Every finding on record at Greenwood Meadows

Based on record review and interview, the facility failed to ensure an accurate assessment for 1 of 25 residents reviewed for MDS (Minimum Data Set) assessment accuracy. (Resident 85)Finding includes:On 12/4/25 at 2:19 p.m., Resident 85's clinical record was reviewed. The diagnoses included, but were not limited to, generalized anxiety disorder, major depressive disorder, and dementia.The notice of PASARR (Preadmission Screening and Resident Review) Level II Outcome, dated 3/6/25, indicated, Final Determination By: .Determination Date: 3/6/25, Level II Outcome: Long Term Approval without Specialized Services.The Annual MDS assessment, dated 11/19/25, did not indicate Resident 85 had a PASARR level II or depression.The MAR (Medication Administration Record) indicated, from 10/31/24 - 11/27/25 the resident had an active order for mirtazapine (a medication used to treat major depressive disorder) 7.5 mg (milligram), for diagnosis of major depressive disorder.During an interview with the MDS Coordinator on 12/5/25 at 11:15 a.m., she indicated section A1500 on the MDS assessment, dated 11/19/25, was marked no in error and indicated it should have been marked yes, for PASARR Level II. The MDS Coordinator indicated the resident had an active diagnosis of major depressive disorder on 11/19/25. The MDS Coordinator indicated the Annual MDS assessment, dated 11/19/25, was marked no in error and it should have been marked yes, for diagnosis of depression. The MDS Coordinator indicated the facility did not have an MDS policy and they utilized the RAI (Resident Assessment Instrument) tool to complete the MDS assessments.On 12/5/25 at 12:00 p.m., a review of the RAI, Version 3.0 User's Manual, Version 1.20.1 October 2025, for section A1500 of MDS, Code 1, yes: if PASARR Level II screening determined that the resident has a serious mental illness and/or ID (Intellectual disability)/DD (Developmental disability) or related condition . The RAI also indicated for section I5800, Depression, Diagnosis status: Active or Inactive is a 7-day look-back period.3.1-31(d)

Based on interview and record review, the facility failed to ensure the resident was included in their care planning process for 1 of 1 resident reviewed for care planning. (Resident 110)Findings include: During an interview on 12/1/25 at 1:59 p.m., Resident 110 indicated she had not been invited to her care plan meeting. On 12/5/25 at 11:08 p.m., the clinical record was reviewed. The diagnoses included, but were not limited to, malignant breast cancer and malnutrition. A Significant Change Minimum Data Set (MDS) assessment, dated 10/15/25, indicated Resident 110 had mild cognitive impairment and the care plan completion date was 10/22/25. The clinical record lacked documentation of resident was included in her care planning process. During an interview on 12/5/25 at 11:42 a.m., the MDS Coordinator indicated the resident and resident's family would be invited to a care plan meeting after the comprehensive MDS assessment was completed. Resident 110 would need to have a care plan meeting after her Significant change MDS, dated [DATE]. The MDS Coordinator indicated she could not find any documentation of Resident 110 being included in her care plan process after 10/15/25. During an interview on 12/5/25 at 12:33 p.m., The Director of Nursing (DON) indicated she could not find any documentation of Resident 110 being included in her care plan process after 10/15/25. On 12/5/25 at 12:15 p.m., the DON provided the facility policy, IDT [Interdisciplinary Team] Comprehensive Care Plan Policy, dated 10/2025, and indicated it was the policy currently being used by the facility. A review of the policy indicated, .Resident, resident's representative, or others as designated by resident will be invited to care plan review 3.1-35(c)(2)(C)

Based on observation, interview and record review, the facility failed to monitor weights and implement interventions for a resident with assessed significant weight loss for 1 of 4 residents reviewed for nutrition. (Resident 27) Findings include: On 9/19/24 at 10:18 am, Resident 27 was observed in her bed. Her wrists were small with bony prominence's, and her face showed indications of emaciation with sunken cheeks and hollow eye sockets. On 9/19/24 at 10:40 am, Resident 27's clinical record was reviewed. The diagnoses included, but were not limited to, dementia, hypothyroidism, and vitamin D deficiency. The quarterly review Minimum Data Set assessment, dated 6/3/24, indicated the resident was severely cognitively impaired. The Care Area Assessment Detail Worksheet, dated 3/8/24, indicated the resident had a history of significant weight loss in the prior 180 days. On 4/3/24 the resident weighed 95 pounds. On 7/4/24 the resident weighed 93 pounds. On 8/1/24 the resident weighed 87 pounds, which indicated a significant weight loss of 11.58 percent in 120 days and a significant weight loss of 6.45 percent in 28 days. No weights were recorded between 7/4/24 and 8/1/24. On 8/7/24 the resident weighed 90 pounds. On 9/3/24 the resident weighed 84 pounds, which indicated a significant weight loss of 6.67 percent in 26 days. No weights were recorded between 8/7/24 and 9/3/24. A Follow Up Nutrition Review, dated 9/4/24, indicated, .loss of 5% or more in the last month or loss of 10% or more in the last 6 months .not assessed ., and .gain of 5% or more in the last month or 10% in the last 6 months .yes, on physician-prescribed weight-gain regimen .resident continues on a regular diet . A Dietitian Review, dated 9/9/24, indicated, .resident is at nutritional risk d/t [due to] unintentional weight loss .resident is on regular diet .hx [history] of benecalorie [an unflavored supplement that could increase the calorie and protein content of most foods and beverages] supplement in oatmeal which was providing additional 330 kcals [kilocalories]. Resident stopped eating her oatmeal with benecalorie in it . Physician orders indicated the resident was prescribed benecalorie to be added to her oatmeal from 6/12/24 until discontinued on 8/15/24. No further dietary, nutritional, or pharmacological interventions were ordered or implemented after 8/15/24. The resident was not on a physician-prescribed weight-gain regimen after 8/15/24. On 9/23/24 at 4:20 p.m., the Director of Nursing provided the Resident Weight Monitoring policy, revised 9/2024, and indicated this was the policy used by the facility. A review of the policy indicated, .bi-monthly weights will be obtained at a minimum for .residents who have experienced a significant weight loss of 5% in 30 days, 7.5% in 90 days or 10% in 180 days . During an interview on 9/23/24 at 4:22 p.m., the Director of Nursing indicated residents identified with significant weight loss underwent a minimum of bi-monthly weight monitoring. 3.1-46(a)(1)

Based on interview and record review, the facility failed to ensure a resident with a diagnosis of type 2 diabetes mellitus (chronic high blood sugar which could be controlled with diet, exercise, and some medications) received a therapeutic diet for 1 of 7 residents reviewed for food. (Resident 283) Findings include: During an interview on 9/18/24 at 11:34 a.m., Resident 283 indicated she was a diabetic and was getting cakes with frosting and doughnuts. She should not be getting those desserts because she was a diabetic. On 9/20/24 at 10:25 a.m., Resident 283's clinical record was reviewed. The diagnoses included, but were not limited to, left femur fracture and type 2 diabetes mellitus with diabetic neuropathy (pain and numbness in hands and feet). The After Visit Summary, dated 9/12/24 at 3:28 p.m., indicated diet instructions were progress as tolerated. The After Visit Summary lacked documentation of Resident 283's diet as regular. The dietary order, dated 9/12/24, indicated a regular diet. The Discharge summary, dated 9/12/24 at 10:39 a.m., indicated she had diagnosis of diabetes mellitus for [AGE] years. Her glucose was 183 on 9/10/24 and 163 on 9/9/24. Her diet was a diabetic diet. The Hospitalist Post-Acute Care Note, dated 9/13/24, indicated the resident had diagnosis of diabetes mellitus. The note lacked documentation of resident's diet. The Hospitalist Post-Acute Care Note, dated 9/16/24, indicated the resident had blood sugars of 140-260. The note lacked documentation of resident's diet. The Initial Nutrition Review, dated 9/16/24 at 1:19 p.m., indicated the current diet order was a regular diet. The special diet prior to admission was low sugar. The clinical record lacked documentation once the facility received the discharge summary and saw the diet was a diabetic diet they clarified the diet with the doctor. During an interview on 9/23/24 at 2:45 p.m., Resident 283 indicated when she was at home prior to her admission to the facility her accu-checks were 130-180 mg/dl (milligrams/deciliter). Since she had been at the facility and was getting regular desserts, her accu-checks had been higher. The other day, she received a sugar cream pie. She was unsure if it was a diabetic pie or regular pie, ate the pie, and her accu-check was around 260 mg/dl. During an interview on 9/23/24 at 2:54 p.m., the Director of Nursing Services (DON) indicated when a resident was discharged from the hospital, they would follow the diet they had in the hospital. The facility's diet for diabetics was carbohydrate controlled diet. During an interview on 9/23/24 at 4:24 p.m., the DON indicated when Resident 283 was admitted , they only had the After Visit Summary. They did not receive the Discharge Summary until the next morning. She indicated she did not have any documentation of notifying the doctor of the diet which was on the discharge summary or that he wanted to continue with the regular diet after the discharge summary was received. On 9/23/24 at 4:30 p.m., the DON provided the facility's policy, Nursing Admission/Return Admission Policy and Procedure, dated 7/2024 and indicated it was the policy being used by the facility. A review of the policy indicated .b. Diet - transcribe the diet using the correct terminology .1. Resident being admitted from the hospital must have a discharge summary. If not present at admission, contact the transferring facility for a copy . 1.3-20(a)

Based on interview and record review, the facility failed to notify a provider of laboratory results that fell outside of clinical reference ranges for 1 of 5 residents reviewed for unnecessary medications. (Resident 105) Findings include: On 9/20/24 at 1:58 p.m., Resident 105's clinical record was reviewed. The diagnoses included, but were not limited to, type 2 diabetes mellitus (DM) with diabetic neuropathy, peripheral vascular disease, and surgical amputation of the right leg (below the knee). A review of the current, September, 2024, physician's orders indicated: On 7/4/24, the resident was ordered insulin aspart U-100 (medication used to treat DM) per sliding scale, at bedtime, 8:00 p.m. The order specified to contact the MD (medical doctor) if blood sugar was great than 400. The resident's blood sugar results on the Electronic Medical Record (EMAR) and vitals login included, but were not limited to: -On 9/8/24 at 9:37 p.m., the resident's blood glucose was 421 mg/dL (milligrams per deciliter). The physician was not notified. -On 8/29/24 at 8:33 p.m., the resident's blood sugar was 414 mg/dL. The physician was not notified. -On 8/29/24 at 7:40 p.m., the resident's blood sugar was 423 mg/dL. The physician was not notified. -On 7/29/24 at 8:11 p.m., the resident's blood sugar was 420 mg/dL. The physician was not notified. -On 7/28/24 at 8:38 p.m., the resident's blood sugar was 437 mg/dL. The physician was not notified. A review of the resident's progress notes, from July to September, 2024, did not indicate a reason why the physician was not notified of any glucose result greater than 400 mg/dL. On 9/23/24 at 3:53 p.m., the Director of Nursing (DON) indicated the resident blood sugars were documented under a few different spots and the staff would call the on-call provider if the resident had a blood glucose out of parameters. On 9/24/24 at 4:25 p.m., the DON provided the facility policy, Blood Glucose Monitoring, revised on 2/2015, and indicated it was the policy currently being used. A review of the policy indicated, . Residents who have a physician's order to obtain routine capillary blood glucose will have a physician's order specifying the blood glucose parameters requiring physician notification . The physician will be notified when the resident's blood glucose is outside the physician stated parameters . 3.1-5(a)(3)

Based on interview and record review, the facility failed to protect a resident's right to be free from verbal abuse by a staff member for 1 of 3 residents reviewed for abuse. (Resident B, CNA 1) Finding includes: During an interview on 3/13/24 at 8:46 a.m., the Administrator indicated, on 2/29/24 at approximately 3:30 a.m. LPN 1 called the DON to report CNA 1 for using foul language when CNA 1 was providing care to Resident B. LPN 1 entered Resident B's room and stopped CNA 1 from providing care. LPN 1 asked CNA 1 to leave Resident B's room and wait for LPN 1 at the nurse's station. LPN 1 finished providing care to Resident B then LPN 1 called the DON. The DON told LPN 1 that CNA 1 had to leave the facility. When LPN 1 told CNA 1 that CNA 1 needed to leave the facility, CNA 1 did not leave. CNA 1 went to other staff and called LPN 1 names. LPN 1 called the police. The Administrator believed CNA 1 left the facility as the police arrived. CNA 1 quit working for the facility when CNA 1 would not respond to the Administrator's phone calls during this investigation. On 3/13/24 at 10:00 a.m., the Administrator provided a witness statement, dated 2/29/24, the statement indicated LPN 1 overheard CNA 1 using foul language when CNA 1 was speaking to Resident B. LPN 1 entered Resident B's room and stopped CNA 1 from providing care. CNA 1 exited Resident B's room. CNA 1 was instructed to clock out and leave the building. CNA 1 became agitated and verbally aggressive toward staff. LPN 1 notified the DON and called the police for assistance. CNA 1 exited the facility. The clinical record for Resident B was reviewed on 3/13/24 at 10:02 a.m. The diagnoses included, but were not limited to, diabetes, hip fracture, and anxiety. An Admission MDS (Minimum Data Set) assessment, dated 1/13/24, indicated Resident B was severely cognitively impaired. A progress note, dated 2/29/24 at 3:45 a.m., indicated concern with care noted related to communication. The physician and family were notified. The Administrator and DON were notified. Staff were to observe Resident B and report any changes to the physician. During an interview on 3/13/24 at 12:45 p.m., LPN 1 indicated on 2/29/24 at approximately 3:00 a.m., LPN 1 was sitting at the nurse's station and overheard CNA 1 tell Resident B to get his dirty f****** hands off of CNA 1. LPN 1 walked to Resident B's doorway, which was approximately 10 feet from the nurse's station. By the time LPN 1 got to Resident B's doorway, CNA 1 told Resident B to get his dirty f****** hands off of CNA 1 two more times. LPN 1 asked CNA 1 to stop providing care and exit Resident B's room. Once CNA 1 was out of Resident B's room, LPN 1 asked CNA 1 to wait in the nurse's station for LPN 1 to return. LPN 1 entered Resident B's room to finish providing care to Resident B. When LPN 1 was finished providing care to Resident B, LPN 1 walked away from the nurse's station to get another staff member to witness LPN 1's conversation with CNA 1. When LPN 1 returned to the nurse's station and told CNA 1 she needed to leave the facility. CNA 1 became upset and refused to leave. CNA 1 walked to two other halls to speak with other staff. LPN 1 repeatedly asked CNA 1 to leave the facility and finally LPN 1 had to call the police. CNA 1 left the facility before the police spoke with her. On 3/13/24 at 8:51 a.m., the DON provided a copy of a facility policy, dated 2/2010, titled Abuse Prohibition, Reporting, and Investigation, and indicated this was the current policy used by the facility. A review of the policy indicated it was the policy of the facility to provide each resident with an environment free from abuse. This citation relates to IN00428632. 3.1-27(b)

Based on interview and record review, the facility failed to follow the abuse policy and ensure an alleged perpetrator of abuse was immediately removed from the facility for 1 of 3 allegations of abuse reviewed. (CNA 1) Finding included: During an interview on 3/13/24 at 8:46 a.m., the Administrator indicated, on 2/29/24 at approximately 3:30 a.m., LPN 1 called the DON to report CNA 1 for using foul language when CNA 1 was providing care to Resident B. LPN 1 entered Resident B's room and stopped CNA 1 from providing care. LPN 1 asked CNA 1 to leave Resident B's room and wait for LPN 1 at the nurse's station. LPN 1 finished providing care to Resident B then LPN 1 called the DON. The DON told LPN 1 that CNA 1 had to leave the facility. When LPN 1 told CNA 1 that CNA 1 needed to leave the facility, CNA 1 did not leave. CNA 1 went to other staff and called LPN 1 names. LPN 1 called the police. The Administrator believed CNA 1 left the facility as the police arrived. During an interview on 3/13/24 at 12:45 p.m., LPN 1 indicated on 2/29/24 at approximately 3:00 a.m. LPN 1 was sitting at the nurse's station and overheard CNA 1 tell Resident B to get his dirty f****** hands off of CNA 1. LPN 1 walked to Resident B's doorway, which was approximately 10 feet from the nurse's station. By the time LPN 1 got to Resident B's doorway, CNA 1 told Resident B to get his dirty f****** hands off of CNA 1 two more times. LPN 1 asked CNA 1 to stop providing care and exit Resident B's room. Once CNA 1 was out of Resident B's room, LPN 1 asked CNA 1 to wait in the nurse's station for LPN 1 to return. LPN 1 entered Resident B's room to finish providing care to Resident B. When LPN 1 was finished providing care to Resident B, LPN 1 walked away from the nurse's station to get another staff member to witness LPN 1's conversation with CNA 1. When LPN 1 returned to the nurse's station and told CNA 1 she needed to leave the facility. CNA 1 became upset and refused to leave. CNA 1 walked to two other halls to speak with other staff. LPN 1 repeatedly asked CNA 1 to leave the facility and finally LPN 1 had to call the police. CNA 1 left the facility before the police spoke with her. CNA 1 was under constant supervision by staff after she was told to leave and walked out of the nurse's station. On 3/13/24 at 8:51 a.m., the DON provided a copy of a facility policy, dated 2/2010, titled Abuse Prohibition, Reporting, and Investigation, and indicated this was the current policy used by the facility. A review of the policy indicated any staff member implicated in the alleged abuse will be removed from the facility at once. This citation relates to Complaint IN00428632. 3.1-28(d)

Based on observation, interview, and record review, the facility failed to ensure a resident with an indwelling catheter received care to prevent UTI's (urinary tract infections) for 1 of 1 residents reviewed for catheters. The urinary catheter tubing and bag were resting on the floor. (Resident 65) Findings include: On 9/8/23 at 10:58 a.m., Resident 65 was observed sitting in her wheelchair with the indwelling catheter tubing touching the floor. On 9/11/23 at 10:57 a.m., Resident 65 was observed sitting in her wheelchair with her indwelling catheter bag and tubing touching the floor. On 9/12/23 at 11:46 a.m., Resident 65 was observed sitting in the dinning room in her wheelchair with her indwelling catheter tubing touching the floor. On 9/13/23 at 8:52 a.m., Resident 65 was observed sitting in the dinning room in her wheelchair with her indwelling catheter tubing touching the floor. On 9/13/23 at 11:20 a.m., Resident 65 was observed sitting in the dinning room in her wheelchair with her indwelling catheter tubing resting on the floor. On 9/14/23 at 11:24 a.m., Resident 65 was observed in bed with the indwelling catheter tubing touching the floor. On 9/14/23 at 11:30 a.m., Resident 65's clinical record was reviewed. The diagnoses included, but were not limited to, chronic kidney disease, type 2 diabetes mellitus, vascular dementia, cognitive communication deficit, and personal history of UTIs. A progress note, dated 9/13/23 at 10:07 a.m., indicated the resident had a UTI and was ordered antibiotics for treatment. A review of the resident's current, September 2023, physician's ordered indicated on 9/13/23 the resident was prescribed Macrobid (an antibiotic medication) for UTI treatment. A urinalysis (UA) dated 7/21/23 indicated the resident had a UTI. A UA dated 6/19/23 indicated the resident had a UTI. A UA dated 5/16/23 indicated the resident had a UTI. A 5/5/23 indwelling urinary catheter care plan, current through 10/10/23, indicated an intervention for staff to not allow tubing or any part of the draining system to touch the floor. During an interview on 9/14/23 at 11:30 a.m., the 100 hall Unit Manager (UM) indicated the resident currently had an UTI. During an observation at that time with UM present, the indwelling catheter tubing was observed touching the floor. The UM indicated the tubing should had been clipped up on the bed. 3.1-41(a)(2)

Based on observation, interview, and record review, the facility failed to ensure the daily nurse staffing information sheet was changed each day, the total hours and actual hours worked by licensed staff was broken down into categories, and failed to maintain the sheets for a period of 18 months for 1 of 1 daily nurse staffing information sheets observed. Findings include: On 9/7/23 at 11:00 a.m., the daily nurse staffing information sheet was observed to be on the receptionist desk dated for 9/1/23. The staffing information sheet lacked documentation of each shift broken down by Registered Nurse (RN), Licensed Practical Nurse (LPN) and Certified Nurse Aide (CNA). During an interview on 9/14/23 at 11:57 a.m., the Administrator indicated the nurse staffing information sheet should be changed every day. During an interview on 9/14/23 at 11:58 a.m., the Regional Director of Clinical (RDC) indicated she had changed the sheet on 9/7/23, but was unsure what time it was changed. During an interview on 9/14/23 at 12:11 p.m., the RDC indicated the nurse staffing information sheet from 9/1/2023 was not available because it had been put in the shredder box. On 9/14/23 at 1:19 p.m., the Director of Nursing provided the facility policy, Posted Nurse Staffing Data and Retention Requirements, dated 7/2019, and indicated it was the policy currently being used by the facility. A review of the policy indicated, . Policy: . The facility must maintain the posted daily nurse staff data for a minimum of 18 months . Procedure: 1. The facility must post the the following information at the beginning of each shift . d. The total number and actual hours worked by the following categories of licensed and unlicensed staff . i. Registered nurses, ii. Licensed practical nurse, iii. Certified nurse aides . 7. The Total Hours column should be broken down by total hours worked by RN, LPN and CNA .

Based on interview and record review, the facility failed to ensure the administration of rapid acting insulin (a prescription medication, injected into the fat layer under the skin, used in the treatment of type 1 and 2 diabetes mellitus that begins to take effect after approximately 5 to 15 minutes after injection) was administered to the correct resident for 1 of 3 residents reviewed for insulin administration. (Resident B, Resident C) Finding includes: During an interview on 11/22/22 at 10:15 a.m., RN 1 (Registered Nurse) indicated she was the nurse that administered insulin aspart (rapid acting insulin) to Resident B. The insulin was meant to be administered to Resident C, but she got confused when she looked at the pictures on the MAR (Medication Administration Record) because Resident B and Resident C's pictures are right next to each other, and they were also in the same room. Resident B returned from dinner approximately 45 minutes later and indicated to her that he felt low. She rechecked Resident B's blood sugar and looked at the picture on the MAR again, and that was when she realized she had administered insulin to the wrong resident. She should have paid more attention to the pictures on the MAR to identify the correct resident. Resident C received the correct dose of insulin when he returned from dinner. The clinical record for Resident B was reviewed on 11/22/22 at 10:18 a.m. The diagnoses included, but were not limited to, urinary tract infection, dementia, and heart failure. An Admission MDS (Minimum Data Set) assessment, dated 7/18/22, indicated Resident B was not cognitively intact. A progress note, dated 10/21/22 at 8:31 p.m., indicated before dinner Resident B accidently received insulin aspart 14 units. When Resident B returned from dinner around 6:30 p.m., Resident B stated he was not feeling well, his blood sugar was 58, and at that time the writer realized she administered insulin to wrong resident. Resident B was alert and oriented, 2 glass of orange juice with 7-8 packs of sugar were administered. After 20 minutes the blood sugar was 63, ensure plus with 4 more sugars packets was administered to Resident B. After 20 minutes the blood sugar was 71. The DON (Director of Nursing) and on call Nurse Practitioner were notified. After 30 minutes the blood sugar was 71. A 12 oz (ounce) soda given to Resident B. Also received order from the Nurse Practitioner to give Glucagon 1 MG (milligrams) and keep checking blood sugar every 15 minutes until blood sugar is above 100, then continue checking blood sugar every hour for 24 hours. After 15 minutes of Glucagon administration blood sugar was 119. Nurse Practitioner and DON made aware. Resident B was alert and able to swallow. Thirty minutes later blood sugar was 141. Hospice informed and family informed. The clinical record for Resident B lacked a diagnosis for diabetes mellitus. The clinical record for Resident B lacked a physician's order for insulin aspart. On 11/22/22 at 11:15 a.m. The Director of Nursing provided a nursing skills competency, titled Insulin Pen Administration, dated 6/2018. A review of the skills competency indicated, 1. Verify resident . On 11/22/22 at 7:12 a.m. The Director of Nursing provided a copy of a facility policy, titled General Dose Preparation and Medication Administration, dated 12/1/2017, and indicated this was the current policy used by the facility. A review of the policy indicated facility staff should verify each time a medication is administered that it is the current medication, at the correct dose, at the correct route, at the correct rate, at the correct time, for the correct resident . This Federal tag relates to Complaint IN00394996. 3.1-37(a)

Based on observation, interview, and record review, the facility failed to implement care plan interventions for 1 of 4 residents reviewed for falls. Neon tape was not applied to the wheelchair breaks. (Resident 11) Finding includes: On 10/17/22 at 10:37 a.m., Resident 11 was observed sitting in her wheelchair with significant left-sided facial bruising and a large bandage on the back of her right hand. The bruising varied in coloration from deep purple to red, extending from her forehead down to her left cheek, and a large hematoma was observed above the resident's left eyebrow. There was no neon tape applied to the resident's wheelchair breaks at this time. On 10/17/22 at 10:40 a.m., Resident 11's clinical record was reviewed. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A fall event report, dated 10/9/22 at 8:11 a.m., indicated the resident had an unwitnessed fall after she attempted to reposition herself in her unlocked wheelchair. The Progress Notes indicated the following: - On 10/9/22 at 9:33 a.m., the resident was heard yelling from her room. She was found sitting on the floor next to her wheel chair and stated she forgot to lock the wheelchair before she repositioned herself which caused the wheelchair to move away. The resident stated that she bumped her left side of forehead on the floor and sustained a left-sided forehead hematoma and a right hand skin tear. - On 10/10/22 at 11:49 a.m., an IDT (interdisciplinary team) review note indicated the resident had a bruise to her left eye which was 100% purple in color. She also had sustained a left eye and right hand skin tear. A new care plan intervention initiated was to apply neon tape to her wheelchair breaks. - On 10/18/22 at 2:18 p.m., the resident continued to have bruising to left eye and skin tears to her right hand and left forehead. Resident 11's current care plan, dated 2/9/17 with a goal date of 11/15/22, indicated an intervention was implemented on 10/9/22, for neon tape to be applied to her wheelchair breaks. During an interview on 10/21/22 at 1:01 p.m., the resident indicated she had a fall which resulted in the left side of her face hitting the floor. The large hematoma remained over brow and a foam dressing remained to the back of her hand. The resident was observed sitting up in her wheelchair without neon tape in place on the breaks. On 10/24/22 at 10:56 a.m., an observation of the resident's wheelchair indicated no neon tape was applied to her wheelchair brakes. During an interview on 10/24/22 at 11:43 a.m., the Director of Health Services (DHS) indicated per a signature log that the neon tape was applied on 10/10/22. She did not know for certain if the staff applied the neon tape to the resident's wheelchair breaks or if the resident removed the tape. 3.1-35(g)(2)

Based on observation, interview, and record review, the facility failed to notify the physician of a change in condition for 1 of 4 residents reviewed for falls. The physician was not notified of new onset pain and low blood pressure following a fall. (Resident 105) Finding includes: On 10/18/22 at 2:25 p.m., non-skid strips were observed to be on the floor beside Resident 105's bed. On 10/21/22 at 10:22 a.m., Resident 105 was observed to be lying in bed with non-skid strips beside her bed. On 10/20/22 at 9:55 a.m., Resident 105's clinical record was reviewed. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set (MDS) assessment, dated 7/14/22, indicated Resident 105 had moderately impaired cognition. A Fall Event, dated 9/10/22 at 9:19 p.m., indicated Resident 105 was found lying on her right side in her room. She had a bruise to her forehead. A progress note, dated 9/11/22 at 3:58 a.m., indicated Resident 105 had pain in her right leg. The pain radiated from her right hip to her right knee. Her blood pressure was 74/47 mm/Hg (millimeters/Mercury) while lying down and 80/54 mm/Hg while sitting. The September 2022 PRN (as needed) Medication Administration History indicated the following: -On 9/11/22 at 3:57 a.m., Resident 105 was administered [MEDICATION(S)]-acetaminophen (a narcotic pain medication) 5-325 mg (milligrams) for pain. The pain medication was not effective. -On 9/13/22 at 4:18 a.m., Resident 105 was administered [MEDICATION(S)]-acetaminophen 5-325 mg (milligrams) for pain. The pain medication was somewhat effective. The Hospitalist Post-Acute Care note, dated 9/12/22 (no time indicated), indicated Resident 105 had complaints of right hip pain after fall on 9/10/22. She had pain with ambulation and range of motion. She had [CONDITION(S)] (low blood pressure) throughout the weekend. The recommendation was a right hip x-ray. The x-ray dated, 9/13/22 at 8:33 a.m., indicated right [CONDITION(S)]. The clinical record lacked documentation of physician notification of right hip pain or low blood pressure on 9/11/22. During an interview on 10/21/22 at 11:55 a.m., the Director of Health Services (DHS) indicated she could not provide documentation of the nurse practitioner or physician being notified on 9/11/22 when Resident 105 complained of right hip and knee pain or low blood pressure. On 10/21/22 at 2:20 p.m., the DHS provided the facility's policy, Fall Management Policy, with a revised date of 8/2022, and indicated this was the policy currently being used by the facility. A review of the policy indicated .3. The physician will be contacted immediately, if there are injuries, and orders will be obtained . On 10/24/22 at 2:18 p.m., the DHS indicated they did not have a physician notification policy. 3.1-5(a)(1)

Based on observation, interview, and record review, the facility failed to ensure care and services were provided to maintain the residents highest practicable well being for 1 of 2 residents reviewed for skin conditions and 1 of 3 residents reviewed for hospitalization s. Vital signs, blood sugars, and a thorough assessment were not completed following a change in condition and a skin rash was not reevaluated after treatment. (Resident 90, Resident 88) Findings include: 1. On 10/20/22 at 11:23 a.m., Resident 88's clinical record was reviewed. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the Progress Notes for Resident 88 included the following: - On 9/22/22 at 3:55 a.m., Resident vomited in bed, gave prn [as needed] zophran [sic, a medication to prevent nausea and vomiting] sublingual [under the tongue]. CNA [certified nursing assistant] cleaning resident up. - On 9/22/22 at 5:16 a.m., Resident vomited in bed again, asked her if she thinks it may be something she ate that is making her sick, resident states she is not sure. Set HOB [head of bed] at 45 degrees, notified MD [medical doctor] in communication book. - On 9/22/22 at 8:09 a.m., Writer checked resident glucose and reading hi [high]. Writer rechecked glucose and reading was hi again. Resident was lethargic and unable to answer neurological questions. Writer notified on call MD [medical doctor] and new orders given. Writer notified son of new orders and he understood. Son stated that his mother called him last night and stated that she was not feeling well and that she was nauseated. Writer informed son that prn medication was given. Resident was transferred to [hospital name] for further evaluation and treatment. The Vitals Report for Resident 88 indicated the following: 9/22/22 at 12:23 a.m., oxygen saturation 95%, blood pressure 132/69, respirations 18, pulse 67, temperature 98.4. 9/22/22 at 6:43 a.m., oxygen saturation 93% and temperature 96.8. 9/22/22 at 7:03 a.m., blood sugar 498. 9/22/22 at 8:39 a.m., blood sugar 500. 9/22/22 at 11:47 a.m., blood sugar off scale: high. The clinical record lacked documentation of vital signs, blood sugar, and a thorough assessment being completed from the time the resident started vomiting at 3:55 a.m. until 7:03 a.m. A document titled, Internal Medicine Attending Attestation dated 9/22/22, at 2:58 p.m., for Resident 88 indicated the resident presents due to mental state change . Assessment/Plan 1. Acute metabolic [CONDITION(S)] 2. diabetic ketoacidosis without coma 3. acute [CONDITION(S)] [urinary tract infection] 4. elevated troponin 5. [CONDITION(S)] 6. AKI on [CONDITION(S)] 7. coronary artery disease 9. chronic heart failure . During an interview on 10/21/22 at 9:50 a.m., the Director of Nursing Services (DNS) indicated the night shift nurse did not check Resident 88's blood sugar or vital signs on 9/22/22 after the resident started vomiting. During an interview on 10/21/22 at 10:51 a.m., Licensed Practical Nurse 1 indicated Resident 88 was cognitively not acting right when she came on shift the morning of 9/22/22. She immediately checked her blood sugar and it was high. She checked it again and it was high. It was unusual for the resident to vomit so she called the nurse practitioner for new orders. During an interview on 10/21/22 at 12:24 p.m., Registered Nurse 1 indicated Resident 88 started vomiting about 3:30 a.m. She could not remember if she took or vital signs or blood sugar that night. On 10/21/22 at 11:15 a.m., the facility indicated they did not have a policy related to completing vital signs, blood sugars, or a thorough assessment for a resident with diabetes mellitus who starts vomiting. 2. On 10/18/22 at 10:14 A.M., Resident 90 was observed lying in his bed. The skin on his hands, arms, chest, face, and legs was dry, red, and flaking. At that time, Resident 90 indicated his skin was itchy and stinging. Resident 90 was unsure if he was receiving treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] On 10/19/22 at 11:05 A.M., Resident 90 was observed lying in his bed. The skin on his hands, arms, chest, face, and legs was dry, red, and flaking. At that time, Resident 90 indicated his skin was itchy and uncomfortable. On 10/20/22 at 11:26 A.M., Resident 90 was observed lying in his bed. The skin on his hands, arms, chest, face, and legs was dry, red, and flaking. At that time, Resident 90 indicated his skin was itchy and uncomfortable. On 10/19/22 at 2:40 P.M., Resident 90's clinical record was reviewed. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission MDS (Minimum Data Set) assessment, dated 9/19/22, indicated the resident was cognitively intact. A nursing progress note, dated 10/12/2022 at 9:08 A.M., indicated, Resident with rash all over body, warm to touch .put in communication book . A nursing progress note, dated 10/14/2022 at 3:16 P.M., indicated, .Patient with red rash and dry skin. NP [Nurse Practitioner] aware. Patient has hx [history] of allergic reaction to previous antibiotic. Benadryl given per orders. A nursing progress note, dated 10/17/2022 at 1:06 A.M., indicated, .New skin issue on L arm, resident scratched himself since it's too itchy . The resident's admission face sheet, dated 9/13/22, indicated, .no known drug allergies . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The clinical record lacked follow up for Resident 90's continued skin rash following treatment. During an interview on 10/21/22 at 9:45 AM, the Director of Nursing indicated the resident developed an allergic reaction to an antibiotic which caused his skin to be red, dry, and itchy. The resident was given benadryl for several days. 3.1-37(a)

Based on interview and record review, the facility failed to ensure ongoing assessment and oversight of the resident before, during, and after [CONDITION(S)] treatments, including monitoring the resident's condition during treatments, and failed to have ongoing communication and collaboration with the [CONDITION(S)] facility for 1 of 1 resident reviewed for [CONDITION(S)] services. (Resident 11) Findings include: On 10/19/22 at 9:40 a.m., Resident 11's clinical record was reviewed. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's [CONDITION(S)] communication documents from September 2022 to October 24, 2022, indicated 15 out of 23 visits had no [CONDITION(S)] nurse communication notes. The [CONDITION(S)] nursing sections were blank. During an interview on 10/24/22 at 10:58 a.m., the Director of Health Services (DHS) indicated the [CONDITION(S)] communication tool is not always returned to the facility. She indicated staff would sometimes try to call the [CONDITION(S)] center to see if they could get information. On 10/24/22 at 2:15 p.m., the DHS provided the facility policy, [CONDITION(S)] Care, revised on November, 2017, and indicated it was the policy currently being used. A review of the policy indicated, .Ongoing assessment of the resident's condition and monitoring for complications before and after [CONDITION(S)] treatments received at a certified [CONDITION(S)] facility . Ongoing assessment and oversight of the resident before, during, and after [CONDITION(S)] treatments, including monitoring of the resident's condition during treatment, monitoring for complications . Ongoing communication and collaboration with the [CONDITION(S)] facility regarding [CONDITION(S)] care and services . 3.1-37(a)

Based on observation, interview, and record review, the facility failed to ensure a self medication administration assessment was completed for 1 of 7 residents observed for medication administration. Staff left medications in the resident room without a self medication administration assessment. (Resident 220) Finding includes: On 10/17/22 at 12:04 p.m., Qualified Medication Aide (QMA) 1 was observed to hand Resident 220 a cup with [MEDICATION(S)] HCL (a medication used to treat high blood pressure) 0.2 mg (milligrams) and turn and leave the room. On 10/17/22 at 12:30 p.m., Resident 220's clinical record was reviewed. The diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The Significant Change Minimum Data Set (MDS) assessment, dated 8/5/22, indicated Resident 220 was cognitively intact. During an interview on 10/17/22 at 12:49 p.m., QMA 1 indicated Resident 220 was alert and oriented and did not require observation during medication administration. During an interview on 10/21/22 at 10:30 a.m., the Director of Nursing Services (DNS) indicated Resident 220 had not had a medication self administration assessment completed and it had not been normal practice to leave medications at the bedside. On 10/24/22 at 2:17 p.m., the DNS provided the facility policy, General Dose Preparation and Medication Administration dated 12/1/2007, and indicated it was the policy currently being used by the facility. A review of the policy indicated, . 5. During medication administration, facility staff should take all measures required by facility policy and applicable law, including, but not limited to the following . 5.9 observe the resident's consumption of the medication [s] . 3.1-11(a)

Based on interview and record review, the facility failed to ensure radiological services were provided immediately, as indicated by the physician's order, to a resident who sustained a fall with injury for 1 of 1 resident reviewed for radiology services (Resident 140). Findings include: On 3/5/20 at 3:05 p.m., Resident 140's closed clinical record was reviewed. [DIAGNOSES REDACTED]. Resident 140's Event Report, dated 1/2/20 at 2:03 a.m., indicated, . Heard a loud noise from resident's room. Resident began to yell for help. Entered room to find resident lying on her side in her bathroom with her w/c (wheelchair) next to her. Resident was unable to explain what she was doing or attempting to do. No internal or external rotation noted to lower extremities . Resident 140's January, 2020, physicians orders indicated the following: -On 1/2/20 at 3:13 a.m., the resident was ordered a STAT (immediate) hip x-ray. The order was discontinued, on 1/2/20 at 6:10 a.m., related to a date entry error. -On 1/2/20 at 6:10 a.m., the resident was ordered a hip x-ray. The order was discontinued, on 1/2/20 at 1:58 p.m. No reason was listed for the order being discontinued. -On 1/2/20 at 1:58 p.m., the resident was ordered a hip x-ray. The order was discontinued, on 1/7/20 at 12:09 p.m., due to the resident being discharged . Resident 140's progress notes indicated the following: 1/2/20 at 9:50 a.m., Contacted X-ray company regarding ETA (estimated time of arrival) of x-ray, dispatch reaching out to tech. 1/2/20 at 10:04 a.m., IDT (interdisciplinary team) fall review . patient was found on floor in bathroom, had transferred self to w/c from bed, propelled self into bathroom and upon attempting to transfer from w/c to toilet fell to floor. No injuries noted, ROM (range of motion) intact to all extremities .Patient started having bilateral hip pain post fall. MD (Medical Doctor) notified new orders for x-rays, new orders for Tylenol were obtained and dose administered . NP (nurse practitioner) will evaluate should additional pain medicine be required for pain control. 1/2/20 at 1:52 p.m., Contacted X-ray company regarding ETA of x-ray, dispatch reaching out to tech. 1/2/20 at 3:57 p.m., Contacted X-ray company regarding ETA of x-ray, dispatch reaching out to tech. Spoke with supervisor unable to give time, will call back . still waiting for mobile x-ray. 1/2/20 at 10:44 p.m., (Radiology Services Name) in facility earlier this eve (evening) for xray hip/pelvis . spoke with family regarding preference of reaching out to ortho (orthopedics) 1/3/20 or sending to ER (emergency room ) for eval (evaluation). POA (power of attorney) opted for ER . 1/3/20 at 10:29 a.m., . Resident was admitted to (Hospital Name) for pubis rami fractures identified in xrays completed on 1/2/20 . Resident was immediately assessed by nurse who noted increase in pelvic pain. Nurse notified on-call MD who ordered STAT (immediate) xrays . STAT Xrays completed (sic) and concluded Lt (left) pelvic rami fractures . Resident admitted to hospital r/t (related to) fractures . Resident 140's Radiology Report, dated 1/2/20 at 5:53 p.m., indicated, Pelvis 1-2 views . Acute/subacute left pubic rami fractures seen with mild displacement. Conclusion: Acute/subacute left pubic rami fractures . Interview, on 3/06/20 at 3:32 p.m., LPN 1 indicated staff did not send resident out due to the Nurse Practitioner instructions to wait on radiology and resident did no sustain a life-threatening injury. Interview, on 3/06/20 at 4:00 p.m., the Director of Nursing Services indicated she did not know why the second x-ray order was canceled and reordered. On 3/6/20 4:20 p.m., the Facility Administrator provided the (Radiology Services Name) Portable Diagnostic Services Agreement, dated 11/18/13, and indicated it was the contract currently being used by the facility. A review of the contract indicated no specific time frames in regard to service response time. 3.1-49(g)

Based on observation, interview, and record review, the facility failed to ensure the 200 unit dining room was free from scuffed walls, peeling wall paper, and a damaged electrical box cover plate. Twelve of 43 residents on the 200 unit dined in the 200 unit dining room. Findings include: On 3/2/20, at 11:15 A.M., the 200 unit dining room was observed to have peeling wall paper on the southeast and southwest walls, scuffs on the southeast and south wall, and a broken electrical box cover plate on the southeast wall. During an interview, on 3/6/20 at 10:30 A.M., the facility Administrator indicated the 200 unit dining room walls and electrical box cover plate were in need of repair. Twelve of 43 residents on the 200 unit dined in the 200 unit dining room. On 3/5/20 at 10:00 A.M., the Director of Health Services provided the Resident Rights, revised date of 7/2019, and indicated these were the Resident Rights currently used by the facility. A review of the Resident Rights indicated, .the resident as the right to a safe, clean, comfortable, and homelike environment . 3.1-19(f)(5)

Based on observation, interview, and record review, the facility failed to ensure the privacy and confidentially of residents' personal medical information for 2 of 2 residents observed to have personal health information taped to a wall in their room. (Resident 46, Resident 110) Findings include: 1. On 1/30/2019 at 2:50 p.m., Resident 46's room was observed to have a sign taped on the wall which gave personal medical information. The sign indicated, Please change (residents name) sheets in the morning during her care. Allow her to assist with clean up of her room within safe parameters from wheelchair level placing objects in desired areas in order to reduce behavioral disturbances and morning issues with perseverating (sic) on this task. On 2/1/2019 at 10:13 a.m., Resident 46's room was observed to have the same sign taped on the wall. On 2/4/2019 at 10:10 a.m., Resident 46's room was observed to have the same sign taped on the wall. 2. On 1/29/2019 at 10:19 a.m., Resident 110's room was observed to have two signs taped on the wall which gave personal medical information. One sign indicated, Please use the soft bristle brush daily to brush her hair to reduce matting in the posterior aspect of her head. Detangler (sic) is located in the shower. The other sign indicated, During upper body bathing allow the patient to complete passive range of motion to the right upper extremity into shoulder flexion. Position the right lower extremity in right heel boot to tolerated elevation on pillow. Transfer using beasy board from bed to wheelchair with two helpers for safety with bed inflated to the most firm setting. On 1/30/2019 at 10:08 a.m., Resident 110's room was observed to have the same two signs taped on the wall. On 2/4/2019 at 10:03 a.m., Resident 110's room was observed to have the same two signs taped on the wall. During an interview, on 2/4/2019 at 11:35 a.m., the Director of Nursing Services (DNS) indicated the signs should not be there. During an interview, on 2/4/2019 at 11:36 a.m., the Administrator indicated the signs should be behind the closet door. On 2/4/2019 at 2:38 p.m., the DNS provided the current facility policy, Use and Disclosure of Protected Health Information with a revised date of October, (YEAR). A review of the policy did not address the taping of signs in the resident's room listing personal medical information. 3.1-3(o)

Based on observation, interview, and record review, the facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessment for 1 of 5 resident reviewed for activities of daily living. (Resident 116) Findings include: On 1/29/19 at 2:37 p.m., Resident 116 was observed to be wearing mechanical prosthetic hooks on both upper extremities and limb prostheses on both lower extremities. Interview, at that time, Resident 116 indicated she had to wear them all the time when she was out of bed. On 1/30/19 at 3:00 p.m., Resident 116 was observed to be wearing mechanical prosthetic hooks on both upper extremities and limb prostheses on both lower extremities. On 1/30/19 at 3:33 p.m., Resident 116's clinical record was reviewed. [DIAGNOSES REDACTED]. A review of Resident 116's January, 2019, current physicians orders indicated, Start date: 12/5/18: Add padding to prosthetic ring over back. A Physical Therapy Plan of Care, start date of 12/26/18 with an end of care date of 2/4/19, for Resident 116 indicated, Patient lives in this long term care facility . The patient performed self feeding with setup when using prostheses . During an interview, on 2/1/19 at 11:15 a.m., RN 2 indicated Resident 116 consistently utilized her upper limb prosthesis to eat and lower limb prostheses to self propel around the facility the wheelchair. She is very independent. During an interview, on 2/4/19 at 12:19 p.m., Resident 116's daughter indicated her mother used her limb prostheses every day, as soon as she gets out of bed. Resident 116's Quarterly MDS assessment, dated 1/1/19, indicated the resident had impairment on both sides of her upper and lower extremities and utilized a wheelchair as a mobility device. The MDS did not indicate the resident used limb prostheses. A review of the Resident Assessment Instrument (RAI) Version 3.0 Manual, Section G0600 . Mobility Devices . check G0600D, limb prosthesis: if the resident uses an artificial limb to replace a missing extremity . 3.1-31(d)

Based on observation, interview, and record review, the facility failed to ensure residents were showered per their bathing preferences for 3 of 4 residents reviewed for choices. (Resident 19, Resident 116, and Resident B) Findings include: 1.) On 1/29/19 at 10:39 a.m., Resident 19 was observed with unclean hair. Interview, at that time, Resident 19 indicated she would like to get her showers in the morning, however, staff was giving them to her in the evening, I just wash up in the bathroom sink. On 1/31/19 at 11:00 a.m., Resident 19's clinical record was reviewed. [DIAGNOSES REDACTED]. A review of Resident 19's preference sheet, dated 1/29/19, indicated the resident wanted 2-3 showers a week in the morning. A review of Resident 19's Shower Reports, dated 12/3/18 through 1/17/19 indicated the resident was on a Monday and Thursday evening shower schedule. A Shower Report, dated 12/3/18, indicated Monday Eve (evening) . Refused x 3 (3 times) wants in morning. During an interview, on 1/31/19 at 3:30 p.m., the Director of Nursing Services indicated Resident 19 is on a Monday and Thursday evening shower schedule. On 2/4/19 at 3:11 p.m., the Executive Director provided the facility policy, Resident Rights, revised on August, (YEAR), and indicated it was the policy currently being used. A review of the policy indicated, Self-Determination. A resident has the right to: Choose activities, schedules, and health care consistent with his or her interests, assessments, and plans of care . Make choices about aspects of his her life in the facility that are significant such as schedules, including . bathing . 2.) During an interview, on 1/29/19 at 2:37 p.m., Resident 116 indicated she preferred 3 showers a week. On 1/30/19 at 3:33 p.m., Resident 116's clinical record was reviewed. [DIAGNOSES REDACTED]. A review of Resident 116's preference sheet, dated 1/1/19, indicated the resident wanted bathed 3 times a week. A review of Resident 116's Shower Reports, dated 12/11/18 through 1/30/19, indicated the resident was scheduled to receive showers twice a week, on Wednesday and Saturday evenings. During an interview, on 1/31/19 at 3:30 p.m., the Director of Nursing Services indicated Resident 116 is on a Wednesday and Saturday shower schedule. On 2/4/19 at 3:11 p.m., the Executive Director provided the facility policy, Resident Rights, revised on August, (YEAR), and indicated it was the policy currently being used. A review of the policy indicated, Self-Determination. A resident has the right to: Choose activities, schedules, and health care consistent with his or her interests, assessments, and plans of care . Make choices about aspects of his her life in the facility that are significant such as schedules, including . bathing . 3). On 1/31/19 at 10:23 a.m., Resident B's clinical record was reviewed. The [DIAGNOSES REDACTED]. The admission Minimum Data Set (MDS) assessment, dated 12/20/18, indicated Resident B had severe cognitive impairment, to choose between tub bath, shower, bed bath or sponge bath was very important, and required one person physical help with bathing. The Personal Preferences Assessment, dated 12/20/18, indicated Resident B preferred a shower in the morning two times a week. A care plan, initiated on 11/21/18 and current through target date 4/28/19, for Resident B indicated: PROBLEM: Resident requires assistance with ADLs (activities of daily living) including bed mobility, transfers, eating and toileting related to: weakness and debility, fatigue & SOB (shortness of breath) r/t (related to) [MEDICAL CONDITIONS], impaired mobility, incontinence, dementia, poor motivation r/t depression .GOAL .Resident has a desire to improve current functional status .APPROACH .Assist with bathing as needed per resident preference. Offer showers two times per week in AM, partial bath in between Resident B's assignment sheet, undated, indicated shower days were in the evening. Resident B's Shower report indicated the following: -On 1/15/19, the shower was offered on Tuesday evening. -On 1/18/19, the shower was offered on Friday evening. -On 1/22/19, the shower was offered on Tuesday evening. -On 1/25/19, the shower was offered on Friday evening. -On 1/29/19, the shower was offered on Tuesday evening. During an interview, on 2/1/19 at 11:48 a.m., Certified Nursing Assistant (CNA) 1 indicated Resident B was an evening shift shower. During an interview, on 2/1/19 at 11:57 a.m., Registered Nurse (RN) 1 indicated Resident B was an evening shower. On 2/4/19 at 3:11 p.m., the Executive Director (ED) provided the facility's policy, Resident Rights, dated 8/18, and indicated it was the policy currently being used by the facility. A review of the policy indicated, .Choose activities, schedules, and health care consistent with his or her interests, assessments, and plans of care .Make choices about aspects of his her life in the facility that are significant such as schedules, including but not limited to sleeping, waking, eating, and bathing . This Federal tag relates to Complaint IN 107. 3.1-3(u)(1)

Based on observation, interview, and record review, the facility failed to provide supervision to maintain resident's safety while wandering which resulted in a fall with fracture that required medical intervention for 1 of 7 residents reviewed for accidents. (Resident 348) Findings include: On 2/16/18 at 2:56 p.m., Resident 348's clinical record was reviewed. Her admitted was 2/1/18. [DIAGNOSES REDACTED]. Resident 348's admission Minimum Data Set (MDS) assessment, dated 2/8/18, indicated she had severe cognitive impairment; wandered daily; wandering significantly intruded on the privacy or activities of others. A review of Resident 348's care plan, dated 2/1/18, indicated she had a risk for falls due to required assistance with activities of daily living (ADLs), weakness, hypertension (HTN), abnormalities of gait. The care plan indicated the following interventions: -Call light within reach -Environmental changes -Personal items in reach -Therapy screen -Non skid footwear when out of bed. Resident 348's care plan lacked documented interventions for assessed wandering and intrusive behaviors. At exit conference, on (MONTH) 22, (YEAR) at 4:00 p.m., the facility did not provide documentation that indicated intrusive wandering careplan with interventions had been developed. A review of Resident 348's progress notes indicated the following: -On 2/4/18 at 12:59 a.m., she was agitated and aggressive all evening, wandered into other resident's rooms and beds. When asked by staff to leave the bed, she became aggressive, yelled, cursed and hit at the nurse. She walked the halls all evening and is now walking the halls at night, in and out of others' rooms, resting for a few minutes and back up. -On 2/4/18 at 4:51 a.m., she continued to roam the halls and into other residents' rooms, cursed at staff when asked to leave their room, stopped to rest for a few minutes. -On 2/7/18 at 1:08 a.m., she was found in another resident's room sitting on the floor. The current room resident indicated Resident 348 had attempted to sleep in the current resident's bed. Resident 348 became combative (scratched and kicked) towards staff and the other resident. Numerous attempts to try and redirect Resident 348 was ineffective. Resident 348's right wrist was swollen and painful to touch. Medical Doctor (MD) was notified and ordered an X-ray of the right wrist. -On 2/7/18 at 2:37 a.m., She attempted to walk back towards her room and began to lose her balance. Staff lowered her to the ground to prevent injury. -On 2/7/18 at 12:58 p.m., a behavior note, dated for 2/7/18 at 1:08 a.m., indicated she was found wandering into another resident's room. She tried to get into another resident's bed. Other resident asked her to leave and then she scratched the other resident. She was new to the facility and was having some difficulty adjusting. She does not know where her room was located at that time. The facility will also clearly mark her room with her name in bold letters. -On 2/8/18 at 8:18 a.m., an Interdisciplinary Team (IDT) skin note indicated she had a new bruise noted to the right wrist. The root cause was from a recent fall with fracture to the right wrist. She preferred to wander freely in unit and goes in and out of other residents' rooms even with re-direction. She refused to comply with staff assistance. -On 2/7/18 at 4:06 p.m., an IDT fall note indicated IDT team reviewed the fall that occurred on 2/7/18 at 2:30 a.m. She attempted to walk herself back to her room and and she lost her balance. The staff was able to intervene and lower her to the floor. She was involved in a resident to resident altercation one hour previous to this fall in which she fell and landed on her wrist. An X-ray showed a fracture to the right wrist. The IDT attributed this fall to increased weakness related to pain from the fracture and increased tiredness from the physical altercation. An orthopedic (musculoskeletal doctor) consult had been scheduled for her. She was being treated for [REDACTED]. -On 2/11/18 at 1:43 a.m., she wandered the halls and into other residents' rooms. She was redirected at least seven times this shift. She closed doors loudly and often woke residents. -On 2/11/18 at 2:13 p.m., she intrusively wandered from room to room and attempted to lay in occupied beds. The cast to right wrist was present and was currently clean dry and intact. -On 2/13/18 at 3:23 a.m., she continued to be intrusive in multiple residents' rooms. When redirected she slammed the doors to those rooms purposefully hard and was agitated. She was redirected back to her room through the night and laid in her bed, but was up shortly after roaming and going into other rooms that were not hers. -On 2/14/18 at 9:43 a.m., she wandered through the halls and into other's rooms daily. On 02/16/18 at 10:22 a.m., Resident 348 was observed sitting in a chair, beside the bed, in the room of Resident 86. Not Resident 348's room. Staff were observed to not provide supervision or redirection to Resident 348. Continued review of progress note indicated: -On 2/18/18 at 12:08 a.m., she wandered about, in and out of other residents' rooms. She became angry when redirected to her own room, slammed doors and argued with staff. -On 2/19/18 at 12:29 a.m., she became agitated during routine care. She spit, hit, pinched, and cursed at staff. She wandered the halls, in and out of every room but her own. She was upsetting some of the residents. She was redirected to her room several times, but refused to stay there. -On 2/19/18 at 5:14 a.m., She continued to roam the halls and into other residents' rooms. Several times she woke and upset them. When staff attempted to redirect, she cursed and scratched the nurse. On 02/20/18 at 09:56 a.m., Resident 348 was observed resting with their eyes shut in a bed in the room of Resident 26. Not Resident 348's room. Staff were observed to not provide supervision or redirection to Resident 348. On 02/20/18 at 12:12 p.m., Resident 348 was observed sitting in dining room (DR) with a blue cast on their right arm eating lunch. During an interview, on 02/20/18 at 11:42 a.m., Qualified Medication Aide (QMA) 1 indicated Resident 348 roamed all day and night and got upset with staff when they try to redirect her from going into other residents' rooms, although residents get frustrated when she wanders in their room. Resident 348 had a bright orange sign with her name on the door, and staff will direct her to room after meals. Resident 348 went into Resident 124's room and tried to get into her bed, which made Resident 124 upset and Resident 348 was found laying on her right arm (incident dated 2/7/18 at 1:08 a.m.). QMA 1 did not indicate how the facility provided supervision to ensure Resident 348's safety from intrusive wandering. On 02/20/18 at 11:58 a.m., the Memory Care Program Coordinator indicated Resident 348 wandered into other residents' rooms and the other residents got frustrated by her wandering. She did not indicate how the facility provided supervision to ensure Resident 348's safety from intrusive wandering. On 02/21/18 at 02:19 p.m., the Director of Nursing (DON) indicated staff was aware of Resident 348 going in and out of other residents' rooms and if staff can't find the resident they start looking in other residents' rooms for her. The staff on memory care unit provide supervision, activities, and keeping the same staff scheduled. On 2/21/18 at 3:35 p.m., the DON provided the policy, Fall Management Program, dated November, (YEAR), and indicated it was the policy currently being used by the facility. The policy indicated, It is the policy of American Senior Communities to ensure residents residing within the facility receive adequate supervision and or assistance to prevent injury related to falls . 3.1-45(a)(2)

Based on observation, interview, and record review, the facility failed to ensure each resident's environment remained free from accidents in that the facility failed to ensure that a Broda chair was sufficiently tilted back as indicated by manufacturer's instructions for 1 of 3 residents reviewed for accidents, which resulted in the resident having tipped over the chair and sustained a subdue hematoma (a collection of blood outside the brain-Web MD). (Resident #C) Findings Include: Resident# C's clinical record was reviewed on 07/02/14 at 12:00 p.m. [DIAGNOSES REDACTED]. Resident #C's BIMS (Brief Initial Mental Status) score was a 03, indicating Resident #C was dependent on nursing staff for daily decision making. Current physician orders [REDACTED]. A nursing note entry indicated, "on 6/15/14 Resident had unwitnessed fall. Resident was found on floor face down with broad chair over resident after fire alarm was clear. Vitals signs taken and skin tear to left side of nose and swelling to left side of head and neck. Resident complained of pain in right shoulder. No active bleeding noted (Resident is on Coumadin therapy). POA (family) contacted and requested Resident #C to be sent to Community South." Nursing notes dated 06/17/14 at 9:40 p.m., indicated Resident #C was readmitted to facility with [DIAGNOSES REDACTED]. No antiplatelet or anticoagulants or thrombolytics (Coumadin therapy) until given okay by attending physician. Review of facility's interdisciplinary team (IDT) notes dated 6/19/14 at 3:39 p.m., indicated the fall review-follow up from Resident #C's fall indicated Resident #C was in the hall waiting to go to bed and the fire alarm went off. Resident #C was put in her room and door closed per protocol. Resident #C then attempted to get up unassisted causing her to fall out of her chair. During the fall she sustained a subdural hematoma and was sent to the ER (emergency room ) and admitted . Upon assessment of Resident#C and their environment and interview with staff it was noted that Resident #C was in her Broda chair without the seat dumped, due to the hast of the situation. Root cause of the fall noted to be resident startled by fire alarm and got up unassisted. Staff education provided on the importance of maintaining a tilted position while up in Broda chair. Care plan reviewed and updated. Interview with Resident #C's son on 07/02/2014 at 3:04 p.m., indicated he was informed of the fall, the diagnosis, and has no concerns related to the care that his mother receives at the facility. Observation of and interview with Resident # C on 06/02/2014 at 3:40 p.m., indicated Resident #C was sitting in a tilted back Broda chair and when approached and her name called, she responded with a "hello." Resident #C did not recall any of the incident when asked and entered into the conversation relating to a totally different subject than what was asked. Interview with ED (Executive Director) on 7/02/14 4:00 p.m., indicated the word "dumping" related to the Broda chair not being tilted back so a resident would not come out of it. He indicated the person involved in the incident was not working today and copies of staff inservices related to the Broda chair were provided by the ED. Review of the manufacturers guidelines for the Broda chair on 07/02/2014 at 4:05 p.m., provided by the ED on 06/02/2014 at 4:00 p.m. indicated on page 2, section 2.5 hazards, under 2.5.2 "Position of Seat Tilt - Danger of Tipping," indicated the manufacturer recommended that the chair's seat be tilted sufficiently to prevent an agitated resident from tipping the chair forward or backward or slumping and sliding in the chair. 3.1-45(a)(1)

Based on record review and interview, the facility failed to ensure the resident received the correct dosage and adequate monitoring of an anticoagulant ([MEDICATION NAME]/[MEDICATION NAME]-blood thinner) to prevent supratherapeutic levels for 1 of 3 resident's reviewed for anticoagulant therapy in a sample of 3 (Resident # B). Findings include: The record for Resident # B was reviewed on 7/22/13 at 11:40 A.M. The resident was discharged from the facility on 7/11/13. [DIAGNOSES REDACTED]. A physician's telephone order dated 6/29/13 indicated [MEDICATION NAME], 3.5 mg (milligrams) daily starting 6/30/13, a PT/INR (anticoagulant blood test) to be completed on 7/6/13 and to call the M.D. with the blood test results prior to administering the dose of [MEDICATION NAME]. Review of the resident's July Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The record lacked documentation of the PT/INR for July 6, 2013. A hospital ED (emergency department) note dated 7/12/13 indicated the resident was sent to the hospital by her physician due to an INR (PT/INR blood test to monitor anticoagulant therapy) of 14 (normal range from 1.5 - 3.5). The resident had just returned home from rehab yesterday (7/11/13). A hospital note dated 7/12/13 indicated the lab test performed in the ED indicated the resident's PT/INR was greater than 18, she was given 10 mg of Vitamin K (used to manage overdosages of [MEDICATION NAME]/[MEDICATION NAME]) and admitted for observation and treatment of [REDACTED]. During an interview with the Director of Nursing on 7/22/13 at 1:39 P.M., she indicated the PT/INR was not done on 7/6/13. This Federal tag relates to Complaint IN 658. 3.1-48(a)(1) 3.1-48(a)(3)