11, indicated: "Problem, Resident is at risk of falling R/T (related to) medications, dx dementia Alzheimers, anemia, HTN, incontinence of urine and bowels, hx of falls." The approaches included: "Observe frequently and place in supervised area when out of bed...." Nurses Notes included the following notations: 6/19/11 at 3:00 A.M.: "Alert (with) confusion...Is (up) ad lib (as desires)...has history of falls - uses pad alarm in chair (and) bed for safety...." 6/19/11 at 8:00 P.M.: "...(Up) ad lib (with) steady gait...." 6/20/11 at 5:30 P.M.: "Housekeeper observed res (resident) laying in doorway of another res room. When doing ROM (range of motion) res c/o (complains of) (right) hip pain...Skin tear noted on (right) elbow 2 1/2 cm (centimeters) x 1 cm. Physician notified...transfer to hospital for possible (right) hip fracture." A Fall Circumstance Report, dated 6/20/11, indicated, "...1.... fall un-witnessed. 2. Describe what the resident was doing prior to the fall...Walking down hall. 3. Describe the position of the resident when first observed after fall... lying on floor in doorway on back...6. Is the resident in pain and/or experiencing difficulty in movement of extremities: Yes (right) hip pain when ROM performed...Describe injuries...Skin Tear (right) elbow...Possible (right) hip fracture...." On 6/22/11 at 10:15 A.M., the Assistant Director of Nursing (ADON) provided CNA assignment sheets. The ADON indicated the sheets were updated daily. The assignment sheet for Resident B indicated she was Independent with mobility and transfers, and was a fall risk. On 6/23/11 at 8:30 A.M., a hospital history and physical for Resident B, dated 6/20/11, was reviewed. The history indicated, "...Assessment: Elderly female with dementia with a right femoral neck (hip) fracture...." An Interdisciplinary Team (IDT) Progress Note, dated 6/21/11, indicated, "IDT reviewed incident which occurred 6/20/11 at 1730 (5:30 P.M.). Resident is up ad lib. She was coming out of a room, going to DR (dining room) when she stumbled et (and) fell . Was sent to the hospital (with) dx (diagnosis ) (right) hip fx (fracture)." On 6/23/11 at 8:45 A.M., the Alzheimer Unit Manager indicated Resident B was ambulating down the hallway with another resident, and "the next thing she knew the housekeeper was saying she needed help" because Resident B was on the floor. The Unit Manager indicated Resident B walked by herself. On 6/23/11 at 10:05 A.M., during an interview with the Director of Nursing (DON) and Administrator, each indicated they did not know why the resident was not receiving assistance with her ambulation, when therapy notes indicated she required assistance. 2. The clinical record of Resident D was reviewed on 6/22/11 at 1:00 P.M. [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) assessment, dated 3/16/11, indicated the resident scored a 4 out of 15 for cognitive status, wandered 1 to 3 days, required extensive assistance for transfer, and supervision with "No setup or physical help from staff" for walking in room and in corridor. Nurses Notes, dated 5/30/11, indicated, "6-2 Weekly Summary - Alert et (and) responsive, Oriented to self - confused to (time and place) - (up) ad lib gait steady...Limited assist (with) ADL's...." A Fall Risk Assessment, dated 6/3/11, indicated, "...Resident is confused and/or disoriented? Yes. If any answer above is 'Yes,' the resident is at risk for experiencing a fall. Proceed to care plan with appropriate interventions based upon the risk factor(s)." An Elopement Risk Assessment, dated 6/3/11, indicated, "1. Resident is independently mobile - either ambulating or in wheelchair? Yes...4. Resident experiences increased confusion at certain times of day i.e. evening? Yes. 5. Resident walks/paces about the facility and is often seen trying to open exit doors? No. If question # 1 is YES and ANY of questions 2-5 are answered YES, the resident is at risk for elopement...Resident has been assigned a scrutiny bracelet? No...describe other interventions: Res makes no attempts to leave unit (without) supervision." An "All Staff Behavior Tracking Record," dated 6/4/11 at 6:45 P.M., indicated, "...On 6-4-11 res had exited St. (station) 2 (Alzheimer's Unit) and was at St 1 nurses station. Was easily redirected back to unit (without) difficulty." A Physician's Progress Note, dated 6/5/11, indicated, "This patient is seen, at the request of nursing, because of an increased amount of pacing. Indeed, she has walked so much that somehow she walked out of the cottage. The exact mechanism of how that occurred is unclear...." A Minimum Data Set assessment, dated 6/8/11, indicated Resident D scored a 6 out of 15 in cognitive status, wandered 1 to 3 days, required limited assistance of one staff for bed mobility and transfer, and supervision with "No setup or physical help from staff" for walking in room and in the corridor. A Physical Therapy Progress Report, dated "06/09/2011 - 06/16/2011," indicated, "Current, Gait Tasks: Deviations: The patient demonstrates muscle weakness causing narrow base of support during gait training with no device and stand by assistance (close enough to reach patient if assist is needed) for 450 (feet) x 2...Precautions: Fall risk, Flight risk...." Nurses Notes included the following notations: 6/15/11 at 9:30 P.M.: "Res rmmt (roommate) came to tell this nurse that res was on the floor et needed help. Upon assessment this nurse found res sitting on floor (with) sm (small) amt (amount) blood coming from nose...Res states she hit face on floor...Res stated 'I slipped trying to get to restroom.' New gripper socks placed on res et assisted to toilet. Will cont to monitor." 6/16/11 at 7:00 A.M.: "This nurse observed res attempting to sit on chair in room. Res missed chair et sat on floor. (Left) arm hit footboard on roommate bed resulting in skin tear 4 cm x .5 (1/2) cm...." 6/18/11 at 4:45 A.M.: "...Has been up ad lib x 2 to bathroom with steady gait...Alert to self with confusion to time and place...." 6/20/11 at 12:45 A.M.: "Staff heard noise went (and) found resident in floor head was bleeding. Resident fell going to BR (bathroom). Hit head on baseboard in her room...laceration 3 cm in length on back of her head area cleansed drsg (dressing) applied...." An Interdisciplinary Team Progress Note, dated 6/20/11, indicated, "IDT reviewed incident which occurred @ 0045 (12:45 A.M.) on 6/20. Res is up ad lib...She was getting up to go to the BR, lost her balance et fell . She received a laceration to back of her head. Interventions include requesting U/A (urinalysis), Blood Pressure x 3 days standing/sitting, et therapy to screen...." A Care Plan, initially dated 9/21/10 and updated 6/20/11, indicated: "Problem, Resident is at risk for falls due to: Dementia, Altered Mental Status...Walks fast pace." The approaches included; "Call light in reach, Non skid footwear, 6/20/11 Request therapy to screen...." On 6/23/11 at 8:45 A.M., during interview with the Alzheimer's Unit Manager, she indicated she was unaware that Resident D had exited the unit. She indicated she had been on vacation for a few days, and that may have occurred while she was gone. She indicated Resident D took herself to the bathroom. On 6/23/11 at 9:00 A.M., the Administrator provided a document, dated 6/6/11, which indicated: "Investigation gathered regarding (Resident D) being off cottage on 6/4/11. Spoke (with) (LPN # 1) who came in at 6P on 6-4-11. He stated that resident was in hallway on St 1, walking slightly behind a visitor. He first thought the visitor was (with) (Resident D) but then realized that the visitor had come to see another resident. He stated he then took (Resident D) by the hand et walked with her back into the cottage area with no difficulty. He stated he made out a behavior sheet for the (illegible). (LPN # 2) for the cottage was not aware (Resident D) had gone off cottage." The Administrator indicated at that time that she thought the resident had just followed a visitor off of the locked unit, and thought she had a Wanderguard on. The Administrator indicated it would not have mattered about the Wanderguard bracelet, because that does not work for the locked Alzheimer unit doors. On 6/23/11 at 9:20 A.M., a skin assessment was requested on Resident D. CNA # 1 motioned for Resident D to come with him to the restroom. CNA # 1 did not provide hands on assistance for the resident to ambulate. The resident was observed to have a slightly tilted, fast gait. CNA # 1 indicated he did not normally work on the locked unit, but that Resident D ambulated by herself. CNA # 1 closed the bathroom door, and left Resident D in the bathroom by herself. On 6/23/11 at 10:05 A.M., during interview with the Administrator and DON, the DON indicated the resident could not have been off of the unit for very long, because LPN # 1 was coming out of the employee lounge and saw Resident D come out of the locked unit with a visitor. The DON and Administrator indicated they thought the resident ambulated independently, and did not know why she did not receive assistance if therapy notes indicated she was unsteady. On 6/23/11 at 1:30 P.M., PT # 1 indicated she estimated the length of the hallway from the Alzheimer Unit doors to the Station 2 nursing station at 80 feet. It was observed to be also approximately 80 feet from the Station 1 nursing station to the Alzheimer Unit doors. 3. The closed clinical record of Resident C was reviewed on 6/22/11 at 12:05 P.M. The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A transfer form, dated 4/29/11, indicated, "...Safety Needs, Fall Prevention; interventions used: Pt. (patient) alarm al all times, Safety checks, Wanderguard...Mental Status, Confused...Disoriented x 3, Uses W/C (wheelchair) at times...." A Fall Risk Assessment, dated 4/29/11, indicated, "New admission, Yes...Resident has [DIAGNOSES REDACTED].? Yes...Resident is confused and/or disoriented? Yes...." If any answer above is 'Yes,' the resident is at risk for experiencing a fall. Proceed to care plan with appropriate interventions based upon the risk factor(s)." An Interim Care Plan regarding the resident's fall risk was lacking in the clinical record. An admission Minimum Data Set (MDS) assessment, dated 5/5/11, indicated the resident scored a 3 out of 15 for cognitive status, required extensive assist of one staff for bed mobility and toilet use, and supervision on one person for ambulating in room and corridor. A test for balance while walking indicated "Not steady, but able to stabilize without human assistance." A test for balance while turning around and surface to surface transfer indicated, "Not steady, only able to stabilize with human assistance." A Physical Therapy Progress Report, dated "05/02/11-05/08/2011," indicated, "...Current, Gait Tasks: Deviations, The patient demonstrates muscle weakness causing lateral trunk lean and decreased velocity during gait training without assistive device and contact guard assist (contact with patient due to unsteadiness) for 200 feet...Precautions: Fall risk, flight risk...." Nurses Notes included the following notations: 5/1/11 at 1:30 P.M.: "Up (and) about ambulates fine in am later after lunch usually leans to (right)...." 5/5/11 at 6:00 P.M.: "Rsn (resident) fell in D/R (dining room) @ this time. Sitting upright on her bottom. Rsn tipped chair backward as was trying to stand up at the same time - fell down on bottom (and) struck (lower) spine area or mid back on seat of chair. 3 circular areas each 2.2 cms red at this time...." 5/7/11 at 9:00 A.M.: "Called to dining room per visitor who stated 'res was attempting to sit in chair - missed seat et sat in floor.' Found res seated on buttocks in front of chair...." 5/8/11 at 1:00 P.M.: "Alert to self. Confused to time et place. Ambulating ad lib about unit. Wandering aimlessly much of day. Gait unsteady @ x's. Lacks safety awareness - leans forward et to side freq while seated...." 5/8/11 at 6:45 P.M.: "Res found sitting on floor in hallway per this nurse et nurse assistant. Res was able to move all extremities. Res was touching above (right) eye area. This nurse noted skin was red above (right) eyebrow et (right) temple area, approx 2 cm x 3 cm...Res was able to stand up (with) assistance of staff...." A Care Plan, dated 5/9/11, indicated "Problem, Resident is at risk for falling R/T (related to) Dx (diagnosis) dementia, and psychotropic drug use." The approaches included, "Attempt different activities that might hold interest...Observe frequently and place in supervised area when out of bed...." A Care Plan prior to 5/9/11 was lacking in the clinical record. During interview with the Unit Manager on 6/23/11 at 8:45 A.M., she indicated she could not recall Resident C falling. 4. On 6/23/11 at 10:45 A.M., Medical Records staff # 1 provided the current facility policy on the "Fall Management Program," revised 3/10. The policy included: "It is the policy of American Senior Communities to ensure residents residing within the facility will maintain maximum physical functioning through the establishment of physical, environmental, and psychosocial guidelines to prevent injury related to falls...A care plan will be developed at time of admission specific to each resident based upon the results of the fall risk assessment...Staff interventions: All staff to be aware of new residents...Check on new residents frequently. Anticipate care needs for confused residents...Do not leave unattended in rooms and/or bathrooms if fall risk...Review staffing during key fall times, OT/PT screens as needed...." This Federal Tag relates to Complaint IN 180. 3.1-45(a)(2)

Based on observation, interview, and record review, the facility failed to ensure a resident maintained her weight, in that the resident had a weight loss of 15.8 pounds in 13 weeks, for 1 of 4 residents reviewed with weight loss, in a sample of 4. Resident A Findings include: 1. On 12/28/10 at 9:30 A.M., the Assistant Director of Nursing (ADoN) provided the current facility policy on "Resident Weights," revised 3/10. The policy included: "...Monthly weights will be obtained by the (blank) day of each month...The weight obtained is entered in the weight log. If this weight has a difference of 3 or more pounds on one month for resident weighing less than 100 pounds, or 5 or more pounds in one month for resident weighing above 100 pounds the weight is to be taken immediately to verify the change. The Nursing department is responsible for identifying the resident with significant unplanned wight loss/gain and meeting with the Dietary Services Manager. The physician is also notified of significant or undesirable weight change...A monthly weight log is sent to the following individuals by the (blank( day of the month: Director of Nursing, Registered Dietitian, Dietary Services Manager, MDS (minimum data set) Coordinator...." On 12/28/10 at 10:15 A.M., the ADoN provided the current facility policy on "Resident Weight Monitoring," revised 3/10. The policy included: "The Director of Nursing Services (or designee) and the Dietary Services Manager will review the weight log no less often than monthly...The interdisciplinary team (IDT) will be alerted to residents who have weight or nutritional concerns. The interdisciplinary team will review residents meeting the following criteria no less than bi-weekly until weight is stable...Residents who have experiences a significant weight loss or gain of 5% in 30 days (7.5% in 90 days) or 10% in 180 days...The physician will be notified of unplanned significant weight loss/gain...." 2. On 12/27/10 at 8:45 A.M., during the initial tour of the Alzheimer's unit, the MDS Coordinator indicated Resident A did not require assistance with eating, and had not had a recent weight loss. Resident A was observed at that time walking in the hallway. The MDS coordinator indicated Resident A frequently paced the hallways. The clinical record of Resident A was reviewed on 12/27/10 at 10:00 A.M. The resident was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. An admission Minimum Data Set (MDS) assessment, dated 10/6/10, indicated the resident had a short-term and long-term memory problem and was moderately impaired in cognitive skills for daily decision-making. The MDS assessment indicated the resident required supervision with eating, and her weight was 119 # (pounds). A Dietary Progress Note, dated 10/11/10 (untimed), indicated, "RD (registered dietician) review (secondary to) Initial Assessment. Resident currently receives a regular diet as ordered. (No) chewing or swallowing difficulty noted. Per meal consumption records 10/2-10/9 consumes (approximately) 50% at breakfast, 45% at lunch, and 50% at dinner. Estimated energy needs should be met (with) intakes >75%...Feeds self (with) staff supervision...Will follow as needed." A Plan of Care, dated 10/11/10, indicated, "Self Care Deficit related to: [DIAGNOSES REDACTED]." A Nurses Note, dated 10/11/10 (untimed), indicated, "...Wanders aimlessly (up and down) hall (with) no rational purpose...." A Nurses Note, dated 11/15/10 at 1:30 P.M., indicated, "...Resident feeds self after set up by staff, appetite fair today...Resident does wander in hallway throughout day...." A Nurses Note, dated 11/29/10 at "2200-0600" (10:00 P.M.-6:00 A.M.): "...Appetite fairly good with encouragement...Does wander up and down hallway...." A Resident Weight Flow Sheet indicated the following: 9/25/10: 118.2 #, 10/4/10: 119.3 #, 10/11/10: 117.0 #, 10/18/10: 111.8 #, 10/25/10: 111.4 #. Physician notification of the 6.8 # weight loss in 1 month was not observed in the clinical record. The Weight Flow Sheet continued: 11/1/10: 109.2 #, 11/8/10: 108.8 #, 11/15/10: 107.2 #, 11/22/10: 109.4 #, 11/29/10: 107.4 #. A Dietary Progress Note, dated 11/30/10 (untimed), indicated, "RD (registered dietician) Update: ...November weight triggers a significant weight decline since admission. Resident's dx (diagnosis) include Dementia...placing resident at risk for poor po (oral) intakes and unplanned weight loss...Receives a regular diet as ordered, tolerates well. Requires cueing at meals, set-up and staff supervision...Appears weight loss is most likely R/T (related to) increase in activity and progressing dementia. Will suggest implementing super cereal at breakfast to provide added cal and protein...Will follow as needed." A physician's orders [REDACTED]." The Resident Weight Flow Sheet continued: 12/2/10: 107.4 #, 12/6/10: 107.4 #, 12/14/10: 105.2 #, and the most recent weight, 12/19/10: 102.4 #. A physician's orders [REDACTED]. Help pt (patient) to feed herself." Nurses Notes, dated 12/23/10 at 9:00 P.M., indicated: "...Appetite is poor. Only sits for short periods of time before becoming agitated. Continuously walks (up and down) hallway...." A Plan of Care related to the resident's weight loss was not observed in the clinical record. On 12/27/10 at 12:15 P.M., Resident A was observed sitting in the dining room with her tray in front of her. Before taking a bite, Resident A got up from the table. LPN # 1 attempted to cue the resident to sit down, but the resident did not comply. LPN # 1 walked with the resident, then sat with the resident at the nurses station, with her noon meal in front of her. LPN # 1 attempted to cue the resident to eat, and she did eat a few carrot sticks, then got up to walk in the halls. On 12/27/10 at 2:15 P.M., the Administrator was interviewed regarding the lack of a care plan regarding weight loss for Resident A. The Administrator indicated the Dietary Manager was new and was trying to fix concerns in the kitchen. The Administrator indicated corporate consultants were supposed to be working on the care plans. The Administrator indicated the physician had been aware of the resident's weight loss. The Administrator indicated Resident A frequently paced the hallways. On 12/28/10 at 9:00 A.M., the clinical record of Resident A was again reviewed. A Dietary Progress Note by the Registered Dietician, dated 12/27/10 (untimed), indicated, "...Per wt (weight) records wt is (down) 9.32 % since 9/5/10 (90 days)...Will recommend MVI (with) mineral daily to ensure 100 % of RDI's (recommended dietary intake) and add 90 cc 2 cal HN (dietary supplement) @ HS (bedtime) followed by 120 cc H2O to help maintain weight. Will continue to follow." A Resident Care Plan, dated 12/27/10, indicated a problem of "Resident is at risk for unplanned weight loss R/T (related to) leaves 25 %+ uneaten majority of meals and (increased) activity level of pacing. Significant wt loss exhibited from 10/10 - 11/10. Wt. stable 11/10 -12/10." The Approaches included, "Honor known food preferences. Monitor meal consumption records. Offer replacement for any meal that < 75 % is consumed. Super cereal @ breakfast. Monitor weight records. Offer snacks between meals. Encourage resident to eat @ meals." On 12/28/10 at 9:45 A.M., the ADoN indicated a newly admitted resident was weighed every week for 4-6 weeks. The ADoN indicated it would be the nurse documenting the resident's weight to report the weight loss to the IDT. The ADoN indicated she could not find documentation in the resident's chart that the physician had been notified of the resident's 6.8 # weight loss from 9/25/10 to 10/25/10. This federal tag relates to Complaint IN 655. 3.1-46(a)(1)