Every finding on record at Heritage Center

Based on observation, interview, and record review, the facility failed to ensure services provided by the facility met professional standards of quality for 2 of 3 closed records reviewed, and 1 of 4 residents observed for medication administration. Blood pressure medication and an inhaler were not administered as indicated in the physician's orders, and a urinary catheter was not placed as ordered. (Resident L, Resident F, Resident M) Findings include: 1. On 6/5/26 at 2:33 P.M., Resident M's clinical record was reviewed. Diagnoses included, but were not limited to, obstructive and reflux uropathy and hydronephrosis. The current Quarterly Minimum Data Set (MDS) Assessment, dated 5/11/26, indicated Resident M was cognitively intact and had an indwelling catheter. Current physician orders included, but were not limited to:May change foley catheter every 21 day and as needed (prn) due to occlusion one time a day every 21 day(s) for obstructive uropathy foley maintenance, dated 3/26/26. Foley catheter size 16 fr (french)/10cc (cubic centimeters) due to diagnosis of urinary retention related to obstructive uropathy, dated 4/22/26. The current care plan for indwelling catheter due to obstructive uropathy was revised 5/5/26. Interventions included, but were not limited to:Change catheter as per medical doctor (MD) orders. Monitor and document intake and output every shift. The clinical record indicated that the resident was sent to the hospital on 6/3/26 for altered mental status. The hospital record indicated that there was a computed tomography (CT) scan of the pelvis and abdomen completed on 6/3/26 at 5:15 P.M. The results indicated the Foley catheter balloon was insufficiently inflated within either the prostatic or distal membranous urethra and should be removed or repositioned. A nursing progress note, dated 6/3/26 at 2:45 A.M., indicated that a 16 fr 30 cc balloon Foley catheter was placed because there was not a 16 fr 10 cc balloon Foley catheter available. Interview on 6/10/26 at 10:03 A.M., the Director of Nursing (DON) indicated she was not aware that CT results showed that Resident M's Foley catheter balloon was improperly inflated. She indicated that there was no notification to her by the night shift staff that they had to use a different sized catheter balloon. She indicated that MD orders should always be followed and she should have been notified if there was a problem. On 6/10/26 at 3:07 P.M., the Administrator provided a current Foley Catheter Orders policy, revised 5/20/26, that indicated .orders must include the following: size of the foley, amount of fluid to inflate, diagnosis . On 6/10/26 at 3:09 P.M., the Administrator provided a current Charting and Documentation revised 7/2022, that indicated .documentation of procedures and treatments will include care-specific details including: the date and time procedure/treatment was provided, the name and title of the person who provided care, the assessment and/or any unusual findings obtained during the procedure/ treatments, how the resident tolerated the procedure, .notification of family, physician, or other staff if indicated . 2. Observation on 6/8/26 at 8:35 A.M., Licensed Practical Nurse (LPN) 4 entered Resident F's room and administered medications. LPN 4 assisted Resident F with taking two puffs of the Breyna inhaler but did not offer Resident F to rinse her mouth following the inhaler administration. On 6/8/26 at 10:30 A.M., Resident F's clinical record was reviewed. Physician orders included, but were not limited to:Breyna Inhalation Aerosol 160-4.5 MCG/ACT (micrograms per puff) administer two puffs every 12 hours rinse mouth after use; Start date 5/20/26 On 6/9/26 at 9:15 A.M., the Breyna (budesonide and formoterol fumarate) aerosol insert was reviewed and indicated warnings and precautions: Advise the patient to rinse his/her mouth with water without swallowing after inhalation to help reduce the risk [of oral infection] . On 6/10/26 at 2:46 P.M., the Administrator provided an undated policy titled Medication Administration that indicated All medications and biologicals will be administered only with physicians orders. 3. On 6/8/26 at 10:58 A.M., Resident L's clinical record was reviewed. Diagnosis included, but was not limited to, hypertension. The most recent quarterly Minimum Data Set (MDS) Assessment, dated 3/19/26, indicated no cognitive impairment and independent with all activities of daily living (ADLs). Physician orders included, but were not limited to: hydralazine 25mg (milligrams) three times a day for hypertension. Hold if systolic blood pressure <110, dated 8/7/25. Resident L's Medication Administration Record (MAR) for April 2026 and May 2026 indicated, but was not limited to, the following administrations of Hydralazine: 4/14/26 at 2:30 P.M. blood pressure 122/74, medication not given due to out of parameters. 4/17/26 at 2:30 P.M. blood pressure blank, medication administration blank. 5/1/26 at 2:30 P.M. blood pressure indicated N/A, medication administered. 5/2/26 at 8:30 A.M. blood pressure 108/68, medication administered. 5/5/26 at 2:30 P.M. blood pressure marked X, medication not given due to out of parameters. Resident L's clinical record lacked a blood pressure reading for 4/17/26 at 2:30 P.M., 5/1/26 at 2:30 P.M., and 5/5/26 at 2:30 P.M. On 6/10/26 at 10:17 P.M., Qualified Medication Aide (QMA) 3 indicated when a medication was not given, the reason code would be entered into the MAR. She indicated a checkmark was entered when given. On 6/10/26 at 12:30 P.M., the Director of Nursing (DON) indicated she could not find a reason for the administration of hydralazine or lack of administration in Resident L's clinical record. On 6/10/26 at 2:41 P.M., a current non-dated Licensed Nurse job description was provided that indicated Administers medication and performs treatments as ordered by the physician . This citation relates to Intake 2990683 and Intake 3036667. 410 Indiana Administrative Code (IAC) 16.2-3.1-35(g)(1)

Based on observation, interview, and record review, the facility failed to ensure infection control practices and standards were followed for 1 of 3 residents reviewed for urinary catheters and 1 of 1 residents reviewed for wounds. (Resident N and Resident R). Foley catheter tubing was observed on the ground and gloves were not changed between touching soiled surfaces and clean surfaces. Findings include: 1. On 6/4/26 at 11:59 A.M., Resident N was observed sitting in his wheelchair outside in the courtyard. A Foley catheter bag and tubing were hanging under the wheelchair. The tubing was observed touching the ground. At 12:14 P.M., Resident N wheeled himself inside. The catheter tubing dragged the ground into the building and continued to touch the floor once inside the facility. On 6/5/26 at 2:08 P.M., Resident N's clinical record was reviewed. Diagnoses included, but were not limited to, postpolio syndrome, benign prostatic hyperplasia (BPH), and paraplegia. The most current Quarterly Minimum Data Set (MDS) Assessment, dated 3/19/26, indicated Resident N was cognitively intact, was dependent on staff (staff does all the effort) for transfers, had an indwelling catheter, and did not have a urinary tract infection (UTI). A care conference was completed on 2/11/26 where care plans were reviewed. Current care plans included, but were not limited to:I have diagnosis of BPH and require a Foley Catheter, dated 6/6/23 Current physician orders included, but were not limited to:Foley catheter 16 french (fr)/10 cubic centimeters (cc) due to diagnosis of urinary retention related to obstructive uropathy, dated 2/8/26 Interview on 6/10/26 at 12:48 P.M., the Infection Preventionist (IP) indicated catheter tubing should not be resting on or dragging the floor, and that it should be elevated off the floor or other surfaces. On 6/10/26 at 2:08 P.M., the Administrator provided a current Foley Catheter Orders policy, revised 5/20/26, that indicated Prevent infection by ensuring bag is below bladder level and that drainage bag and tubing are always off the floor. 2. On 6/8/26 at 10:24 A.M., Resident R's clinical record was reviewed. Diagnoses included, but were not limited to, tracheostomy and quadriplegia. The current 5-day Minimum Data Set (MDS) Assessment, dated 4/29/26, indicated Resident R was cognitively intact and had wounds, a tracheostomy, and gastrostomy tubes. Current physician orders included, but were not limited to:Right Heel treatment: wash with soap and water, pat dry, apply betadine-soaked gauze to wound and cover with bordered gauze dressing every day shift for pressure, dated 6/4/26. Left Heel treatment: clean with soap and water apply betadine wound, cover with bordered gauze dressing every day shift, dated 5/21/26.Observation on 6/9/26 at 10:14 A.M., the Wound Nurse donned gloves and removed the dressing on Resident R's left foot. She picked up the iPad and placed it next to the resident's foot. The Wound Nurse removed the soiled gloves, sanitized her hands, and donned new gloves. She cleaned the wound, and without changing gloves, took a picture of the wound with the iPad. The Wound Nurse removed the soiled gloves, sanitized her hands, and applied a new dressing to the resident's left foot. Without changing gloves, the Wound Nurse picked up her cell phone to use the inbuilt flashlight to observe the wound on the right leg and touched the iPad to take pictures of the wound on the resident's right leg. She removed the soiled gloves, sanitized her hands, donned new gloves, and cleaned and dressed the resident's right leg. The Wound Nurse removed the soiled gloves and sanitized her hands. She proceeded to preview pictures on the iPad with clean hands without cleaning the iPad. Interview on 6/10/26 at 12:48 P.M., the Infection Prevention Nurse (IP) indicated staff should not be using the same gloves to touch a wound or wound dressing and then touch phone, tablet, or computer. The staff should change gloves in between soiled and clean tasks. On 6/10/26 at 3:05 P.M., the Administrator provided a current Cleaning Equipment policy, revised 10/2020, that indicated .each piece of equipment coming in direct contact with the resident is disinfected with an approved disinfectant . This citation relates to Intake IN3036667. 410 Indiana Administrative Code (IAC) 16.2-3.1-18(b)(1)410 IAC 16.2-3.1-18(l)

Based on interview and record review, the facility failed to ensure care plan conferences were completed quarterly for 13 of 25 residents admitted reviewed for care plans. (Resident 1, Resident 16, Resident 14, Resident 22, Resident 17, Resident 26, Resident 42, Resident 45, Resident 49, Resident 75, Resident 99, Resident 105, Resident 115) Findings include: 1. On 4/22/25 at 9:03 A.M., Resident 26 indicated that the facility did not involve her in reviewing her care plan and that she did not attend care plan conference meetings quarterly. On 4/23/25 at 9:27 A.M., Resident 26's clinical record was reviewed. Diagnosis included, but was not limited to, generalized anxiety disorder. The most current Quarterly MDS Assessment, dated 2/20/25, indicated Resident 26 was cognitively intact, was dependent on staff (staff does all the effort) for transfers, and received an antianxiety medication and opioid during the 7-day lookback period. The most recent care plan conference was dated 10/29/24. On 4/24/25 at 2:30 P.M., the MDS Coordinator indicated that the IDT met quarterly to discuss residents' plans of care, but they were not documented in the clinical record unless the resident or resident's family attended. On 4/25/25 at 10:54 A.M., the Director of Nursing (DON) indicated that IDT notes for care plan conferences were not able to be provided 2. On 4/22/25 at 10:06 A.M., Resident 75's clinical record was reviewed. Diagnoses included, but were not limited to, anxiety, depression, and respiratory failure. The most recent Significant Change MDS Assessment, dated 12/24/24, indicated no cognitive impairment. Resident 75's clinical record lacked documentation that the IDT had held a care conference in the previous 12 months 3. On 4/22/25 at 12:40 P.M., Resident 42's clinical record was reviewed. Diagnoses included, but were not limited to, dementia, anxiety, and Parkinson's disease. The most recent Quarterly MDS Assessment, dated 2/16/25, indicated a severe cognitive impairment. Resident 42's clinical record lacked documentation that the Interdisciplinary Team (IDT) had held a care conference in the previous 12 months. 4. On 4/22/25 at 12:48 P.M., Resident 99's clinical record was reviewed. Diagnoses included, but were limited to, dementia and adjustment disorder. The most recent Quarterly MDS Assessment, dated 1/15/25, indicated a severe cognitive impairment. Resident 99's clinical record lacked documentation that the IDT had held a care conference in the previous 12 months. 5. On 4/22/25 at 12:49 P.M., Resident 115's clinical record was reviewed. Diagnoses included, but were not limited to, unspecified dementia and need for assistance with personal care. The current Quarterly MDS Assessment date 1/14/25 indicated Resident 115 was severely cognitively impaired. Resident 115 was dependent on transferring and needed partial to moderate less than 1/2 the time showering, dressing, and eating. The most recent care plan conference was dated 10/31/24. 6. On 4/22/25 at 1:14 P.M., Resident 1's clinical record was reviewed. Diagnoses included, but were not limited to, diffuse traumatic brain injury with loss of consciousness and traumatic hemorrhage of cerebrum. The current Quarterly MDS assessment dated [DATE] indicated Resident 1 is severely cognitively impaired. The resident is totally dependent for hygiene, eating, transferring, and dressing. The most recent care plan conference was dated 7/30/24. 7. On 4/22/25 at 1:47 P.M., Resident 45's clinical record was reviewed. Diagnoses included, but were not limited to, muscle weakness (generalized), age-related osteoporosis without current pathological fracture, and history of falling. The current Annual MDS assessment dated [DATE] indicated that the resident was severely cognitively impaired. Resident 45 was dependent on assistance for dressing, transferring and toileting The most recent care plan conference was dated 4/18/24 8. On 4/22/25 at 1:50 P.M., Resident 105's clinical record was reviewed. Diagnoses included, but were not limited to, acquired absence of left leg above the knee and muscle weakness generalized. The current Quarterly MDS assessment dated [DATE] indicated Resident 105 was cognitively intact. Resident 105 was dependent on toileting, needed supervision with transferring, and needed partial assistance less than 1/2 time for hygiene. The most recent care plan conference was dated 4/18/24. 38770 9. On 4/22/25 at 12:58 P.M., Resident 22's clinical record was reviewed. Resident 22 was admitted on [DATE]. Diagnoses included, but were not limited to, urinary tract infection. The most recent Quarterly MDS Assessment, dated 3/19/25, indicated Resident 22 was cognitively intact, required supervision from staff for toileting, required partial assistance from staff (staff do some of the work) for transfers, and was frequently incontinent of urine. The most recent care plan conference held for Resident 22 was 12/30/24. Additional quarterly care plan conferences held in the last 12 months were requested. During an interview on 4/25/25 at 1:18 P.M., the Administrator indicated there were no additional care plan conferences to be provided. 48147 10. On 4/22/25 at 2:11 P.M., Resident 16's clinical record was reviewed. Diagnosis included, but was not limited to, acute posthemorrhagic anemia. The most current Quarterly MDS Assessment, dated 2/19/25, indicated that Resident 16 was not assessed for cognitive ability because she was rarely or never understood and was dependent on staff (staff does all the effort) for Activities of Daily Living (ADLs). The most recent care plan conference was dated 7/29/24. 11. On 4/23/25 at 8:59 A.M., Resident 14's clinical record was reviewed. Diagnosis included, but was not limited to, Parkinson's disease. The most current Quarterly MDS Assessment, dated 2/24/25, indicated Resident 14 was cognitively intact and required partial to moderate assistance of staff (staff does less than half of the effort) for Activities of Daily Living (ADLs). The clinical record lacked a care plan conference completed in the last 12 months. 12. On 4/23/25 at 1:16 P.M., Resident 17's clinical record was reviewed. Diagnoses included, but were not limited to, atrial fibrillation and history of falling. The most current Quarterly MDS Assessment, dated 2/5/25, indicated Resident 17 had moderate cognitive impairment, required substantial to maximal assistance of staff (staff does more than half of the effort) for toileting and bathing, and had one fall with injury since the prior assessment. The clinical record lacked a care plan conference completed in the last 12 months. 48057 13. On 4/23/25 at 9:35 A.M., Resident 49's clinical record was reviewed. Resident 49 was admitted on [DATE]. Diagnoses included, but were not limited to, cerebral infarction. The most recent Quarterly MDS Assessment, dated 2/28/25, indicated Resident 49 was moderately cognitively intact and was dependent on staff (staff do all of the work) for toileting, bathing, and transfers. The clinical record lacked quarterly care plan conferences held for Resident 49 in the last 12 months. During an interview on 4/25/25 at 1:18 P.M., the Administrator indicated there were no care plan conferences to be provided. On 4/25/25 at 1:18 P.M., the Administrator provided a current Care Conference Policy and Procedure, revised 11/2024, that indicated Each resident will have an Interdisciplinary Care Plan developed and maintained by the Interdisciplinary Team . Care Conference will be conducted as requested by Resident/Family or staff. All disciplines will be represented by a health care professional or his/her designee. 3.1-35(d)(2)(B) 3.1-35(e

Based on observation, interview, and record review, the facility failed to ensure safe and secure storage of all medications for 2 of 5 medication carts and 3 of 3 medication rooms observed. Medication refrigerator temperature logs were not filled out, loose pills were observed in medication carts, and medication carts were observed unlocked. (Horizons Unit, Harbor Unit, Wellsprings Unit) Findings include: 1. On 4/21/25 at 8:56 A.M., the Horizons Unit medication storage room was observed. A temperature log dated February 2025 and included a small fridge, small locked fridge, and large fridge, had temperatures listed for 2/1/25, and 2/16/25 through 2/18/25. All other dates were blank. The same form, dated April 2025, had temperatures listed for 4/16/25 through 4/18/25. All other dates were blank. A separate form dated February 2025 included the medication room temperature and a different refrigerator temperature. The form listed temperatures for 2/1/25. All other dates were blank. The same form, dated April 2025, had temperatures listed from 4/16/25 through 4/18/25. All other dates were blank. At that time, the Unit Manager (UM) 23 indicated she was unaware where the March 2025 temperature logs were, and did not know why the current temperature logs were not filled out. On 4/21/25 at 9:12 A.M., the Harbor Unit medication storage room was observed. A temperature log for the room temperature and refrigerator, dated March 2025, did not have any temperatures documented. The same form, dated April 2025, lacked temperatures for 4/18/25 and 4/20/25. At that time, UM 25 indicated she did not know why the temperatures had not been documented, and could not locate the temperature log for February 2025. On 4/21/25 at 9:18 A.M., the Wellsprings Unit medication storage room was observed. A temperature log for the room temperature and refrigerator, dated March 2025, lacked temperatures for 3/23/25 and 3/29/25. The temperature logs for February 2025 and April 2025 were all filled in and current. On 4/24/25 at 1:36 P.M., the Director of Nursing (DON) provided temperature logs for the Horizons Unit from January 2025 through April 2025. The temperature logs were completely filled out and differed from the temperatures that were documented on the temperature logs in the medication room. The DON indicated the completed temperature logs were located at the nurses station and the Unit Manager was unaware they were kept there. 2. On 4/21/25 at 9:08 A.M., the Harbor Unit medication cart was observed with the following loose pills: a white oval tablet with marking L484 a white capsule with no marking a white round tablet with marking AC358 a pink round tablet with marking L141 At that time, Licensed Practical Nurse (LPN) 27 indicated the medication carts should have been cleaned out every shift. On 4/21/25 at 9:18 A.M., the Wellsprings Unit medication cart was observed with the following loose pills: a white oval tablet with marking APO a yellow oval tablet with marking 152 3. On 4/21/25 at 9:15 A.M., during a random observation, a medication cart on the Harbor Unit was observed unlocked with no staff around the cart or in the hall. At that time, Qualified Medication Aide (QMA) 31 was observed to come out of a resident's room at the other end of the hall, and then to the unlocked medication cart. At that time, she indicated the medication carts should be kept locked. On 4/21/25 at 10:06 A.M., during a random observation, a medication cart on the Wellsprings Unit was observed unlocked with no staff around the cart or in the hall. One resident was observed sitting in a wheelchair by the nurses station where the cart was located. At 10:10 A.M., Registered Nurse (RN) 9 locked the medication cart. On 4/23/25 at 9:56 A.M., during an random observation, a medication cart on the Horizons Unit was observed unlocked with 4 residents sitting in wheelchairs in the common area by the cart. A staff member locked the medication cart at 9:58 A.M. On 4/25/25 at 1:18 P.M., the DON provided a current Storage of Medications policy, last revised April 2007, that indicated The facility shall store all drugs and biologicals in a safe, secure, and orderly manner . Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes.) containing drugs and biological's shall be locked when not in use . The policy did not include documentation of temperature logs. 3.1-25(m)

Based on observation, interview, and record review, the facility failed to ensure a safe, sanitary, and comfortable environment to help prevent the development and transmission of infections for all residents. Hand washing was not adequately performed during medication administration, cups were handled by the rims during a meal observation, clean linen was not handled appropriately, and activity items were not washed after use. (Wellsprings Unit, Registered Nurse (RN) 42, Resident 89) Findings include: 1. During a medication pass on 4/24/25 at 7:52 A.M., RN 42 was observed to enter Resident 236's room with a medication cup of pills. RN 42 placed the medication cup on the bedside table, assisted the resident to put on her pants and shoes, then washed her hands for 11 seconds. RN 42 then obtained the resident's blood pressure, administered the medications in the cup, and assisted to insert the resident's hearing aides. 2. During a lunch observation on 4/21/25 from 11:47 A.M. through 12:15 P.M. on the Wellsprings Unit, the following was observed: Resident 89 was utilizing a cloth activity board at a table, placing the corner of it in her mouth to bite one of the knots in the board. Prior to lunch being served, the Activities Staff picked up the activity boards from the table, including the one Resident 89 had put in her mouth, and placed them all together on a cart in the corner of the room with other activity items. Certified Nurse Aide (CNA) 45 was observed filling cups with ice and drinks at the counter. She lifted each cup by the rim to fill them. When using the ice scoop, the back of CNA 45's hand was making contact with the ice in the tray. All of the filled drink cups were then served to the residents in the dining room. 3. On 4/21/25 at 10:11 A.M., during a random observation, a staff member was observed to carry folded clean linen against her uniform top, then placed them into the clean linen closet. During an anonymous interview on 4/22/25 at 8:38 A.M., a resident indicated staff would carry linen without a cart, set it on the floor, pick it back up, then use the linen. On 4/25/25 at 10:12 A.M., the Infection Preventionist (IP) indicated staff should carry clean linen away from their body or in a bag and hands should be washed for 20-30 seconds. At that time, the Director of Nursing (DON) indicated staff could put the activity boards away and reuse them without washing per policy, and that staff on that unit typically stayed the same and knew which board had been used by which resident. On 4/25/25 at 1:18 P.M., the Administrator provided a current non-dated Activity/Busy Blanket Suggested Guidance policy that indicated Blankets will be washed when finished using, when soiled, or daily On 4/25/25 at 1:18 P.M., the Administrator provided a current non-dated Linen Handling policy that indicated Always carry soiled or clean linen away from body On 4/25/25 at 1:18 P.M., the Administrator provided a current Water Pass policy, last updated November 2024, that indicated Do not touch rim or inside of cup On 4/24/25 at 1:45 P.M., the Assistant Director of Nursing (ADON) provided a current Hand Hygiene policy, last updated November 2016, that indicated hands should be rubbed for 20 seconds during hand washing. 3.1-18(b) 3.1-18(l)

Based on interview and record review, the facility failed to ensure a resident's dignity was respected for 1 of 1 resident reviewed for dignity. A resident was told to urinate in her brief instead of being assisted to the toilet for staff convenience. (Resident 14) Finding includes: On 4/21/25 at 10:02 A.M., Resident 14 appeared to be teary. She indicated that she was upset about staff treatment of her the night of 4/20/25. She indicated that she was in bed and needed to use the toilet. An agency aide told her that she did not want to help her to the toilet and to urinate in her brief instead because she preferred to change the resident in bed. The resident indicated that she finally did urinate in her brief and the aide changed her. On 4/23/25 at 8:59 A.M., Resident 14's clinical record was reviewed. Diagnoses included, but were not limited to, Parkinson's disease. The most recent Quarterly Minimum Data Set (MDS) Assessment, dated 2/24/25, indicated that Resident 14 was cognitively intact, required partial to moderate assistance of staff (staff does less than half of the effort) for toileting, and had no behaviors. A Bladder Continence Assessment, dated 7/2/24, indicated that the resident was on a toileting program. Staff were to assist the resident at night when awake and as needed to help establish a routine for urinary elimination and improve incontinence. A current Activities of Daily Living (ADL) Self Care Performance Deficit care plan, last revised on 11/20/24, indicated that Resident 14 required physical assistance of two staff with transfers, assistance of one staff onto the bedpan, and assistance of two staff for the bedside commode. A current risk for perineal irritation related to incontinent episodes, last revised on 6/6/24, included an intervention for staff to routinely check for incontinence through the night and offer to assist with toileting when awake. On 4/24/25 at 9:19 A.M., Certified Nurse Aide (CNA) 11 indicated that Resident 14 used the toilet on her own schedule. Whenever she had to go, she was assisted to the toilet. On 4/24/25 at 10:04 A.M., CNA 11 was observed assisting Resident 14 to the toilet. At that time, Resident 14 indicated CNA 11 was much gentler with her than the aide from the night before because the night aide jerked on her gait belt multiple times to get her to stand up. On 4/25/25 at 9:27 A.M., CNA 11 indicated that if a resident complained of the previous shift being rough, she would report it to the nurse. She indicated she did report Resident 14's complaint about the night shift staff being rough to a nurse. On 4/25/25 at 9:50 A.M., Licensed Practical Nurse (LPN) 7 indicated that if an aide reported that a resident had an issue with another staff member, she would tell the Administrator immediately. In an email from a confidential source on 4/25/25 at 10:54 A.M., it was indicated that Resident 14 was concerned with an aide that did not honor the resident's wishes and was very rude. On 4/25/25 at 1:18 P.M., the Administrator provided a current Quality of Life - Dignity policy, dated 9/15/17, that indicated Residents shall be treated with dignity and respect at all times. Treated with dignity means the resident will be assisted in maintaining and enhancing his or her self-esteem and self-worth . Demeaning practices and standards of care that compromise dignity are prohibited. Staff shall promote dignity and assist residents as needed by: . Responding to the resident's request for toileting assistance . 3.1-3(a)

Based on interview and record review, the facility failed to ensure the Admission Minimum Data Set (MDS) Assessment was completed within 14 days of admission for 1 of 1 residents reviewed for new admissions. (Resident 335) Finding includes: On 4/22/25 at 1:30 P.M., Resident 335's clinical record was reviewed. Diagnosis included, but was not limited to, end stage renal disease. Resident 335 was admitted to the facility on [DATE]. The Admission Minimum Data Set (MDS) Assessment, dated 4/21/25, indicated it was still in process and not completed. The MDS dashboard included a warning that the Admission MDS was overdue. On 4/24/25 at 2:30 P.M., the MDS Coordinator indicated that the facility's policy was to follow the Resident Assessment Instrument (RAI) Manual. The most current RAI Manual, dated October 2024, indicated that an Admission MDS Assessment completion date was no later than the 14th calendar day of the resident's admission (admitted + 13 calendar days). 3.1-31(d)(1)

Based on interview and record review, the facility failed to ensure Minimum Data Set (MDS) assessments were completed no less than once every 3 months for 1 of 13 resident quarterly MDS assessments reviewed. (Resident 75) Finding includes: On 4/22/25 at 11:06 A.M., Resident 75's clinical record was reviewed. Diagnosis included, but was not limited to, stage 3 chronic kidney disease. The most recent completed MDS assessment was a significant change MDS assessment, dated 12/24/24. A quarterly MDS assessment, due 3/26/25, was still in progress (13 days late). 3.1-31(d)(3)

Based on interview and record review, the facility failed to ensure a resident's Minimum Data Set (MDS) Assessment was completed accurately for 1 of 5 residents reviewed for unnecessary medications. (Resident 4) Finding includes: On 4/22/25 at 12:27 P.M., Resident 4's clinical record was reviewed. Diagnoses included, but were not limited to, prediabetes and chronic pain syndrome. The most recent Annual Minimum Data Set (MDS) Assessment, dated 2/19/25, indicated Resident 4 was cognitively intact, received hypoglycemic medication during the 7-day look back period, and did not receive an anticonvulsant during the 7-day lookback period. Current physician orders included, but were not limited to: gabapentin (an anticonvulsant medication) oral capsule 100 milligrams (mg) - Give one capsule by mouth two times a day for pain, dated 1/31/25 The clinical record lacked an order for a hypoglycemic medication. On 4/24/25 at 2:14 P.M., the MDS Coordinator indicated that she marked hypoglycemic in error and meant to mark anticonvulsant. On 4/24/25 at 2:30 P.M., the MDS Coordinator indicated that the facility's policy was to follow the Resident Assessment Instrument (RAI) Manual.

Based on observation, interview, and record review, the facility failed to ensure the development of a resident's comprehensive care plan for 1 of 2 residents reviewed for Hospice and 1 of 1 residents reviewed for UTI. (Resident 45, Resident 22) Findings include 1. On 4/22/25 at 11:09 A.M., Resident 45's clinical record was reviewed. Diagnoses included, but were not limited to, transient cerebral ischemic attack, occlusion and stenosis of left middle cerebral artery, and need assistance with personal care. The current Annual Minimum Data Set (MDS) assessment dated [DATE] indicated that the resident was severely cognitively impaired. Resident 45 was dependent on assistance for dressing, transferring and toileting. The current physician order included but was not limited to: Consult (name )Hospice for decline in health dated 3/6/25. There is no care plan for (name) Hospice for Resident 45. During an interview on 4/24/25 at 1:40 P.M., the Director of Nursing indicated there should be an initial care plan if a resident enters Hospice. 48057 2. On 4/22/25 at 12:58 P.M., Resident 22's clinical record was reviewed. Resident 22 was admitted on [DATE]. Diagnosis included, but were not limited to, urinary tract infection. The most recent MDS Assessment, dated 3/19/25, indicated Resident 22 was cognitively intact, required supervision from staff for toileting, required partial assistance from staff (staff do some of the work) for transfers, and was frequently incontinent of urine. Physician orders included, but were not limited to: Nitrofurantoin macrocrystal capsule 50 MG (milligrams) Give one capsule by mouth at bedtime for prophylaxis colonized klebsiella; Start date 1/7/25. Resident 22's clinical record lacked a care plan related to monitoring for frequent urinary tract infections or continuous antibiotic use. The following dates, during the last 12 months, Resident 22 had a positive urine culture indicating a urinary tract infection: 2/25/25 12/14/24 10/20/24 9/28/24 8/3/24 6/30/24 5/11/24 During an interview on 4/25/25 at 1:30 P.M., the Administrator indicated that the development of care plans was based on the Resident Assistant Instrument (RAI) Manual. 3.1-35(a)

Based on interview and record review, the facility failed to ensure neurological assessments were completed following unwitnessed falls for 2 of 2 residents reviewed for falls. Facility policy for completion of neurological assessments was not followed when staff failed to complete the required neurological assessments initially following a fall as well as follow-up assessments. (Resident 45, Resident 105) Findings include: 1. On 4/22/25 at 1:47 P.M., Resident 45's clinical record was reviewed. Diagnoses included, but were not limited to, muscle weakness (generalized), age-related osteoporosis without current pathological fracture, and history of falling. The current Annual MDS assessment dated [DATE] indicated that the resident was severely cognitively impaired. Resident 45 was dependent on assistance for dressing, transferring and toileting. The current physician orders included, but were not limited to: Dycem (anti-sliding device) in wheelchair to prevent sliding down in chair dated 3/16/25. Use no-skid mat next to the window side of bed dated 8/12/24. The current fall risk care plan revised on 12/23/24 related to getting up on their own, impaired safety awareness, and muscle weakness included interventions that included, but were not limited to: Reminder sign to call for assistance dated 4/5/25. Offer non-skid socks and or non-skid shoes dated 3/18/24. Upon getting up place resident in day room recliner dated 3/7/25. A progress note dated 4/4/25 at 4:07 P.M. indicated that Resident 45 had an unwitnessed fall in the room doorway into her room lying on her right side. Neurochecks and vital signs were started at 4:00 P.M. and were to be completed every two hours. The initial assessment lacked pupil reactions for the first two assessment time. The neurochecks and vital signs with signatures were lacking at 8:00 P.M. and 10:00 P.M. The neurochecks and vital signs that were to be done every 2 hours from 4/5/25 at 6:00 A.M. until 4:00 P.M. lacked documentation of pupillary response and a nurse's signature. A progress note dated 3/18/25 at 10:51 P.M., indicated that Resident 45 has an unwitnessed fall in the day room where she was found sitting next to her recliner. Neurochecks and vital signs were started on 3/18/25 at 8:51 P.M. and were completed every two hours. The neurochecks and vital signs were not signed off every two hours by a nurse from 6:45 A.M. on 3/19/25 until 4:45 P.M. on 3/19/25. During an interview on 4/24/25 at 1:17 P.M., the Assistant Director of Nursing (ADON) indicated the Registered Nurse (RN) will do a neuro assessment immediately for all falls. If the fall is witness and not hit head vital signs are done every shift for 24 hours. The ADON indicated if the fall was unwitnessed the neurochecks are to be done every 2 hours after the initial hour. The sheets should be filled out completely. 2. On 4/22/25 at 1:47 P.M., Resident 105's clinical record was reviewed. Diagnoses included, but were not limited to, acquired absence of left leg above the knee and muscle weakness generalized. The current Quarterly Minimum Data Service (MDS) assessment dated [DATE] indicated Resident 105 was cognitively intact. Resident 105 was dependent on toileting, needed supervision with transferring, and needed partial assistance less than 1/2 time for hygiene. The current physician orders included, but were not limited to: Falls prevention measures in place per care plan every shift dated 4/5/24. Activity Order: Up with assistance of (x) 2 with a sliding board for staff every shift dated 5/1/24 The current fall care plan indicated the resident is a fall risk due to injury, weakness, amputation of the leg, and altered mobility revised on 5/21/24. Interventions included but were not limited to: Instruct on use of the call light dated 5/21/24. Ensure anti-tippers are in proper position on each shift dated 2/12/25, and bed in the lowest position dated 5/21/24. A nursing progress note dated 2/12/25 at 6:15 P.M. indicated Resident 105 had a fall from a wheelchair that tipped when anti-tipper rolls were not engaged after resident returned from an appointment. Vital signs and neurochecks were started at this time but lacked documentation of a fall risk assessment. During an interview on 4/24/25 at 1:17 P.M., ADON indicated that the Registered Nurse (RN) will do an assessment to be completed on resident with each fall. On 4/25/25 at 1:18 P.M., the Administrator provided a current policy Fall Risk Assessment reviewed on 4/24. The policy indicated the purpose of the fall risk is .is to identify residents at risk of falling and ensuring that each resident has preventive measures in place to reduce the risk of falls .the procedure was to complete all items on the forms 3.1-37

Based on observation, interview, and record review, the facility failed to ensure a resident unable to carry out activities of daily living (ADLs) received the necessary services to maintain good grooming and personal hygiene for 1 of 4 residents reviewed for skin concerns. A resident with long toe nails had not been seen by podiatry or had toe nails trimmed. (Resident 124) Finding includes: On 4/22/25 at 12:30 P.M., Resident 124's clinical record was reviewed. admitted was 12/4/24. Diagnoses included, but were not limited to, Alzheimer's disease, dementia, anxiety, and depression. The most recent quarterly Minimum Data Set (MDS) assessment, dated 3/12/25, indicated a severe cognitive impairment. Resident 124 required substantial to maximum assistance (helper does more than half the effort) with showering. Current physician orders included, but were not limited to: May see podiatrist of choice, dated 12/4/24. A current ADL care plan, last revised 12/30/24, included, but was not limited to, an intervention to check nail length and trim and clean on bath day and as necessary, initiated 12/6/24. A consent form for podiatry was signed by Resident 124's Power of Attorney (POA) on 12/6/24 as part of the admission packet. Resident 124's clinical record lacked documentation that her toe nails had been cleaned or trimmed. On 4/23/25 at 9:38 A.M., Resident 124's feet were observed. Toe nails on both feet were very long, thick, and with a layer of dirt underneath. At that time, Unit Manager (UM) 15 indicated podiatry came to the facility on ce a month, would be there the following week, and Resident 124's daughter had recently requested for the resident to be seen by them. She indicated a resident's podiatry consent might be signed at admission, but the resident would not be seen unless there was a significant change or the family requested it. She further indicated she had spoken to Resident 124's daughter on 3/12/25 and she had voiced a need for podiatry. On 4/23/25 at 9:52 A.M., Registered Nurse (RN) 9 indicated Resident 124 had not seen podiatry, and the nurses on the unit were responsible for trimming her toe nails, and the aides were responsible for nail care (cleaning). She indicated a progress note would be completed when toe nails were trimmed. On 4/25/25 at 1:18 P.M., the Administrator provided a procedure form for nail care. At that time, he indicated there was not an actual policy, but the form was followed by staff. The form indicated step by step instruction for cleaning and trimming nails, but did not include timing on which nail care should have been done. 3.1-38(a)(3)(E)

Based on observation, interview, and record review, the facility failed to ensure daily weights were completed to assess for complications of Congestive Heart Failure and a resident received thorough assessments for care of edema to lower extremities for 1 of 1 residents reviewed for edema. (Resident 22) Finding includes: During an observation on 4/22/25 at 8:46 A.M., Resident 22's bilateral lower legs were observed to have edema. Resident 22 indicated she was not weighed daily and sometimes has to ask for her second edema pill because staff will only bring her one. On 4/22/25 at 12:58 P.M., Resident 22's clinical record was reviewed. Diagnoses included, but were not limited to, congestive heart failure (CHF), and urinary tract infection. The most recent Quarterly Minimum Data Set (MDS) Assessment, dated 3/19/25, indicated Resident 22 was cognitively intact, required supervision from staff for toileting, required partial assistance from staff (staff do some of the work) for transfers, and was frequently incontinent of urine. Physician orders included, but were not limited to: Weights daily one time a day for CHF (congestive heart failure) Update MD (physician) if three pounds gained in 24 hours or five pounds in seven days; Start date 12/27/24 Current care plans included, but were not limited to: I have diastolic CHF and cardiomegaly, monitor feet and hands for edema; Start date 3/3/25 A care summary, dated 4/21/25, indicated the Nurse Practitioner observed Resident 22 and indicated Resident had some increased edema to bilateral lower extremities. During an interview on 4/25/25 at 9:25 A.M., Nurse 12 indicated Resident 22 had increased bilateral lower extremity swelling recently and was swelling was assessed during daily weight check. The following dates in the clinical record indicated Resident 22 was not weighed or assessed, or refused to be weighed or assessed, for increased edema in April 2025: 4/5 4/7 4/8 4/12 4/15 4/16 4/18 4/22 During an interview on 4/24/25 at 1:43 P.M., the Director of Nursing (DON) indicated weights should be recorded as ordered and was how a resident was monitored with CHF, and weight gain should be reported to physician. On 4/25/25 at 2:32 P.M., the Administrator provided a policy titled Weights, dated 8/06, that indicated More frequent weights may be indicated if: resident exhibits edema. Report fluctuations Record weight. 3.1-37(a)

Based on observation, interview, and record review, the facility failed to ensure treatment and services were provided to prevent urinary tract infections (UTI) for 1 of 5 residents reviewed for UTIs. The physician was not notified of a suspected UTI, a resident with increased symptoms was not tested for a UTI, an antibiotic was given without a culture, and the resident received double the amount of an antibiotic as ordered. (Resident 102) Findings include: On 4/22/25 at 11:11 A.M., Resident 102's clinical record was reviewed. Resident was admitted [DATE]. Diagnosis included, but were not limited to, Alzheimer's disease. The most recent admission Minimum Data Set (MDS) assessment, dated 3/18/25, indicated a severe cognitive impairment. Resident 102 required partial to moderate assistance (helper does less than half the effort) with toileting and showering. The resident was frequently incontinent of bladder and bowel. Physician orders included, but were not limited to: Ceftriaxone (Rocephin) (an antibiotic) 1 gm (gram) IM (intramuscularly) one time only for suspected UTI, dated 4/4/25. Cephalexin (Keflex) (an antibiotic) 250 mg (milligrams) three times a day for suspected UTI for 6 days, dated 4/5/25. Alert charting - Progress note document urine smell, color, and appearance every shift for suspected UTI for 3 days, dated 4/1/25. A current toileting care plan, last revised 3/17/25, indicated resident required nursing intervention to improve self-performance in toileting. Interventions included, but were not limited to, cleansing self after elimination required assistance with cleaning self, dated 3/17/25. Resident 102's clinical record lacked a current or resolved UTI care plan. Progress notes included, but were not limited to: 4/1/25 at 4:23 P.M. Resident with increased combativeness and resistance to care. Often incontinent of bowel and had to be checked frequently. Urine dark and cloudy with foul odor. Resident was placed on UTI protocol. The facility physician was not notified of increased behaviors or condition of urine. 4/2/25 at 2:13 P.M. Resident was combative with staff during care and agitated. The behavior had increased since admission. Urine continued to be dark and cloudy with a foul odor. Resident was unable to report any other signs or symptoms of UTI due to cognition. Hospice aware. The facility physician was not notified of increased behaviors or condition of urine. 4/3/25 at 2:23 P.M. Urine continued to be dark and cloudy with foul odor. Continued with increased behaviors and agitation. New incontinence and hematuria (blood in urine). Reported to triage, and indicated would send off to Nurse Practitioner (NP) to review. The clinical record lacked a response from the NP. 4/3/25 at 2:30 P.M. Resident combative, hitting, resistive to care, yelling and curing at staff. Antianxiety medication administered to resident prior to care did not help with behavior. 4/3/25 at 6:35 P.M. Resident fell to her knees in the dining room. Resident indicated she was getting up and just fell on her knees. 4/4/25 at 9:41 A.M. Triage notified again of signs and symptoms of UTI including increased behaviors, combativeness, hematuria, new incontinence, and cloudy dark urine. Resident not a candidate for in and out cath as resident is combative with any hand-on care from staff. Difficult to toilet and would not be able to accurately get sample New order for an antibiotic obtained from the NP for suspected UTI. The note did not indicate an attempt for a urinalysis. A urinalysis was not ordered. A physician's order note, dated 4/4/25 at 12:37 P.M. indicated to administer a one time dose of Rocephin (an antibiotic) 1 gm (gram) IM (intramuscularly). Also administer Keflex (an antibiotic) 250 mg (milligrams) three times a day for 7 days. 4/7/25 at 11:00 A.M. Resident had 2 doses of IM Rocephin on 4/4/25. 4/7/25 at 2:35 P.M. Urine was straw colored but remained cloudy with foul odor. Resident incontinent of bowel and bladder during shift. Resident also continued with behaviors of being combative, hitting, cursing, and yelling during care. The facility physician was not notified of continued signs and symptoms or behaviors. Resident 102's Medication Administration Record (MAR) for April 2025 included, but was not limited to, the following: Progress note document urine smell, color, and appearance every shift for 3 days checked off as completed, but did not document the progress note for 1 of 3 shifts on 4/2/25, 2 of 3 shifts on 4/2/25, or 1 of 1 shift on 4/4/25. Ceftriaxone (Rocephen) 1 gm IM one time dose was given 4/4/25 at 8:38 P.M. On 4/23/25 at 11:27 A.M., Registered Nurse (RN) 9 indicated when a resident was showing signs of a UTI, the staff would place them on a 3 day UTI protocol to monitor them for sign and symptoms. After 3 days, staff would send the information to the physician. If the resident had hematuria, however, would ask for a urinalysis or if the resident was on hospice would speak with hospice to get a urinalysis ordered. On 4/25/25 at 10:12 A.M., the Infection Preventionist (IP) indicated a urinalysis with culture and sensitivity should always be ordered with UTI symptoms prior to ordering an antibiotic to ensure the correct antibiotic was given. On 4/24/25 at 10:43 A.M., Hospice Aide 19 and Certified Nurse Aide (CNA) 21 were observed to assist Resident 102 in the shower. Resident 102 refused to allow staff to wash her peri area, and staff offered to allow her to wash herself. A washcloth with soap was handed to the resident, and the resident washed her front peri area. The resident then washed her back area, then with the same washcloth, wiped the front peri area again. The aides did not address the action with the resident or make an attempt to wash the front peri area with a different washcloth. On 4/25/25 at 12:50 P.M., the DON indicated on 4/4/25 the day shift nurse had given Resident 102 the one time dose of Ceftriaxone 1 gm but had not documented it in the MAR. The same day, evening shift had not seen that it had been given, and gave the dose again. She indicated at that time that Resident 102 could be combative and staff did not feel they could get a urine sample from her. She indicated because of the lack of a urine sample, the NP ordered both the IM injection of Ceftriaxone as well as the course of oral antibiotics for the suspected UTI. At that time, she indicated a care plan for UTI was not always initiated with a positive UTI, and was only entered if care plans happen to be reviewed during the window that the resident had a current infection. On 4/25/25 at 1:18 P.M., the DON provided a current non-dated Suspected UTI Check List form that indicated the procedure for the UTI protocol. The form lacked instructions on when to initiate the protocol, and for how long to keep the protocol in place. On 4/25/25 at 1:18 P.M., the DON provided a current non-dated perineal care procedure form that indicated to wipe from front to back when cleaning to prevent the spread of infection. Policies for the UTI protocol and management of UTI were requested and not provided. A policy for care plan initiation was requested and not provided. 3.1-41(a)(2)

Based on interview and record review, the facility failed to ensure dietitian recommendations were implemented to prevent unnecessary weight loss for 1 of 3 residents reviewed for nutrition. (Resident 49) Finding includes: On 4/23/25 at 9:35 A.M., Resident 49's clinical record was reviewed. Resident 49 was admitted on [DATE]. Diagnosis included, but were not limited to, cerebral infarction. The most recent Quarterly MDS Assessment, dated 2/28/25, indicated Resident 49 was moderately cognitively intact and was dependent on staff (staff do all of the work) for toileting, bathing, and transfers, required set-up assistance from staff for eating, and had experienced unexpected weight loss. The clinical record indicated Resident 49 had lost 21.44% body weight from 10/4/24 (147.4 pounds) to 4/1/25 (115.8 pounds). On 12/20/24 1:01 P.M., the Registered Dietitian (RD) entered a progress note that indicated RD reviewed weight loss and intake, requesting to start 90 Milliliters (ml) Med Pass (nutritional supplement) BID. The clinical record lacked an order for MedPass started or a rationale for Med Pass not being started per RD recommendation from 12/20/24 through 1/26/25. On 1/10/25 at 9:40 A.M., the RD entered a progress note that indicated review of weight changes, requesting for physician/nurse practitioner to consider appetite stimulant and start 90 ml MedPass twice a day, and weekly weights. The electronic medication administration record indicated MedPass 90 ml supplement two times a day was not started until 1/27/25. On 2/28/25 at 10:41 A.M., the RD entered a progress note that indicated follow up and review of weight changes. Current weight 124 pounds on 2/21/25. Requesting Mighty Shake (supplement) with lunch meal. Weekly weights for four weeks. The clinical record lacked an order for Mighty Shakes started or a rationale for Mighty Shakes not being started per RD recommendations. A progress note, dated 4/7/25 at 4:50 P.M., indicated the nurse notified the physician of of 10% weight loss. On 4/9/25 10:30 A.M., the RD entered a progress note indicating RD reviewed continued weight loss, down 31.6 pounds over the last 6 months, requesting weekly weights. The clinical record lacked an order for weekly weights or a rationale for weekly weights not being completed per RD recommendations after the 4/9/25 RD review. During an interview on 4/24/25 at 1:43 P.M., the Director of Nursing indicated Resident 49's weight loss and RD recommendations just got overlooked. On 4/25/25 at 2:32 P.M., the Administrator provided a policy titled Weights, dated 8/06, that indicated Weekly weights will be initiated if Resident experiences a five pound weight loss or gain in a one month period, Resident suddenly begins eating less than 50% of meals; Weekly weights are to be continued until weight is stable. 3.1-46(a)(1)

3. On 4/22/25 at 11:11 A.M., Resident 102's clinical record was reviewed. Resident was admitted [DATE]. Diagnosis included, but was not limited to, Alzheimer's disease. The most recent admission MDS assessment, dated 3/18/25, indicated a severe cognitive impairment. Physician orders included, but were not limited to: Lorazepam (an antianxiety medication) 2 mg (milligrams)/ml (milliliter), give 0.5 ml every 6 hours as needed, dated 3/12/25 and discontinued 4/15/25. The same order for Lorazepam was placed from 4/15/25 through 4/16/25 and again from 4/16/25 to current. The clinical record lacked a rationale from the physician to continue Lorazepam as needed after the initial 14 days. On 4/24/25 at 1:47 P.M., the Assistant Director of Nursing (ADON) indicated use of an as needed antianxiety medication should be reviewed 14 days after starting the medication and if the medication was to be continued, a rationale for continuance should be documented. On 4/25/25 at 1:18 P.M., the DON provided a current Anti-Anxiety Medication Review policy, dated 2/2025, that indicated PRN [as needed] Anti-psychotic/Anti-anxiety medications will initially be given a 14 day with re-assessment order. After an initial 14-day order, the order must be reassessed. Physicians can choose to extend their preference . 3.1-48(a) 2. On 4/22/25 at 1:59 P.M. Resident 23's clinical record was reviewed. Resident 23 was admitted on [DATE]. Diagnoses included, but were not limited to, hypertensive heart disease with heart failure. The most recent Significant Change Minimum Data Set (MDS) Assessment, dated 2/7/25, indicated Resident 23 was moderately cognitively intact, required supervision from staff for transfers, and was receiving hospice services. Current physician orders included, but were not limited to: Lorazepam (antianxiety medication) oral concentrate 2 MG/ML (milligrams/milliliter) Give 0.25 ml by mouth every hours as needed for anxiety or restlessness; Start date 1/29/25 (No end date) Ativan Benadryl Haldol Gel (ABH Gel) 0.5 mg/25 mg/1 mg (milligrams) Apply to wrist topically every four hours as needed for anxiety, wear gloves when administering, rub into wrist, and apply to wrist topically three times a day for anxiety; Start date 3/26/25 (No end date) The clinical record lacked prescribing practitioner rationale for as needed anti-anxiety medications ordered beyond 14 days, or medication end dates.Based on interview and record review, the facility failed to ensure residents were free from unnecessary medications for 3 of 4 residents reviewed for as needed (PRN) antianxiety medications. Residents' PRN antianxiety medications were ordered for greater than 14 days. (Resident 16, Resident 23, and Resident 102) Findings include: 1. On 4/22/25 at 2:11 P.M., Resident 16's clinical record was reviewed. Diagnoses included, but were not limited to, anxiety disorder. The most current Quarterly Minimum Data Set (MDS) Assessment, dated 2/19/25, indicated Resident 16 was not assessed for cognitive impairment because she was rarely or never understood, was dependent on staff (staff does all the effort) for Activities of Daily Living (ADLs), and did not receive an antianxiety medication during the 7-day look back period. Current physician orders included, but were not limited to: Ativan (an antianxiety medication) solution 2 milligrams per milliliter (mg/ml) - Give 0.25 ml sublingually every two hours as needed for anxiety for 90 Days, dated 4/7/25 with a stop date of 7/6/25 Discontinued physician orders included, but were not limited to: Ativan solution 2 mg/ml - Give 0.25 ml sublingually every two hours as needed for restlessness/anxiety, dated 8/7/24 and discontinued on 2/3/25 Ativan solution 2 mg/ml - Give 0.25 ml sublingually every two hours as needed for restlessness/anxiety for 60 Days, dated 2/3/25 and completed on 4/4/25 The clinical record lacked a physician evaluation or rationale for the continuance of the PRN antianxiety medication every 14 days. On 4/25/25 at 10:54 A.M., the Director of Nursing (DON) provided a rationale that was signed by the physician and not dated. At that time, the DON indicated she was unsure of when the physician signed the rationale.

Based on interview and record review, the facility failed to establish a complete stewardship program for antibiotic use to ensure antibiotics ordered by a physician were given as ordered and that appropriate antibiotics were given based on culture results for 3 of 4 residents reviewed for urinary tract infections. (Resident 22, Resident 75, and Resident 42) Findings include: 1. During an interview on 4/22/25 at 8:39 A.M., Resident 22 indicated she had an ongoing burning pain in her bladder. On 4/22/25 at 12:58 P.M., Resident 22's clinical record was reviewed. Resident 22 was admitted on [DATE]. Diagnosis included, but was not limited to, urinary tract infection (UTI). The most recent Quarterly Minimum Data Set (MDS) Assessment, dated 3/19/25, indicated Resident 22 was cognitively intact, required supervision from staff for toileting, required partial assistance from staff (staff do some of the work) for transfers, and was frequently incontinent of urine. Resident 22's clinical record lacked a care plan related to monitoring for frequent urinary tract infections or continuous antibiotic use. UTI #1 On 5/11/24 Resident 22's urine culture resulted with growth of organisms Pseudomonas aeruginosa and Enterococcus faecalis. A physician order was entered for Cefepime HCl (antibiotic) intravenous solution reconstituted two GM (grams) use two gram intravenously two times a day for UTI for 14 administrations; Start date 5/13/24. The Electronic Medication Administration Record (EMAR) indicated doses on 5/13/24 and 5/17/24 at 8:30 P.M. were not given to Resident 22. UTI #2 On 9/28/24 Resident 22's urine culture resulted in growth of organism Citrobacter freundii complex. A physician order was entered for Cephalexin capsule 500 MG (antibiotic) give one capsule by mouth three times a day for UTI for 20 administrations; Start date 10/01/24. The EMAR indicated doses on 10/5/24 at 2:30 P.M. and 10/6/24 at 8:30 P.M. were not given to Resident 22. UTI #3 On 10/20/24 Resident 22's urine culture resulted with growth of organism Klebsiella pneumoniae. A physician order was entered for Ciprofloxacin Oral Tablet 500 MG (Milligrams) (antibiotic) Give one tablet by mouth three times a day for UTI until 10/28/24; Start Date 10/21/24. The EMAR indicated doses on 10/23/24 and 10/24/24 at 8:30 P.M. were unavailable and not given to Resident 22. A progress note dated 11/5/24 at 11:57 A.M., indicated the physician's office called with new order of Macrobid (nitrofurantoin) 50 MG every evening for prophylactic/UTI prevention. A progress note dated 11/5/24 at 3:47 P.M., indicated the physician called and stated resident was worried that order for Macrobid (nitrofurantoin) may cause further cardiac issues, order for Macrobid was placed on hold. A progress note dated 11/6/24 at 9:19 A.M., indicated physician gave an order to discontinue Macrobid (nitrofurantoin) and no prophylactic antibiotic would be started due to multiple allergies. UTI #4 C(resistant to Macrobid/nitrofurantoin). A physician order was entered for Nitrofurantoin (Macrobid) macrocrystal (antibiotic) 50 MG Give one capsule by mouth at bedtime for prophylactic antibiotic; Start Date 12/31/24. The EMAR indicated doses on 1/3/25, 1/4/25, 1/5/25, and 1/6/25 were unavailable and not given. UTI #5 On 2/25/25 Resident 22's urine culture resulted with Proteus mirabilis, with no susceptibility available. A physician order was entered for Fosfomycin tromethamine oral packet 3 GM give one packet by mouth every 48 hours for pain until 3/8/25, total of 3 doses; Start date 3/2/25. The EMAR indicated zero doses of Fosfomycin were administered to Resident 22 between 3/2/25 and 3/8/25. On 4/25/25 at 10:12 A.M., the Infection Prevention Nurse (IP) indicated antibiotics should be administered as prescribed, if an antibiotic is unavailable staff should retrieve the antibiotic from the emergency drug kit or order the medication immediately from pharmacy, and that pharmacy delivers medications every night. On 4/25/25 at 1:18 P.M., the Administrator provided a policy titled Antibiotic Stewardship, dated 9/17, that indicated Review antibiotics on a monthly basis along with infections and classify if criteria met or not. Notify physicians of prescribing habits via quarterly review. 38770 2. On 4/22/25 at 10:06 A.M., Resident 75's clinical record was reviewed. Diagnoses included, but were not limited to, stage 3 chronic kidney disease, anxiety, and depression. The most recent significant change Minimum Data Set (MDS) assessment, dated 12/24/24, indicated no cognitive impairment and no behaviors. Resident had an indwelling urinary catheter. Physician orders included, but were not limited to: UA (urinalysis) with C&S (culture and sensitivity) if indicated one time only for high wbc (white blood cell) count, dated 4/2/25. Cipro (an antibiotic) 250 mg (milligrams) twice a day for 10 administrations, dated 4/4/25 and discontinued 4/6/25. Cefdinir (an antibiotic) 250 mg twice a day for 5 days, dated 4/6/25 and discontinued 4/7/25. Cefdinir 300 mg twice a day for 10 administrations, dated 4/7/25. A recurrent UTI care plan was resolved on 3/5/25. The clinical record lacked a UTI care plan after that date. The clinical record lacked an order for Ceftin (an antibiotic). Resident 75's April 2025 Medication Administration Record (MAR) indicated the following: a urinalysis was completed on 4/2/25. Cipro 250 mg was given once on 4/4/25, twice on 4/5/25, and once on 4/6/25 for a total of 4 doses. Cefdinir 250 mg was given on 4/6/25 at 8:30 P.M. and on 4/7/25 at 8:30 A.M. Progress notes included, but were not limited to, the following: 4/4/25 at 4:21 P.M. New order from Nurse Practitioner (NP) for Cipro 250 mg twice a day for 5 days. 4/6/25 at 10:03 A.M. Discontinue Cipro and start Ceftin 250 mg twice a day for 5 days. 4/7/25 at 8:30 A.M. Nurse received a call from pharmacy related to the order for Cefdinir 250 mg. Medication did not come in that strength, only 300 mg. A urine culture report, resulted 4/6/25, indicated the bacteria found in the urine was resistant to Cipro. The bacteria was susceptible to cefdinir as well as Ceftin. On 4/25/25 at 11:24 A.M., the Director of Nursing (DON) provided an emergency drug kit (EDK) transaction form that indicated Cefuroxime axetil (Ceftin) 250 mg was obtained for Resident 75 on 4/6/25 at 3:47 P.M. Cefdinir 300 mg was obtained for Resident 75 on 4/7/25 at 9:01 A.M. On 4/25/25 at 11:26 A.M., the DON indicated the nurse that entered the antibiotic orders into Resident 75's clinical record picked the wrong medication when she entered cef. She had picked Cefdinir instead of the Ceftin that had been ordered. That was why the pharmacy called the following day to inform that Cefdinir did not come in 250 mg doses. 3. On 4/22/25 at 12:40 P.M., Resident 42's clinical record was reviewed. Diagnoses included, but were not limited to, dementia, anxiety, and Parkinson's disease. The most recent quarterly MDS assessment, dated 2/16/25, indicated a severe cognitive impairment. Resident 42 was frequently incontinent of bladder. Physician orders included, but were not limited to: Ciprofloxacin (Cipro) (an antibiotic) 250 mg twice a day for 9 days and give 1 tablet one time a day only for 1 day, dated 4/19/25 and discontinued the same day. Bactrim DS (an antibiotic) 800-160 mg twice a day for 6 administrations, dated 4/20/25. A urinalysis on 4/18/25 indicated a urinary tract infection (UTI). The culture result indicated the organism found was resistant to Cipro. Resident 42's MAR for April 2025 indicated Cipro had been administered once on 4/19/25. On 4/25/25 at 10:12 A.M., the Infection Preventionist (IP) indicated a urinalysis with culture and sensitivity should always be ordered with UTI symptoms prior to ordering an antibiotic to ensure the correct antibiotic was given. On 4/24/25 at 1:45 P.M., the Assistant Director of Nursing (ADON) provided a current Antibiotic Stewardship and Suspected UTI SBAR policy, last updated September 2017, that indicated The use of this procedure can help reduce unnecessary prescribing and lead to fewer antibiotic failures . The procedure indicated to observe the resident's signs and symptoms for 72 hours, then send findings to the physician if a UTI was suspected. The policy did not indicate guidelines for prescribing antibiotics related to culture results. 3.1-18(b)

Based on observation, interview and record review, the facility failed to ensure the MDS (Minimum Data Set) Assessment was completed accurately for 1 of 1 resident reviewed for elopement and 1 of 5 residents reviewed for falls. (Resident 117, Resident 115) Findings include: 1. On 3/15/24 at 9:30 A.M., Resident 117's clinical record was reviewed. Diagnosis included, but was not limited to, dementia. The most recently Quarterly MDS Assessment, dated 12/29/23, indicated Resident 117 had severely impaired cognition and did not use a wander/elopement alarm during the 7-day look back period. Physician orders included, but were not limited to: Secure Care bracelet applied to right ankle. Check placement per nursing measure. Expiration: May 2024, dated 3/15/24. Secure Care bracelet applied to ankle. Check placement per nursing measure every shift for Elopement Prevention, starting 8/23/2023 and discontinued on 3/15/24. The December 2023 TAR (treatment administration record) indicated Resident 117's Secure Care bracelet was applied and checked three times daily in December except on 12/17/23 during the evening shift. A current behaviors care plan, dated 8/23/23, indicated Resident 117 required a Secure Care device due to wandering and exit seeking behaviors. On 3/15/24 at 12:15 P.M., Resident 117 was observed sitting in a recliner with a Secure Care bracelet on her right ankle. On 3/18/24 at 9:35 A.M., MDS Coordinator 9 indicated that wander/elopement alarm should be marked on the 12/29/23 MDS Assessment, and that it was a coding error. 2. On 3/13/24 at 2:50 P.M., Resident 115's clinical record was reviewed. Diagnoses included, but were not limited to, dementia and history of falling. The most recent Quarterly MDS Assessment, dated 2/22/24, indicated Resident 115 had severe cognitive impairment, used a bed alarm daily, and did not use a chair alarm. Physician orders included, but were not limited to: Nursing to check placement and functioning of bed/chair alarm every shift for resident safety, dated 12/29/23. The February 2024 MAR indicated the placement and functioning of the bed/chair alarm was checked three times daily in February. A current falls care plan, revised 11/30/23, included an intervention bed/chair alarm, dated 10/13/23. On 3/11/24 at 11:58 A.M., Resident 115 was observed sitting in a wheelchair in the dining room of the Wellsprings Unit with a chair alarm in place. On 3/19/24 at 9:21 A.M., MDS Coordinator 7 indicated the chair alarm was coded wrong on the 2/22/24 Quarterly MDS Assessment and should have been checked. At that time, she indicated that the facility followed the RAI (Resident Assessment Instrument) User Manual. The RAI User Manual indicated Chair alarm includes devices such as a sensor pad placed on the chair or wheelchair or a device that clips to the resident's clothing . Wander/elopement alarm includes devices such as bracelets, pins/buttons worn on the resident's clothing, sensors in shoes, or building/unit exit sensors worn by/attached to the resident that activate an alarm and/or alert the staff when the resident nears or exits a specific area or the building. This includes devices that are attached to the resident's assistive device (e.g., walker, wheelchair, cane) or other belongings.

Based on record review, interview, the facility failed to ensure preventative measures were in place or orders were followed to prevent an ulcer from forming and progressing for 1 of 2 residents reviewed for facility acquired skin ulcers. (Resident 11) Findings include: On 3/14/24 at 8:26 A.M., Resident 11's clinical record was reviewed. Diagnoses included, but were not limited to, type 2 diabetes mellitus, Alzheimer's disease, and restless leg syndrome. The most recent Quarterly MDS Assessment, dated 2/20/24, indicated Resident 11 was cognitively intact, required extensive assistance of two staff for mobility, transfers, and toileting, and was receiving oxygen therapy. Current physician orders included, but were not limited to: Daily skin check If any new area of skin impairment found, follow altered skin integrity policy. Every day make note if new area found. Start date 1/20/24. Cleanse daily with normal saline, Betadine, and apply foam dressing every shift for left achilles pressure area. Start date 3/7/24. Assess left Achilles Pressure ulcer and dressing daily. Start date 3/8/24. Doxycycline Hyclate (antibiotic) Oral Tablet 100 MG ( milligrams) Give 1 tablet by mouth two times a day for left heel wound for 7 Days. Start date 3/14/2024. Current care plans included, but were not limited to: I have potential for altered skin/pressure injury, date initiated 3/2/21; [nursing staff provide] daily skin checks, date initiated 12/28/22. On 3/19/24 at The DON provided a treatment administration record for the following order for the month of February and March 2024: Daily skin check. If any new area of skin impairment found, follow altered skin integrity policy every day shift make note if new area found; start date 1/20/24. The following dates during February and March 2024 lacked a documentation of completion for this order: 2/9/24 2/13/24 2/16/24 2/20/24 3/8/24 A progress note on 3/6/24 at 1:47 P.M., indicated Resident 11 approached staff and requested pain medication due to pain in the left leg and and left ankle, and staff will continue to monitor. Documentation between 3/6/24 at 1:47 P.M. to 3/7/24 4:21 P.M. lacked follow up or assessment of the area in pain indicated by Resident 11. An initial skin/wound note on 3/7/24 at 4:21 P.M. indicated an unstageable pressure area, acquired in facility, was found. Measurements included H 4.3cm(centimeters), L 2.2cm, W 2.3cm. The wound was unable to be staged due to the amount of slough/eschar (dead/necrotic tissue) and serous exudate (drainage) present. A progress note on 3/11/24 at 6:23 P.M., indicated Resident 11 had odor and purulent (containing pus/infection) drainage coming from the pressure area on the left achilles. The physician was notified. A progress note on 3/12/24 at 10:20 A.M. indicated an order received for Keflex Oral Capsule 500 MG (antibiotic) Give 500 mg by mouth four times a day for Wound for 7 Days. A skin and wound evaluation dated 3/12/24 indicated the left achilles wound measured 3.2 cm(centimeters) in length, and 2.0 cm in width, area of 5.6 cm, and was unable to be staged due to the amount of slough and purulent drainage present. During an interview on 3/19/24 at 2:31 P.M., the DON (Director of Nursing) indicated Resident 11 did have an order for daily skin checks, was unsure how the wound on Resident 11's left achilles happened, and indicated the wound could have been left untreated and unchecked for 24 hours. A skin assessment or altered skin integrity policy was requested on 3/19/24 at 10:29 A.M, but was not provided. A policy titled Pressure Injury Prevention and Management, revised 12/23, was provided by the Administrator on 3/19/24 at 11:47 A.M., and indicated the policy is To ensure that a resident who is admitted to the facility receives care consistent with professional standards of practice to prevent pressure ulcers .and prevent additional pressure injuries from developing. All dressings/pressure injuries will be assessed daily. 3.1-40(a)(1)

Based on observation, interview, and record review, the facility failed to ensure residents received consistent implementation of interventions to prevent falls for 2 of 5 residents reviewed for accidents related to falls. Fall interventions were observed out of place, and care plans were not updated following falls. (Resident 115, Resident 86) Findings include: 1. On 3/13/24 at 2:50 P.M., Resident 115's clinical record was reviewed. The resident was admitted to the facility on [DATE] following surgical repair of a right shoulder fracture from a fall that occurred at the resident's home. Diagnoses included, but were not limited to, dementia and history of falling. The most recent full Admission MDS (Minimum Data Set) Assessment, dated 9/12/23, indicated Resident 115 had severe cognitive impairment, required extensive assistance of 2 or more staff for bed mobility and transfers, required extensive assistance of 1 or more staff for toileting, and had fallen resulting in a fracture in the 6 months prior to admission. No alarms were used. The most recent Quarterly MDS Assessment, dated 2/22/24, indicated Resident 115 had severe cognitive impairment, required extensive assistance of 2 or more staff for bed mobility, transfers, and toileting, and had 2 or more falls with no injury since the prior assessment and 2 or more falls with injury (not major) since the prior assessment. A bed alarm was used daily. A chair alarm was not used. An admission fall risk assessment, dated 9/7/23, indicated Resident 115 was at high risk for falls. The most current quarterly fall risk assessment, dated 2/22/24, indicated Resident 115 was at high risk for falls. Physician orders included, but were not limited to: Nursing to check placement and functioning of bed/chair alarm every shift for resident safety, dated 12/29/23. Falls prevention measures in place per care plan every shift, dated 9/7/23. The admission comprehensive falls care plan, dated 9/7/23, included the following interventions: Remind resident to use call light for assistance before transferring, initiated 9/7/23 and resolved 11/30/23. Bed in lowest position, initiated 9/7/23. Offer non-skid socks and/or non-skid shoes, initiated 9/7/23. Instruct on use of call light, initiated 9/7/23. Ensure frequently used items are within reach: call system, glasses, light cord, water, phone, tissues, initiated 9/8/23. The clinical record indicated Resident 115 sustained 24 falls from 9/12/23 through 1/25/24. Fall 1 9/12/23 at 1:30 A.M. Fall was not witnessed. The resident fell while attempting to use the bathroom unassisted. The new immediate nursing intervention was bed in lowest position. Intervention Add reminder sign to use call light at bedside was added to the care plan on 9/12/24. Fall 2 9/12/23 at 7:35 P.M. Fall was not witnessed. The resident stated that she crawled on the floor. The new immediate nursing intervention was monitor reswal [sic]. Intervention Toilet after supper and offer to place in bed was added to the care plan on 9/13/23. Fall 3 9/17/23 at 8:12 A.M. Fall was not witnessed. The resident fell while attempting to use the bathroom unassisted. The resident complained of pain in her right arm and bruising was noted. The new immediate nursing intervention was bed and chair alarms. Intervention Bed/chair alarm was added to the care plan on 9/18/23. Fall 4 10/17/23 at 5:30 P.M. Fall was not witnessed. The resident fell while walking in her room unassisted. The resident was documented to have a hematoma on the right side of the back of her head and a bruise on the lateral side of her right hip. The new immediate nursing intervention was toilet res (resident) every 2 hours. A nurse's progress note, dated 10/18/23 at 10:29 A.M., indicated an order was received to send Resident 115 to the emergency room (ER) for treatment and evaluation after a small amount of blood was observed draining from the hematoma and the resident was unable to raise her right arm. A re-admission note, dated 10/18/23 at 4:26 P.M, indicated the resident returned from the ER with no new orders, and the CT (computed topography) scan (an imaging scan used to detect internal injuries) of the head and cervical spine was negative for injury. Intervention Encourage resident to go to dining room for lunch and supper meals was added to the care plan on 10/18/23. Fall 5 10/27/23 at 7:15 P.M. Fall was not witnessed. Staff found the resident on the fall mat by her bed on her knees. The new immediate nursing intervention was continue current interventions. An IDT (Interdisciplinary Team) note, dated 10/30/23 at 9:54 A.M., indicated video monitoring would be added to the care plan. Intervention video monitor in place in room to assure safety when in room was added to the care plan one month later on 11/30/23. Fall 6 11/25/23 at 9:10 P.M. Fall was not witnessed. Staff found the resident lying on the floor next to the bed. The resident was documented to have a hematoma on the back of her head with bleeding present. The PCP (primary care physician) was notified, and orders were given to send the resident to the ER for treatment and evaluation. The new immediate nursing intervention was continue current interventions. Intervention remove fall mat was added to the care plan on 11/27/23. A re-admission note, dated 11/29/23 at 2:27 P.M., indicated the resident was readmitted to the facility from the hospital with 11 staples to a laceration on the back of her head and bruising present. Fall 7 11/29/23 at 11:40 P.M. Fall was not witnessed. Staff found the resident on her knees in front of her bed. The new immediate nursing intervention was must have floor pad in place when resident in bed. Intervention winged mattress was added to the care plan on 11/30/23. Fall 8 11/30/23 at 5:18 P.M. Fall was not witnessed. Staff found the resident with her head on the floor and her body still in the chair in a recliner in the dayroom. The new immediate nursing intervention was Dycem in recliner or w/c [wheelchair]. Intervention Dycem when sitting in recliner was added to the care plan on 12/1/23. Resident 115 was admitted to hospice on 12/13/23. Fall 9 12/16/23 at 12:00 A.M. Fall was witnessed through the video monitor. The resident fell while walking with her walker. The new immediate nursing intervention was resident placed near nurse's station in recliner for closer observation. Interventions Offer recliner in dayroom when restless and have hospice review meds for restlessness were added to the care plan on 12/18/23. A social service progress note, dated 12/18/23 at 12:14 P.M., indicated the resident tested positive for COVID-19. A physician's order, dated 12/18/23 at 11:00 P.M., indicated Strict in room isolation, single room occupancy, droplet precautions, all services brought to room, must remain in room r/t [related to] having an active infection with highly transmissible or epidemiologically significant pathogens that have been acquired by physical contact or airborne or droplet transmission [COVID-19] every shift for precaution with an end date of 12/27/23. Fall 10 12/22/23 at 1:05 P.M. Fall was not witnessed. The resident fell after getting up out of bed without assistance. An initial falls note, dated 12/22/23 at 1:05 P.M., indicated the bed alarm was not in place and the chair alarm was in the bed but was not turned on. The new immediate nursing intervention was educate staff to follow fall care plans. The care plan was not updated with a new intervention at that time. Fall 11 12/22/23 at 5:07 P.M. Fall was not witnessed. Staff saw the resident on the floor in front of her bed through the video monitor. The new immediate nursing intervention was seat resident in recliner in room with TV [television] on [channel] or news when restless. The care plan was not updated with a new intervention at that time. Fall 12 12/22/23 at 7:07 P.M. Fall was not witnessed. Staff found the resident lying on the floor in front of her bed. The new immediate nursing intervention was bed in lowest position, call light within reach - staff to monitor and check Q2H [every two hours]. The care plan was not updated with a new intervention at that time. Fall 13 12/25/23 at 3:00 A.M. Fall was not witnessed. Staff found the resident lying on the floor in front of her bed. The new immediate nursing intervention was strongly recommend for resident to be moved closer to nurse's station so that staff can reach her room quicker. The care plan was not updated with a new intervention at that time. Fall 14 12/25/23 at 1:00 P.M. Fall was not witnessed. Staff found the resident sitting on her bathroom floor. There was no new immediate nursing intervention documented. The care plan was not updated with a new intervention at that time. Fall 15 12/25/23 at 2:50 P.M. Fall was not witnessed. Staff found the resident sitting on the floor in front of her bed. The new immediate nursing intervention was re-educated regarding call, don't fall and placed call light in hand after securing to shirt and had resident demonstrate appropriate use of call light. The care plan was not updated with a new intervention at that time. Fall 16 12/25/23 at 3:50 P.M. Fall was not witnessed. Staff found the resident sitting on the floor in front of her bed. There was no new immediate nursing intervention documented. Intervention ask family if they can provide assist [sic] to sit with resident during the day while sick with COVID was added to the care plan on 12/26/23. Fall 17 12/28/23 at 5:33 P.M. Fall was not witnessed. The initial falls note, dated 12/28/23 at 5:33 P.M., indicated the resident was found lying on the floor next to the bed and the alarm was not sounding. The new immediate nursing intervention was check resident Q2H [every 2 hours], falls mat ineffective d/t [due to] tripping hazard, ensure alarm is on and functioning. Nursing to check placement and functioning of bed/chair alarm every shift for resident safety, dated 12/29/23, was added to physician's orders. The care plan was not updated with a new intervention at that time. Fall 18 12/29/23 at 1:52 P.M. Fall was not witnessed. Staff found the resident on one knee at the bedside. The initial falls note, dated 12/29/23 at 1:52 P.M., indicated the alarm was not functioning. The new immediate nursing intervention was resident to come off isolation precautions for COVID, resident to be in common areas when aggitated [sic]. Intervention place in common area when aggitated [sic] and toileting schedule was added to the care plan on 12/29/23. Fall 19 12/30/23 at 2:00 P.M. Fall was not witnessed. Staff found the resident on her knees in front of her bed. The new immediate nursing intervention was continue current interventions. Intervention Assist to recliner after meals was added to the care plan on 12/30/23. Fall 20 1/3/24 at 5:23 P.M. Fall was not witnessed. Staff found the resident sitting on the floor in front of her bed. The resident indicated she hit her head but was unable to give any other information regarding the fall. The new immediate nursing intervention was family et [and] staff education. Staff education r/t [related to] bringing resident out of her room et into the dayroom at mealtimes et for activities. Family education to inform staff when leaving so staff can ensure interventions are in place. Intervention educate family to let staff know when they leave so resident can be moved back to common area was added to the care plan on 1/4/24. Fall 21 1/11/24 at 3:30 A.M. Fall was not witnessed. Staff found the resident lying on the floor near the doorway of her room. The new immediate nursing intervention was resident needs to be moved closer to nurse's station. Intervention room moved closer to nurses station was added to the care plan on 1/11/24. Fall 22 1/11/24 at 9:57 A.M. Fall was witnessed. The resident was observed walking without assistance and fell . The initial falls note, dated 1/11/24 at 11:18 A.M., indicated the resident hit the back of her head against a dresser. The resident was documented to have a laceration on the back of her head with bleeding present. The initial falls note and progress notes did not indicate whether the bed alarm was sounding at that time. The new immediate nursing intervention was checked function of bed/chair alarm - changed batteries. The PCP was notified, and orders were received to send the resident to the ER for treatment and evaluation. A physician visit note, dated 1/11/24 at 3:15 P.M., indicated the resident returned from the ER with 3 staples in place to the laceration on the back of her head with no active bleeding and orders to remove the staples in 8 days and monitor for any changes. Intervention offer to get up in Broda to eat breakfast on back porch was added to the care plan on 1/12/24. Facility census information indicated Resident 115 was moved to a different room on 1/12/24 at 6:26 A.M. There were no progress notes related to that move. Fall 23 1/16/24 at 3:07 P.M. Fall was not witnessed. Staff found the resident lying next to her bed in her room. The resident indicated she needed to get the blankets off the bed. The new immediate nursing intervention was continue with current intervention. Intervention Hospice to review meds was added to the care plan on 1/17/24. Fall 24 1/25/24 at 8:25 P.M. Fall was not witnessed. Staff found the resident sitting on the floor next to her bed. The resident indicated she was trying to get up. The new immediate nursing intervention was bed bolster to side of bed not against wall. Intervention floor alarm and low bed were added to the care plan on 1/26/24. On 3/14/24 at 11:38 A.M., Resident 115 was observed sitting in a wheelchair while participating in an activity with a chair alarm in place. The gray cord going from the chair alarm pad to the alarm box attached to the back of her wheelchair was not plugged in and hanging on the floor, and the lights on the alarm box were not on. On 3/14/24 at 11:56 A.M., CNA (Certified Nurse Aide) 4 indicated the cord to Resident 115's chair alarm was not plugged in and the alarm was not functioning. At that time, she indicated the cords had been loose and staff made a request for new ones, but they had not received them. On 3/14/24 at 11:59 A.M. in an interview with Resident 115's family member, it was indicated that the alarms were not always plugged in when she visited. At that time, she indicated she had made her concerns regarding the safety of the resident known to staff during a previous care conference meeting. On 3/17/24 at 11:30 A.M., the DON (Director of Nursing) indicated care plans should be updated with new and relevant interventions following a fall. She indicated that nurses would update the care plan immediately after a fall and the MDS Coordinator updated the care plans once an intervention was agreed upon in the IDT meeting. On 3/19/24 at 9:21 A.M., MDS Coordinator 7 indicated the chair alarm was coded wrong on the 2/22/24 Quarterly MDS Assessment and it should have been checked. 48057 2. On 3/18/24 at 11:08 A.M., Resident 86's clinical record was reviewed. Diagnoses included, but were not limited to, dementia, history of falling, and muscle weakness. The most recent Quarterly MDS, dated [DATE], indicated Resident 86 was severely cognitively impaired and required extensive assistance of 1 staff for mobility, transfers, and toileting. Current physician orders included, but were not limited to: Fall prevention measures in place per careplan every shift, start date 10/6/23. Ativan (antianxiety) 2MG/ML (milligrams/milliliter) Give 0.25 mL sublingually at bedtime for anxiety, restlessness. Start date 3/11/24 Morphine 20 MG/ML Give 0.25 mg/mL by mouth every 30 minutes as needed for pain until comfortable. Start date 11/13/24 Current care plans included, but were not limited to: I have a history fall with T11 fracture prior to my admission and have experienced fall with left hip fracture since my admission, remain at risk for fall with injury related to muscle weakness, impaired balance, impaired cognition related to dementia, use of narcotic. Interventions include: Bed/chair alarm date initiated 11/6/23, revision on 3/5/24; Floor mat at bedside date initiated 3/5/24; Video monitor in room date initiated 12/18/23; Bed in lowest position date initiated 10/6/23. Falls that occurred, and interventions implemented following each fall, in the past 5 months were recorded in the clinical record: Fall 1 An initial falls note, dated 10/14/23 at 12:05 A.M., indicated Resident 86 had an unwitnessed fall in her room. The new intervention placed following the fall stated Remind resident to call for assist. Fall 2 An initial falls note, dated 12/16/23 at 10:30 P.M., indicated Resident 86 had an unwitnessed fall in the room of another Resident. The new intervention placed following the fall stated Resident brought to nurse's station to ease with anxiety/confusion. Fall 3 An initial falls note, dated 12/21/23 at 10:09 A.M., indicated Resident 86 had an unwitnessed fall in her room. The new intervention placed following the fall was blank . Fall 4 An initial falls note, dated as a late entry on 1/6/24 at 10:15 P.M., indicated Resident 86 had an unwitnessed fall in her room. The new intervention placed following the fall was blank. Fall 5 An initial falls note, dated as a late entry on 2/17/24 at 2:30 P.M., indicated Resident 86 had an unwitnessed fall in her room and the pressure alarm was on silent at the time of the fall. The new intervention placed following the fall stated a medication review would be completed per hospice. Fall 6 An initial falls note, dated as a late entry 2/23/2024 at 7:10 P.M., indicated Resident 86 had an unwitnessed fall in her room. The new intervention placed following the fall stated Continue current interventions. During an observation on 3/19/24 at 8:45 A.M., Resident 86's video monitor was facing the window and was not in view of the Resident, and no bed or chair alarm were in the Resident's room. RN 5 indicated staff turn the camera when providing care and forgot to turn the camera back within view of the Resident, and that the bed alarm was removed due to the Resident no longer weighing enough to keep the sensor working properly. During an observation on 3/19/24 at 10:53 A.M., RN 5 indicated Resident 86's bed should be in the lowest position but was not in the lowest position, and lowered the bed to the lowest position. During an interview on 3/19/24 at 2:31 P.M., the DON indicated the interdisciplinary team was going to discontinue orders and care plans but we have been too busy update documentation due to the survey being in progress. The clinical record lacked documentation regarding communication with hospice or documentation that orders or care plans pertaining to falls were to be discontinued during the survey review period from 3/11/24 to 3/19/24. On 3/19/24 at 8:51 A.M., the Administrator provided a current Interdisciplinary Care Plans policy, revised 9/23, that indicated Assessments are made and revisions of the care plan are completed as necessary to maintain a current profile of the resident. A weekly high-risk meeting will be held to discuss with IDT .any other high risk residents for potential significant changes, to include but not limited to falls . Progress or lack of progress toward their goals or approaches should be addressed at this time. On 3/19/24 at 8:51 A.M., the Administrator provided a current Falls Checklist for Incident/Accident Report, revised 8/2023, that indicated An intervention is something that you will do to prevent another fall from occurring. Look at previous interventions, if the same intervention has been used do not use this intervention again. Intervention must be appropriate for the fall. Do not leave this portion out. You must have an intervention . This intervention must be added to Care Plan and put in progress note. 3.1-45(a)(2)

Based on observation, interview, and record review, the facility failed to ensure residents admitted without pressure ulcers were provided effective interventions to prevent the development of an unstageable pressure ulcer on the spine for 1 of 5 residents who met the criteria for review of pressure ulcers. (Resident B) Finding includes: During an observation on 6/27/22 at 10:25 A.M., Resident B was observed laying in bed on Resident's back with blankets covering Resident B's shoulders. During an observation on 6/28/22 at 8:24 A.M., Resident B was observed laying in bed on Resident's back with blankets covering Resident B's shoulders. During an observation on 6/30/22 at 11:34 A.M., Resident B's dressing was changed. Resident B had a small white area on Resident B's spine on the lower portion of the back. On 6/28/22 at 8:58 A.M., Resident B's clinical record was reviewed. Current diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The most recent quarterly MDS (minimum data set) Assessment, dated 5/19/22 indicated Resident B required extensive assistance of 2 or more persons for bed mobility, transfers, and toileting. The MDS Resident B has a stage 3 pressure ulcer (Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling). Current Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] .Nursing Measure-Daily skin check for HCC [hierarchical condition category] Pressure Ulcer Risk Assessment with a score of 21 or below. If any new areas of skin impairment found, follow altered skin integrity policy. every day shift Make note if new area found, dated 3/4/22. Hydrogel Gel (Carbomer Gel Base)--Apply to lower spine topically every day shift for pressure area for 14 Days clean area with NS [normal saline] apply hydrogel to wound cover with foam dressing, dated 6/30/2022. Resident B failed to receive skin checks on the following dates: 3/6/22 through 3/10/22 3/22/22 4/9/22 5/5/22 5/8/22 5/24/22 A skin and wound evaluation note on 3/28/22 indicated Resident B had a deep tissue injury pressure ulcer on her spine acquired at the facility. Wound measurements included: area-15.5cm, length-13.0cm, width 1.7cm. Current care plans included, but were not limited to, I have unstageable pressure ulcers to my spin [spine], revised 6/27/22 and I have potential for altered skin/pressure injury r/t [related to] impaired bed mobility, weakness, revised 5/4/22. During an interview on 6/30/22 at 11:31 P.M., RN (Registered Nurse) 5 indicated Resident B acquired an unstageable pressure ulcer after being admitted to the facility. During an interview on 7/5/22 at 2:01 P.M., RN 5 indicated Resident B should have daily skin assessment's. A policy on following orders and skin assessment was requested but not provided. This Federal tag relates to Complaint IN 901. 3.1-40(a)(1)

Based on observation, interview, and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent falls for 2 of 5 residents reviewed for falls, both residents received fractured femurs from their falls. Resident 41 had five additional falls after the fracture one resulting in a major injury. (Resident 41, Resident 76) Findings include: 1. On 7/1/22 at 10:51 A.M., Resident 41's clinical record was reviewed. Diagnoses included, but were not limited to, nontraumatic [CONDITION(S)] and dementia. The most recent admission MDS (minimum data set) Assessment, dated 4/7/22, indicated Resident 41 had a severe cognitive impairment, and required assistance of 1 (one) staff for all ADLs (activities of daily living). The MDS indicated Resident 41 had not fallen in the previous 6 months prior to admission, and had fallen 1 (one) time since admission to the facility. A current falls care plan, initiated 3/29/22, indicated at risk for falls related to muscle weakness, impaired balance, impaired cognition, forgetfulness to use walker, getting up without assistance, and wandering. Interventions included, but were not limited to, offer non-skid socks/shoes (dated 3/29/22), offer non-skid socks at bedtime (dated 5/2/22), keep walker within reach (dated 5/10/22), use of bolster on the right side of the bed (dated 6/29/22), and for staff assistance to recliner after meals (dated 6/12/22) Resident 41's falls included: Fall 1: 3/31/22 10:45 A.M. Resident fell in dayroom attempting to sit in recliner from standing with walker. Upon notification to the resident's representative, the POA (power of attorney) wished for resident to continue with up ad lib (freely) waiver as resident would not ask for help due to cognition and wandering. The new intervention at that time was Spoke with therapy re [reason] possibly placing Dycem under recliners d/t [due to] how easily they slide on floor. Fall 2: 4/30/22 9:05 A.M. QMA (Qualified Medication Aide) found this nurse during medication administration and requested assistance. Upon entering resident's room and bathroom, resident was sitting on bottom on floor in the bathroom facing the door with legs extended towards bathroom door. Resident had on socks, no shoes. No call light was on. CNA (Certified Nurse Aide) was supporting the resident on the floor. CNA stated that resident was in wc [wheelchair] with socks and night clothes on, but no shoes. CNA assisted resident into the bathroom and onto the toilet to get resident ready for the day. When CNA finished washing resident up and getting her dressed, CNA left resident on the toilet by self to get shoes out of resident's closet. When CNA returned, resident was sitting on the floor in the bathroom, scooting towards the door Resident was not wearing non-skid socks at the time of the fall, and indicated she did not know where she was going. The new intervention at that time was to educate the CNA not to leave resident on the toilet alone. Fall 3: 5/2/22 6:15 A.M. Resident found on the floor of her room by the bed. Resident unable to verbalize how the fall occurred. Resident was wearing regular socks, not non-skid socks. The new interventions at that time were to offer non-skid socks at bedtime, and use a non-skid mat on the floor by the bed. Fall 4: 5/9/22 7:00 P.M. Resident fell in dayroom. Resident got up from counter, and walked across the floor without her walker. A nurse witnessed resident getting up, and before they could reach her, resident fell on buttocks and hit the back of her head. The new intervention at that time was to keep walker within reach. Fall 5: 5/12/22 7:50 A.M. Resident got out of bed, ambulated to dayroom, and entered the bathroom near that area. Staff found resident on the floor of the bathroom sitting next to the commode. Resident was wearing regular white socks at the time of the fall. The new intervention at that time was for resident to be assisted in pajamas every evening with non-skid socks on as in the care plan. The falls care plan was not updated at that time with new intervention. Fall 6: 5/18/22 3:15 P.M., Resident found in another resident's room on her back. Resident's walker was across the room. Resident unable to give information about the fall. No injuries were noted. The new intervention at that time was to initiate a toileting plan for the resident. Fall 7: 5/26/22 7:05 A.M. Resident found in room lying in the floor. Incontinence brief was partially down and soiled with urine. [NAME] was tipped over and slightly under resident's right side. Resident indicated she slipped down when asked about the fall. Injuries at that time included redness to the sacrum/right iliac crest, and carpet rash to right shoulder. At the time of the fall, the lights were low. The fall report indicated All interventions in place with exception to early morning get up. Staff education provided The new interventions at that time were to educate staff on current falls prevention measures and interventions, and a video monitor in resident's room. Fall 8: 5/26/22 8:33 P.M. Resident was in bed, upset about wanting to go home. She was observed walking in the hall with regular socks on, no shoes. Resident hit her head during fall. The new intervention at that time was to ensure resident was wearing non-skid socks. Fall 9: 5/28/22 8:07 P.M. Resident found in her room lying on right side, and unable to give a description of the fall. The new intervention at that time was to provide a night light in her room (care plan not updated with this intervention), and for physical therapy to screen resident. Fall 10: 6/12/22 10:50 A.M. Resident found on the floor of the dining room by a chair on her left side. Resident had gotten up to walk but did not use walker. At that time, resident had a skin tear to the left elbow measuring 0.3cm (centimeter) x 0.3cm. Resident complained of left hip and knee pain as well and an order was given for an x-ray. On 6/12/22 at 3:55 P.M., a follow up fall note indicated the x-ray showed a left femoral head fracture (hip fracture) with displacement. The new interventions at that time were to place a sign on the dining area restricting use when not being monitored, and for staff to assist resident to the recliner after meals. Fall 11: 6/20/22 3:28 P.M. Resident slid from the wheelchair to the floor in the dayroom. The wheelchair was unlocked. The new intervention at that time was to place Dycem in the wheelchair. Fall 12: 6/24/22 2:28 P.M. Resident attempted to transfer self in the dayroom and fell , sitting on the floor in from of her wheelchair. At that time, resident had a skin tear to the left elbow measuring 0.5cm x 0.5cm. Resident was unable to give a description of the fall. The new intervention at that time was to educate new staff member to transfer resident to recliner after meals. The falls care plan was not updated with any new interventions. Fall 13: 6/26/22 8:00 P.M. Resident slid out of her wheelchair in the dayroom. At that time, resident complained of left hip pain from a fracture due to a previous fall. Resident's wheelchair was unlocked. The new intervention at that time was to have visitors inform staff they were leaving so staff will know the resident needed close observation. The falls care plan was not updated with any new interventions. Fall 14: 6/27/22 2:56 P.M. Resident fell from wheelchair in dayroom, found sitting on the floor in front of the wheelchair. Resident was unable to give a description of the fall. Resident's wheelchair was unlocked. The fall report indicated resident was sitting up in w/c [wheelchair], but careplan is for resident to be in recliner after meals The new intervention was to educate staff on current care plan intervention that resident is to be assisted to recliner after meals. The falls care plan was not updated with any new interventions. Fall 15: 6/28/22 9:45 P.M. Resident found lying on the floor of her room on the side of the bed. Resident was unable to give a description of the fall. At the time of the fall, socks were worn. The new interventions at that time were for a bolster to the right side of the bed, ensure bed was in lowest position, use of a winged mattress, and to move resident back to her original unit. On 7/5/22 at 9:32 A.M., Resident 41 was observed in the common area sitting in a wheelchair with a blanket over her. Resident 41's bed was observed without a bolster in or around it. At that time, RN (Registered Nurse) 9 indicated bolsters were hard to find, and that staff was currently using a regular pillow in place of a bolster for Resident 41's bed. On 7/5/22 at 1:25 P.M., Resident 41 was observed sitting in a wheelchair after lunch in the common area with 7 (seven) other residents, also sitting in wheelchairs. There were 5 (five) empty recliners observed in the common area, 1 of which Resident 41 was sitting behind. No staff was observed to offer assistance to Resident 41 to sit in a recliner. During an interview on 7/5/22 at 10:11 A.M., QMA (Qualified Medication Aide) 7 indicated Resident 41 would often try to get up after being assisted to sit, and sometimes would forget her walker. QMA 7 indicated Resident 41 required staff to watch her closely, and toilet her more often to prevent her from falling. During an interview on 7/1/22 at 12:20 P.M., the Interim DON (Director of Nursing) indicated when following up on resident falls, the MDS Coordinator should update the resident's care plan during the IDT (interdisciplinary team) meeting about the fall. On 7/5/22 at 11:17 A.M., a current non-dated falls prevention policy was provided and indicated the policy was in place To ensure that residents are safe and that appropriate preventative measures are initiated to minimize injuries related to falls 2. During record review on 7/1/22 at 11:55 A.M., Resident 76's diagnoses included, but were not limited to, dizziness and giddiness, history of falling, hypertension, muscle weakness, abnormalities of gait and mobility, fracture of part of neck of left femur, and [CONDITION(S)]. Resident 76's most recent quarterly MDS assessment, dated 4/30/22, indicated the resident was cognitively intact, required extensive assistance with transfers and walking. Resident 76's care plan included, but was not limited to, at risk for falls. Interventions included but were not limited to, education to staff on proper use of gait belt (initiated 3/18/22). ADL (Activities of Daily Living) self care performance deficit with interventions that included but were not limited to, physical assist of 1 with gait belt and rolling walker (initiated 2/16/22). Resident 76's nurse's notes included, but were not limited to; 3/17/2022 at 9:23 A.M.Late Note Text: IDT (interdisciplinary team) met to review fall from 3/16/22 where resident fell in bathroom with PCA. New intervention was staff education regarding use of gait belt for all transfers. During an interview on 6/27/22 at 1:29 P.M., Resident 76 indicated they had a fall in March 2022 and fractured their hip. Resident 76 indicated the fall occurred in their room as a staff member was assisting them to their chair. The staff member did not use a gait belt and could not prevent them from falling. On 7/5/22 at 11:15 A.M., the DON (Director of Nursing) supplied a facility policy titled Gait Belt Use, and dated 03/2006. The policy included, .Procedure 1. A gait belt will be use on any resident who requires a staff member to be present for transfers or ambulation . 3.1-45(a)

Based on record review and interview, the facility failed to provide adequate supervision to prevent falls with a major injury for 2 of 4 residents reviewed for falls. Residents D and F sustained falls that resulted in fractures. Interventions in place were not effective, and new interventions were not implemented to prevent future falls. (Resident D, Resident F) Findings include: 1. During an interview on 7/29/20 at 12:05 p.m., the DON indicated Resident D had a fall in the room that resulted in fracture. The fall was unwitnessed by staff. Resident D had X-rays done in the facility and was then sent out to the hospital to be evaluated and treated for [REDACTED]. During a review of Resident D's clinical record on 7/29/20 at 12:13 p.m., Resident D's [DIAGNOSES REDACTED]., [MEDICAL CONDITIONS] disease, abnormalities of gait/mobility, right [MEDICAL CONDITION], and compression fracture to L4. The Annual MDS (Minimum Data Set), dated 5/6/20, indicated Resident D was severely cognitively impaired. Resident D was independent with bed mobility, transfers, and toileting, and was occasionally incontinent of bowel and bladder. The care plans included, but were not limited to, I have difficulty expressing my wants and needs due to Alzheimer's. Initiated on 12/4/19, interventions last revised 12/6/19. Interventions included, but were not limited to, allow adequate time to express needs, asked questions that can be answered with yes/no responses, attempt to anticipate wants/needs. I am an Amber (GEMS classification system of stages of dementia). I am caught in a moment of time. I am all about sensations. I like to explore. Initiated on 12/4/19, last revised 5/27/20. Interventions included, but were not limited to, no safety awareness, adjust and make safer environment to explore. I have an impaired cognitive function and impaired thought process related to Alzheimer's dementia. Initiated on 5/5/18, last revised 8/9/18. Interventions included, but were not limited to, often times forgets safety instructions and leaves his walker sitting or does not bring it at all. I have impaired visual function related to visual field deficit. Initiated on 7/10/20. Interventions included, but were not limited to, ensure the resident is wearing glasses which are free from scratches and in good repair, identify/record factors affecting visual function, including physiological, environmental, and choice. I am at risk for falls and fall related injuries due to: history of falls with and without injury, up ad lib with rolling walker, medication use, impaired safety awareness due to dementia, incontinence of bladder, comorbidities, [MEDICAL CONDITION]/psoriatic arthritis, Alzheimer's dementia, impaired vision due to presence of cataract, impaired balance, often walks away without using walker. Initiated on 5/5/18, last revised on 7/29/20. Interventions included, but were not limited to, bed in lowest position (added 7/21/20), non-skid socks on while in bed (7/29/20), instruct on use of call light, encourage naps or rest periods, ensure frequently used items are within reach: call system, glasses, light cord, water, phone, tissues. I have an ADL (activities of daily living) self care performance deficit related to dementia. Initiated on 5/5/18, last revised on 7/10/20. Interventions included, but were not limited to, encourage me to used call bell for assistance (2/25/20), up with assist x 2 with rolling walker (7/10/20), transferring assistance 6/12/19. The resident has a [MEDICAL CONDITION] related to a fall. Initiated 7/10/20. Interventions included, but were not limited to, anticipate and meet needs, ensure call light is within reach and respond promptly, follow MD orders for weight bearing status, PT/OT evaluation and treatment as ordered, monitor/evaluate/provide with/monitor use of adaptive devices as needed: fracture pain, gait belt, abduction pillow, walker, wheelchair, elevated toilet seat. A Self-Determination of Care form, dated 10/24/18, was provided by the DON (Director of Nursing) on 7/30/20 at 10:30 a.m. It indicated the POA (Power of Attorney) had requested the order: Resident up ad lib in room only with walker, not be administered. Requested the order be changed to: Up ad lib in facility with walker. Risk noted: fall that may cause injury, no injury, or death. The form was signed by the POA, facility representative, and the physician. The Care Plans lacked the new intervention of reevaluating the resident's up ad lib status waiver with the family. During an interview with the DON on 7/30/20 at 11:10 a.m., she indicated the waiver had not been reviewed since 2018, and the resident physical functioning and mental status had declined since the waiver was signed. A walker should have been in use at the time of his fall. Hospital records indicated, An x-ray of the pelvis and right hip, dated 7/3/20, indicated, possible subtle fracture involving the right intertrochanteric hip, correlate with CT. A CT pelvis without contrast, dated 7/4/20, indicated, Comminuted intertrochanteric fracture of right hip, with moderate chronic [MEDICAL CONDITION] joint space narrowing. A Hip 2 or 3 views with pelvis unilateral, dated 7/5/20, Internal fixation right [MEDICAL CONDITION] with anatomic alignment. Progress notes indicated, 6/11/20 at 1:53 a.m.- Resident has had slight weight loss and is noted to be sleeping more and eating less the last few weeks. MD family updated and requested medication review. 6/15/20 at 12:09 p.m.- Medication review requested due to increased drowsiness and decrease in appetite. Suggested to change time of [MEDICATION NAME] (antidepressant) and change up [MEDICATION NAME] (medication used to treat Alzheimer's) or lower dose. Requested [MEDICATION NAME] be discontinued as resident has advanced dementia. No new orders at this time. 7/3/20 6:29 p.m.- Fall note: Called to room after QMA walked past room and saw resident lying on floor. Upon questioning resident was unable to recall what he was doing or what had happened. He was laughing as we entered the room. He was assessed for any skin injury. ROM (range of motion) done to all extremities. Pain was noted with palpations and with ROM as well as of R (right) hip/pelvic area. He would not allow full ROM of right hip. Brought up to a sitting position with assist x 2 persons. Assisted to a standing position, which he would not put weight on right foot. He was grabbing at his right buttock and saying it hurts back here. He external rotation, shortening or lengthening was noted. Neurological checks within normal limits. No wt was placed on right leg. Upon sitting in his chair he began to move R leg at the knee region and stated his leg did indeed hurt on that side. He attempted to push himself up in his chair but was unable to move himself with his right leg. Had one tennis shoe on floor. One tennis shoe on, jacket half on. Previous interventions in place. Immediate intervention: assisted off of floor into chair, call light attached to chair, asked for return demonstration of use of call light. Both shoes placed on feet and walker placed within reach. Notified son, DON, MD. Stat X-ray of right hip and pelvis. New intervention: discuss up ad lib status with family. Would like for therapy to see for possible decline in ambulation. Walker was on other side of room. 7/4/20 at 1130 a.m.- Vital signs: 118/78, 68, 20, 98.2 96% on room air. X-ray results from 7/3 of pelvis and right hip. Showing possible subtle fracture of right intertrochanteric hip. Results reported to MD. New orders to send resident to emergency room for evaluation and treatment. Resident and POA notified. Ambulance service notified for pick up. Transferred to emergency room at 11:00 a.m. via ambulance. 7/4/20 at 4:21 p.m.- Call placed to hospital for update on resident. Informed he had been admitted to the ortho unit with a [DIAGNOSES REDACTED]. 7/6/20 at 10:04 a.m.- IDT meeting held to discuss 7/3 fall. Resident was up walking in his room, with one shoe on and one shoe off. He had his jacket half off and half on, assuming he was attempting to take it off. He fell between beds in room. Walker was no where near him, call light was not on. He is up ad lib per signed waiver of family. He is not cognitive enough to explain what he was doing or to remember to use the call light usually. He had complaints of immediate pain and had x-rays ordered. He was transferred the next day after results were received to hospital for further work up. All parties were notified of fall. Will adjust interventions upon return from hospital due to change of condition related to this. 7/7/20 at 5:45 p.m.- Resident returned from hospital via ambulance on a stretcher. admitted with [DIAGNOSES REDACTED]. Resident is alert, drowsy, and usual confused cognition. Skin assessed. Three separate incision points to right upper thigh. 1st is 4.3 cm (centimeters) long with 7 staples, 2nd is 3.5 cm long with 6 staples, and bottom is 3.0 cm long with 6 staples. Resident can not answer questions, does grimace when dressing was being removed and new one placed. Call light lying on chest. During an interview on 7/30/20 at 11:10 a.m., the DON and Administrator indicated Resident D should have been using a walker when ambulating in his room, and it was not near him at the time of the fall. The new intervention of reassessing his ad lib status had not been added to his care plan since his readmission, and his functionality had decreased since his up ad lib waiver was signed in 2018. No staff was in the room at the time of the fall. 2. During an interview on 7/29/20 at 12:05 p.m., the DON indicated Resident F had a fall in the room that resulted in fractures. The fall was unwitnessed by staff. Resident F had X-rays done in the facility and was then sent out to the hospital to be evaluated and treated for [REDACTED]. During a review of Resident F's clinical record on 7/30/20 at 7:20 a.m., the [DIAGNOSES REDACTED]. The Quarterly MDS, dated [DATE], indicated Resident F was cognitively intact. Resident F required extensive assistance x 1 with toileting and bed mobility, and required extensive assistance x 2 with transfers. Resident F was on a toileting program and was frequently incontinent of bowel/bladder. The care plans indicated, but were not limited to, I have pain/discomfort related to low back pain, [MEDICAL CONDITION] bilateral lower extremities, [DIAGNOSES REDACTED]- neck and shoulder. Initiated on 3/29/28, revised 5/22/20. Interventions included, but were not limited to, monitor for increased risk for falls, monitor for altered mental status, dizziness, sedation. I have an ADL self care deficit related to weakness, low back pain, decreased activity intolerance. Initiated on 4/27/28, revised 5/22/20. Interventions included, but were not limited to, encourage the resident to use the call bell for assistance, encourage resident to sleep in the bed, assist him to the bathroom prior to going to bed, evaluate/address toileting needs, make sure non-skid socks/shoes are not worn down to prevent falling, silent alarm in recliner/wheelchair and bed, ensure frequently used items are within reach: call system, glasses, light cord, water phone, tissues, fall prevention measures, assist with changing pad or brief,self. Assist with transfers on/off commode, cue or assist to bathroom upon rising before lunch/supper and at bedtime. Assist at night and as needed. I have had an actual fall and am at risk for fall with injury related to weakness, leg [MEDICAL CONDITION], use of assistive device to aid in balance and forgetfulness, use of narcotic pain medication, antianxiety, and antidepressant medication. Initiated on 4/27/18, revised 2/13/20. Interventions included, but were not limited to, ambulate with 1 assist, assist to recliner once returned to room from activity or meals, encourage to sleep in the bed assist to bathroom prior to going to bed, ensure that shoes are on once up in recliner for the day, is on toileting program, keep oxygen concentrator in the middle of the room with shorter tubing, make sure non-skid socks/shoes are not worn to prevent falling, silent alarm to bed, recliner, wheelchair. Ensure wearing appropriate footwear when ambulating or mobilizing in wheelchair, ensure frequently used items are within reach, remind resident to use call light for assistance before transferring. Requires nursing intervention to improve self-performance in toileting. Initiated on 4/3/18, revised 5/22/20. Interventions included, but were not limited to, requires assistance with changing pad or brief, cleaning self, assist with transfer on/off commode, toileting program-cue and/or assist resident to bathroom upon rising, before lunch/supper, and bedtime. Assist at night when awake and as needed. Requires restorative nursing program to minimize decline or maintain physical abilities for ambulation. Initiated 5/4/18, revised 5/22/20. Interventions included, but were not limited to, assistive device rolling walker, keep assistive device within reach of resident, lock wheels of wheelchair, physical assistance of one person for gait and balance and management of oxygen. Another for wheelchair management to follow behind, remind resident to keep assistive devices close to body, remind resident to use handrails/grab bars, use gait belt, verbal cues to stand up straight, drop arm beside commode for safe toilet transfers, use assist x 2, encourage the resident to use the call bell for assistance, up with assist x 1 with rolling walker for bed to wheelchair, recommend he always exit and enter the bed using his left side which is stronger. A fall assessment, dated 4/22/20, noted a score of 12, moderate fall risk. A chest and C-spine x-ray, completed in the facility, dated 5/7/20, indicated no acute cardiopulmonary disease. Hospital records indicated, A MRI of the [MEDICATION NAME] spine, dated 5/13/20, indicated acute T2 compression fracture, subacute to chronic T4 compression fracture, chronic T11 compression fracture. Chronic T12 compression fracture with prior vertebroplasty. No focal disc protrusion or significant canal stenosis at any level. Progress notes indicated, 5/5/20 at 8:45 p.m.- Fall note: Resident was on toilet having a BM (bowel movement), attempted to ambulate self back to chair, fell in open floor. fell down walking from bathroom. No witnesses. Vital signs: 154/58, 57, 16, 100% on 2L of O2, 98.5, pain 9/10. 2 skin tears. Chest hurting. Pupils equal and reactive. Alert to person and place. No fluid on floor, no clutter, no fall mat, footwear on at time of fall. Oxygen not on at time of fall. Call light was not on. Prior fall interventions in place. Up x 3 staff to chair. Notified son, MD, administrator, no new orders. New interventions: stay in bathroom with resident at all times. Was using walker as instructed. 5/6/20 at 4:43 p.m.- IDT meeting regarding fall on 5/5/20 after getting up unassisted from commode. New intervention: for staff to stay in room with him while in bathroom. Resident F's care plans indicated he should have been ambulated with one assist. The care plan lacked an effective interventions to prevent the fall on 5/5/20. The new intervention for staff to stay in the bathroom with the resident at all times was not added to the care plans until after the fall on 5/5/20. 5/7/20 at 2:33 p.m.- Skin tears to left arm from fall have steristrips in place, no signs of infection noted. Resident having chest and back pain since fall. X-rays ordered. 5/8/20 at 12:16 a.m.- X-ray result faxed to MD, no fracture or acute cardiopulmonary disease. 5/13/20 at 10:28 a.m. Late entry- Staff assessment completed. Resident requested to be sent to the hospital on [DATE] due to severe chest and back pain. Resident continues to be alert and oriented. He is able to make wants/needs known. 5/13/20 at 10:57 a.m.- Resident stated he wanted to go to the emergency room this morning. Severe back and chest pain. MD was called at 9:50 a.m. and gave order to transfer to hospital. Family was notified at 9:52 a.m., ambulance service was called at 10:35 a.m., ambulance left facility at 11:02 a.m. 5/15/20 at 2:55 p.m.- Resident arrived at 2:55 p.m. Resident is alert and oriented. Up with assist. Lung sounds clear, vital signs taken. Bowel sounds present. Communicates clearly and appropriately. Skin checked. 5/15/20 at 8:23 p.m.- Skilled assessment: clinical condition requiring skilled services: compression fracture of spine. Vital signs within normal limits, BP slightly elevated. Cardiac assessment-circulation, cap refill, [MEDICAL CONDITION], pedal pulses, cap refill within normal limits. Trace [MEDICAL CONDITION] to bilateral lower extremities, pedal pulses present. Lungs are diminished, no shortness of breath, no coughing noted. Bowel sounds active x 4, mixed continence, pupils equal and reactive, generalized weakness noted, resident requires extensive assistance x 2 with transfers, alert x 3, follows commands well. Extensive 2 person assist with gait belt. Denies pain, Safety awareness poor-fair. During an interview on 7/30/20 at 1:05 p.m., the DON (Director of Nursing) indicated the facility averaged approximately 37 falls per month, and this was on track with the amount of falls they had last year. She acknowledged this sounded like a lot of falls, and there were several major injuries, but they were discussed daily in morning meeting, and new interventions were added after each fall. She acknowledged the interventions added were not always effective, and some interventions were not appropriate for the root causes of the falls. During an interview on 7/30/20 at 1:26 p.m., the DON indicated she remembered the shift when Resident F fell and that she was the nurse on duty. She recalled a CNA being in the room with Resident F and they assisted him to the restroom, but was unable to provide this documentation. It was not listed in the fall note or any of the fall documentation. During a review of the current policy, Falls Prevention, revised 12/18, provided by the DON on 7/30/20 at 12:53 p.m., indicated, To ensure that residents are safe and that appropriate preventative measures are initiated to minimize injuries related to falls .fall meeting with IDT held to review each fall. During a review of the current policy, Interdisciplinary Care Plans, dated 11/21/16, provided by the DON on 7/30/20 at 12:53 p.m., indicated, It is the policy of this facility to develop and implement a comprehensive person-centered care plan .for each resident that includes measurable objectives and interventions to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident .prevent declines in the resident's functional status and/or functional levels .the care plan is reviewed with each quarterly MDS assessment .or more frequently if resident's condition changes. Assessments are made and revisions of the care plan are completed as necessary to maintain a current profile of the resident .A weekly high risk meeting will be held to discuss with the IDT scheduled MDS assessments with care plans for potential changes and also other high risk residents for potential significant changes to include, but not limited to falls . This Federal tag relates to Complaints IN 298 and IN 882. 3.1-45(a)

Based on observation, interview, and record review, the facility failed to ensure residents were free from accidents for 1 of 3 residents reviewed for falls. Supervision and effective fall interventions were not in place for a resident with 12 (twelve) falls within the past 10 months, which resulted in a resident receiving a femur fracture and requiring surgical intervention. (Resident 40) Findings include: On 5/14/19 at 11:18 a.m., Resident 40 was observed to be sitting in a recliner in their room. The resident indicated the resident was unable to see and had spilled their breakfast down the front of themselves. The resident did not have glasses in place. The clinical record for Resident 40 was reviewed on 5/15/19 at 2:10 p.m. [DIAGNOSES REDACTED]. A quarterly MDS (Minimum Data Set) assessment, dated 2/24/19, indicated the resident had slight cognitive impairment. A care plan, initiated 5/23/18 and revised on 5/16/19, indicated the resident had an actual fall and was at risk for repeat falls due to medication use, impaired vision, complaints of dizziness, episodes of hallucinations and delusions, and fall with a [MEDICAL CONDITION]. Interventions included, but were not limited to, Assist to bed by 8:00 p.m., initiated 2/11/19. Bed in lowest position, initiated 1/14/19. Due to poor vision, add neon tape to call light so the resident could see better to utilize the call light, indicated 7/30/18, revised 8/22/18. Dycem (non slip material) in recliner seat, initiated 11/28/18. Keep call light clipped near the resident so the resident could reach it, initiated 8/22/18, revised on 8/22/18. Night light in room, initiated 1/14/19. Occupational therapy to evaluate and treat, initiated 9/12/18. Winged mattress on bed, initiated 5/2/19. Offer non-skid socks and/or non-skid shoes, initiated 5/23/18. Monitor for dizziness/[MEDICAL CONDITIONS], initiated 5/23/18. Ambulate resident, initiated 5/23/18. Encourage to stay seated or wait for assistance before transferring, initiated 5/23/18, revised 8/22/18. Schedule/encourage naps or rest periods, initiated 5/23/18. Ensure frequently used items are within reach: call system, glasses, light cord, water, phone, tissues, initiated 5/23/18. Encourage use of glasses, initiated 5/23/18. Instruct in and remind to use call light for assistance, initiated 5/23/18, revised on 8/22/18. A progress note, dated 5/2/19 at 2:45 p.m., indicated the resident was in the recliner prior to fall. Resident heard yelling, CNA staff notified the nurse that resident had fallen. Resident was found lying on the floor in front of the recliner with feet towards the door and head towards the bed. CNA placed pillow under the resident's head. The resident indicated I was getting up to walk to the door to see what was going on. The note indicated the resident indicated they had hit their head and a bump was noted on the left side of the head near the resident's crown. The resident received a skin tear to the left elbow and complained of left hip pain when standing. An x-ray of the left hip was obtained and the resident had received an nondisplaced intertrochanteric [MEDICAL CONDITION] femur. The resident was sent to the emergency room and required surgery to repair the fracture. A new intervention was not put into place after the fall. On 5/21/19 at 12:36 p.m., the Administrator indicated the intervention for Resident 40's 5/1/19 fall had been struck out on the resident's progress notes. The Administrator indicated the intervention was to ensure the resident would sit in the library after lunch. A progress note, dated 5/1/19 at 9:35 p.m., indicated the CNA noted the resident's call light was on and found the resident on their knees on the floor at the foot of the bed. The note indicated the resident was sitting on their knees and denied hitting their head. The resident indicated I woke up and thought where in the world am I? Turned on the light and then wanted to get up to see where I was at. The resident thought the air conditioner may have woken her up. The progress notes indicated the new intervention was to place signage on the overbed table for the resident to read and the resident was educated not to get up without help. The care plan indicated the new intervention included a winged mattress on the resident's bed. A progress note, dated 2/8/19 at 10:05 p.m., indicated the resident was found on the floor at the foot of the recliner. The note indicated the resident was very confused. A new intervention included to try to get the resident to bed earlier. A progress note, dated 11/26/18 at 3:15 p.m., indicated the resident was found on the floor between the recliner and the wheelchair. The resident was unable to describe the fall but indicated they were taking themselves to the bathroom. The note further indicated the call light was not on, but was on the resident's chair. A new intervention indicated the staff was to assure the resident was adhering to the toileting plan that was presently in place. A progress note, dated 9/21/18 at 8:57 a.m., indicated Resident 40 was found on the floor in a sitting position facing the recliner with their back to the bathroom by the bathroom door, leaning on a television cabinet. The resident's rollator was flipped on the side on the opposite side of the resident. New intervention included, add walking program for CNA to walk to all meals and out in the hallway when coming out to the library area and therapy would look at the type of walker the resident was using. The interventions also included the resident would remain up with assist. A progress note, dated 9/17/18 at 9:39 a.m., indicated Resident 40 was found in the floor by the bathroom in a sitting position, leaning on television cabinet facing recliner with rollator on ride side flipped on its side. No call light was on and legs of recliner were up with call light still clipped to the arm of recliner. Resident stated was here with friends and they were getting cookies out of oven. Had 2 large skin tears to the left forearm and left elbow, and multiple bruises on legs and arms. No new interventions were documented. A progress note, dated 9/14/18 at 9:50 a.m. indicated Resident 40 was reaching toward the floor for the call light and slid to the floor from the recliner. The note indicated the call light was clipped to the arm of the chair and had a sheet covering over the recliner. The note indicated the resident had very poor vision. The progress note indicated the new intervention was to place Dycem to the chair to sliding out and not to place a sheet on the recliner chair. A new intervention to the care plan included to place signage on the overbed table to read, Don't get up without help. A progress note, dated 8/24/18 at 1:40 p.m., indicated the resident had a fall on her way to the bathroom. The note indicated the resident was ambulating unassisted. A new intervention included to restart a toileting plan at that time and to ensure the call light was clipped in place. A progress note, dated 8/22/18 at 4:15 p.m., indicated the resident was found kneeling on the floor, attempting to get themselves up but were unsuccessful. Resident 40 indicated they were going to the bathroom when they fell . The resident's care plan was revised at that time. A progress note, dated 7/28/18 at 7:10 a m., indicated the resident was observed on the floor in the doorway, leaning against the doorframe. The resident indicated they were going to the bathroom. A progress note, dated 7/9/18 at 2:31 p.m., indicated the resident had a fall on 7/8/18, time unlisted. The note indicated the resident was obtaining something off the floor and fell out of the wheelchair. The note indicated the new intervention was to have the resident sit in the day room so the resident would not be alone and to request laboratory work and a medication review be completed by the resident's physician. A progress note, dated 7/9/18 at 1:55 p.m., indicated the resident had a fall on 7/6/18 at 2:30 p.m. The note indicated the resident was going to the bathroom and fell . The note indicated the staff would remind the resident to use the call light for assistance and the facility would begin a toileting program. On 5/21/19 at 9:15 a.m., the Administrator indicated the facility had identified fall as an issue. She indicated the facility had started to use silent alarms for some of the residents to reduce frequent falls and they have helped with some of the frequent falls. She indicated the facility had been unable to identify a root cause analysis of Resident 40's falls and care plans were updated at each fall meeting. She further indicated the facility had a fall meeting every morning. The current facility policy, dated 3/2006 and revised on 12/2018, provided by the Administrator on 5/21/19 at 10:06 a.m., indicated it was the policy of the facility to ensure residents were safe and that appropriate preventative measures were initiated to minimize injuries related to falls. 3.1-45(a)

Based on interview and record review, the facility failed to ensure a resident received the correct dosage of insulin on 2 different occasions, resulting in hospitalization , for 1 of 3 residents reviewed who received insulin, in a sample of 9. (Resident G) Findings include: The clinical record of Resident G was reviewed on 9/11/17 at 2:00 P.M. [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. The Medication Administration Record [REDACTED].M. A Nurses Note, dated 4/7/17 at 6:00 A.M., indicated, When administering [MEDICATION NAME], order misread, wrong dose given. Resident alert oriented speaking with this nurse. BS (blood sugar) 122. A Nurses Note, dated 4/7/17 at 6:15 A.M., indicated, Triage notified of med error. (Name of physician) requested resident be sent to hospital for monitoring. A hospital history and physical, dated 4/7/17 at 10:06 A.M., indicated, .She presents to the ER after she apparently received 100 units of [MEDICATION NAME] this morning instead of her usual 10 units at the NH (nursing home) .Assessment/Plan: Unintentional Insulin Overdose .Will monitor sugars frequently and administer [MEDICATION NAME] (sugar water solution) if needed The resident returned to the facility on [DATE]. A physician's orders [REDACTED].Inject 10 unit (sic) subcutaneously in the morning A Nurses Note, dated 8/9/17 at 5:15 A.M., indicated, Notified triage of insulin administration. Order obtained for accu checks q4 (every 4 hours). A Nurses Note, dated 8/9/17 at 7:30 A.M., indicated, (Name of physician) called with orders to check blood sugar Q2 (every 2 hours) until 1700 (5:00 P.M.) and Q4 after until 0600 (6:00 A.M.) 8/10/17, start peripheral line (IV) stat (immediately), and give D5 (IV solution) if blood sugar <150. A Nurses Note, dated 8/9/17 at 11:49 A.M., indicated, (Name of Nurse Practitioner) here to see resident. Orders to encourage Glycerna (nutritional supplement) between meals and especially @ hs (bedtime) .Placed on ALERT charting. A Nurses Note, dated 8/9/17 at 10:04 P.M., indicated, Continues to get accuchecks every 2 hours with no s/s (signs or symptoms) of hypo or [MEDICAL CONDITION] (low or high blood sugar) observed A Care Plan, initially dated 10/14/14 and updated on 6/22/17, indicated, .I am a diabetic and have the potential for hypo/[MEDICAL CONDITION]. The Interventions included: Insulin and/or oral hypoglycemis (sic) as ordered by MD. On 9/12/17 at 11:15 A.M., during an interview with the Administrator and Director of Nursing (DON), the DON indicated the first medication error was committed by RN 1, who was a nurse that usually didn't work on Resident G's unit. The DON indicated the second error was committed by a new nurse, who gave Resident G the wrong dose and wrong insulin. The DON indicated the resident received 100 units instead of 10 units the first time, and 50 units the second time. The DON indicated staff was inserviced regarding correct insulin administration following the errors. On 9/12/17 at 1:30 P.M., the Administrator provided documentation of inservices and counseling forms. A Medication Discrepancy Report, dated 8/9/17, indicated, Accidentally gave resident another res. (resident's) insulin dose. Res. should have received 10 units [MEDICATION NAME], gave 50 units of [MEDICATION NAME] (insulin) to res. by mistake. The inservices included: Nursing Implications For Administration of Insulin: a. Be certain to give the correct type of insulin. b. You need to be aware of the correct dosing range for each insulin type. If you are unsure of a current insulin dose look it up and double check that dose with another nurse .c. Prepare the correct dosage. Have another nurse double-check the dose before you administer the injection The inservices also included: . When you are giving medication, regardless of the type of medication, you must always follow the six rights. Each time you administer a medication, you need to be sure to have the: 1. Right individual 2. Right medication 3. Right dose 4. Right time 5. Right route 6. Right documentation .Each time you give a medication, you must systematically and conscientiously check your procedure against these six rights .Each time you give a medication, you also need to remember to do the Three Checks'. This means that you are going to do a 'triple-check' to make sure that the six rights are present time that you give a medication The inservices included: What is [MEDICATION NAME] (insulin)? .[MEDICATION NAME] is a long-acting insulin .It works by slowly releasing insulin into your body over a whole day and night. This produces a constant level of insulin that helps to control your blood sugar .it's also essential to make sure that you're using the correct insulin at each injection The manufacturer's information for [MEDICATION NAME]indicated: [MEDICATION NAME] is a long-acting human insulin .The starting dose should be individualized .converting from other insulin therapies may require adjustment of timing and dose .Closely monitor glucoses On 9/12/17 at 2:15 P.M., the Administrator and DON provided the current facility policy on Medication Administration, dated 10/16. The policy included, All medications .will be administered only with a physician's written order. All medication orders should include the name of the medication, dosage, route of administration, frequency of administration and a diagnosis/indication for use. This Federal tag is related to Complaint IN 957. 3.1-25(b)(9) 3.1-48(c)(2)

Based on record review and interview, the facility failed to ensure the necessary care and services was provided for 1 of 5 residents who suffered from [DIAGNOSES REDACTED] and received a sliding scale insulin in a total sample of 7; in that, ice water cloths were used to stimulate the resident who was in an altered state of consciousness related to low blood sugars; the resident required admission to the local hospital for treatment of [REDACTED]. Resident G Findings include: a. The clinical record of Resident G was reviewed on 5/16/12 at 11:05 A.M., and indicated Resident G was admitted with a [DIAGNOSES REDACTED]. Review of nursing notes included the following: On 5/12/12 at 9:35 P.M., Resident G's blood sugar was 75. Resident G was given peanut butter and apple juice by the facility. On 5/13/12 at 3:05 A.M., Resident G's blood sugar was 96 and the resident was offered a snack but refused it. The facility informed the importance of having a snack to the resident but the resident continued to refuse it . On 5/13/12 at 6:20 A.M., Resident G was unresponsive and had a blood sugar of 27. She was cool to touch. Resident G was given [MEDICATION NAME] 1 mg I.M. (intramuscularly) at that time and bathed with cold wash cloths to the face, head, neck, chest, legs, feet, and abdomen. At 6:35 A.M., Resident G had a blood sugar of 27 and remained unresponsive. The resident's physician triage was notified and an order was received to give [MEDICATION NAME] 1mg I.M. and to update triage in 15 minutes. At 6:37 A.M., [MEDICATION NAME] 1 mg IM was given to Resident G as ordered. Her vital signs indicated Resident G's temperature was 95.1 degrees Fahrenheit axillary. (The resident's normal temperature ranged between 98 and 98.2 degrees) The resident remained unresponsive and continued to be bathed with cold wash cloths to the face, head, neck, chest, legs, feet, and abdomen. The staff attempted to arouse the resident verbally and by touch. At 6:52 A.M., Resident G had an blood sugar of 41. The physician' triage was notified and an order was received. [MEDICATION NAME] 1 mg IM was given as ordered. The resident's vital signs included a temperature of 95 degrees Fahrenheit and the resident remained unresponsive. The resident also had white froth at her mouth with occasional blowing respirations. At 7:08 A.M., Resident G's blood sugar was 61. The physician's triage was informed and the facility received a new order. At 7:09 A.M., Resident G was given Glucose 45 Gel 15 Grams orally as ordered. Resident G remained unresponsive and her temperature was 95 degrees Fahrenheit. The resident continued to be bathed with cold wash cloths to the face, head, neck, chest, feet, and abdomen and the staff continued to attempt to arouse the resident. At 7:24 A.M., Resident G's blood sugar was 44 and the physician's triage was notified. The facility received the order to transfer the resident to the emergency room . At 7:25 A.M., the ambulance was notified to transport the resident to the emergency room . The resident continued to have cold wash cloths to the face, head, neck, chest, feet, and abdomen. The facility also continued to arouse the resident verbally and by touch. The resident remained unresponsive and the temperature was 95 degrees Fahrenheit. At 7:30 A.M., Resident G's family was informed of Resident G's condition and order to transfer the resident to the emergency room . At 7:45 A.M., the ambulance arrived to transport the resident to the hospital. Resident G's temperature was 95 degrees Fahrenheit at the time of the transfer. LPN # 1 was interviewed on 5/17/12 at 5:34 A.M. LPN #1 indicated she was notified of Resident G's condition at approximately 6:30 A.M. on 5/13/12. LPN #1 indicated she went to Resident G's room and found the resident unresponsive. LPN #1 indicated she attempted to arouse the resident both verbally and by touch. LPN #1 indicated she was informed of the resident Accu-check results at that time. She indicated Resident G was wrapped with iced wash cloths which were applied to her bilateral axillas and bilateral groin areas and cool wash cloths placed on the top of the resident's head and across her shoulders and around the back of her neck. LPN #1 indicated the resident had not had her vital signs checked prior to her entering the room. LPN #1 indicated initially another staff member attempted to obtain the resident's temperature axillary, but was unable to obtain due to the resident having had ice to both her axillas. LPN #1 indicated the resident's temperature was obtained orally. LPN #1 indicated the thermometer normally registers at 95 degrees Fahrenheit when use is initiated. LPN #1 indicated Resident G did not have the ice to her any longer that 20 - 25 minutes and the ice was removed, the resident dried and clean clothing applied to the resident. LPN #1 also indicated the resident did arouse at one point and flailed her arms and yelled out. LPN #1 indicated the Glucose Gel was given to Resident G slowly at this time. The staff did not receive a physician order [REDACTED]. On 5/16/2012 at 11:05 A.M., The Director of Nurses indicated the facility did not have a policy for use of iced wash cloths for resident care. The emergency transport records were reviewed on 5/17/12 at 10:30 A.M., the time of the initial call was 7:59 A.M. on 5/13/12. The transport arrived at the facility at 8:09 a.m., the assessment notes began at 8:13 A.M. as follows: "Primary Impression: Diabetes-[DIAGNOSES REDACTED]" "Secondary Impression:Environmental-Hypothermia" "Other Impression: R/O (rule out)-[DIAGNOSES REDACTED], and Nursing Facility Staff Induced Hypothermia" 8:13 A.M. through 8:56 A.M. No body temperature was recorded by the ambulance staff. The assessment was "pale color, cold temperature..." A Blood Glucose level was recorded at 8:15 A.M. of 48 mg/dl. Intravenous fluids of 10 percent [MEDICATION NAME] was started at 8:18 A.M. Another blood glucose was tested at 8:39 A.M. and was recorded as 157 mg/dl. Summary notes included: "Staff reports they have been battling with patient's blood sugar since 0300 (3:00 A.M.) today unable to get blood sugar above 40 mg/dl. Informed their treatment has consisted of 3 doses of 1 mg [MEDICATION NAME] IM (intramuscularly), po ( per mouth) administration of glucose gel, 'slowly' while the patient is unconscious and per the staff -'We gave her ice baths to try and arouse her...' They reported they knew she was hypoglycemic and continued to try and arouse her with frigid water. ...Patient is very cold to touch..." "Heritage Staff informs us they stuck her in ice baths because they did not see any changes in the [MEDICATION NAME] administration...." "8:56 A.M. (name of hospital) staff took temperature 84 degrees F." The hospital emergency room record for 5/13/12 at 8:59 A.M. listed the body temperature rectal 84 degrees, pulse was 78, respirations 13, blood/pressure 105/55, Accu check was 114. The history and physical, dated 5/13/12, indicated the resident was being treated for [REDACTED]. b. Resident G had an order on 4/14/12 for [MEDICATION NAME] sliding scale insulin to be given before meals and at bedtime. The insulin would be given in regards to the results of the Accu check (fingerstick test) blood sugar. The sliding scale before meals was as follows: Blood Sugar results 70 - 150 = 0 units 151 - 200 = 1 unit 201 - 250 = 2 units 251 - 300 = 3 units 301 - 350 = 4 units 351 - 400 = 5 units > 400 = 5 units and call M.D. Use one half of the above amounts for the bedtime coverage, depending on the results of the blood sugar. On 5/8/12 at 8:30 P.M., Resident G had a blood sugar of 281. Her bedtime dose would be one half of the 3 units for the 281 blood sugar. She was to receive 1.5 units of [MEDICATION NAME]but received the entire amount of 3 units. On 5/9/12 at 8:30 P.M., the resident's blood sugar was 248 and the resident was given 2 units of [MEDICATION NAME]instead of 1 unit of the [MEDICATION NAME] insulin. On 5/11/12 at 8:30 P.M., the resident's blood sugar was 175, she received 1 unit of [MEDICATION NAME]but she should have received 0.5 units. On interview of LPN # 5/17/12 at 3:35 P.M., the LPN indicated the sliding scale insulin was always given according to each physician's orders [REDACTED]. This federal tag relates to Complaint IN 371. 3.1-37(a)