Every finding on record at Hickory Creek at Connersville

Based on interview and record review, the facility failed to check outside of the door when a security alarm was sounding off and a resident (Resident B) was identified outside of the facility without staff knowledge for 1 of 3 residents reviewed for the risk of elopement. (Resident B) Findings include: The clinical record for Resident B was reviewed on 7/7/2025 at 1:30 p.m. The diagnoses included, but were not limited to, metabolic encephalopathy and vascular dementia. A Significant Change in Status Minimum Data Set assessment, dated 5/13/2025, indicated Resident B was cognitively impaired, was physically aggressive to others, did not exhibit wandering, but did reject care. During the assessment reference period, Resident B needed only supervision or touch assistance for staff for walking 10, 50, and 150 feet with the ability to make two turns. A care plan, initiated on 5/13/2025 and revised on 6/30/2025, indicated an intervention, dated 5/13/2025, of using a wanderguard as ordered (WanderGuard system is a wander management system used in healthcare facilities to protect residents who may wander, especially those with cognitive impairments. These systems use wearable devices, like bracelets, and strategically placed sensors to monitor resident movement and alert staff when a resident approaches a restricted area). An elopement assessment, dated 5/20/2025, indicated Resident B exhibited wandering behaviors, attempted to open the exit doors, and utilized a security bracelet. A physician's order, dated 5/30/2025, indicated for Resident B to use a WanderGuard and check placement every shift for being at risk of elopement. A maintenance report, dated 6/24/2025, indicated all external doors had operational locking mechanisms. Review of the Medication Administration Record (MAR) for Resident B indicated the last documented behavior for Resident B was, on 6/25/2025 at 8:27 p.m., recorded as very anxious. A nursing progress note, dated 6/29/2025 at 3:25 p.m., indicated Resident B was brought back from a leave of absence. A statement written by Certified Nurse Aide (CNA) 2, dated 6/29/2025, indicated on 6/29/2025 she had heard the front door alarm going off. At the time, Resident C was standing by the door. Another staff member turned the alarm off while she escorted Resident C to her room. A statement written by Registered Nurse (RN) 3, dated 6/29/2025, indicated at 3:30 p.m. on 6/29/2025, she had turned off the door alarm after Resident C had been up to it. At 3:45 p.m. on 6/29/2025, she received a call that Resident B was at a house across the street. During an interview with the Administrator, on 7/7/2025 at 2:35 p.m., she confirmed staff did not check outside when the alarm was sounding because they believed it was from Resident C. A timeline of incidents, provided by the Administrator on 7/7/2025 at 1:20 p.m., indicated that on 7/1/2025 the Maintenance Director had noticed the magnetic lock on the front door did not sound like it was making the normal connection. It was then discovered the door was not locking consistently. Vendor 4 was contacted and made an emergency service call on 7/1/2025 at 4:15 p.m. A loose wire was found on the internal mechanism and fixed during that timeframe. A letter from Vendor 4, dated 7/3/2025, indicated the magnetic locking mechanism had a loose power wire which was causing it to be working only intermittently. A procedure, entitled Door Alarm Response, was provided by the Administrator on 7/7/2025 at 1:20 p.m. The procedure indicated . Unlock front door, physically OPEN the door, and look in the immediate vicinity . This Federal tag relates to Complaint IN00462575. 3.1-45(a)(1) 3.1-45(a)(2)

Based on interview and record review, the facility failed to protect the resident ' s right to be free from mental abuse by taking a video on a cell phone without authorization by the facility of 1 of 4 residents reviewed for abuse. (Resident B and Nurse Aide (NA) 3 Findings include: On 6-26-23 at 11:23 a.m., the Executive Director (ED) provided a copy of a facility reported incident that had been reported to the Indiana Department of Health via email on 6-12-23 alleging the facility ED had received a video posted to social media depicting a staff member, NA 3, in a facility bathroom with Resident B, in the image. The report indicated the facility launched an investigation into this on 6-12-23, including statements from staff and residents. The employee was suspended, pending investigation results. The family and attending physician were notified of the incident. The report indicated the social services director would follow-up with Resident B and all residents to ensure mobile devices were not being used during care provided by staff. An addendum on 6-18-23 indicated staff re-education was conducted on the facility's abuse policy, mobile device policy and social media policy, as well as a QAPI (quality assurance improvement plan) was put into place for interviewing staff and residents regarding mobile devices and recordings. In an interview with the ED on 6-26-23 at 1:05 p.m., she indicated the manner in which she learned of the video was the ED of another facility contacted her regarding receiving the video from one of that ED's former employees. The former employee had sent the video to the other ED, thinking it was one of their employees, because of the type of uniform in the video worn by the staff member. The ED indicated the video had been placed on a social media platform. She sent it to me thinking it might be one of our employees and it was. What I saw on the video was of the aide taking a selfie and kind of turned the camera just a little bit and all you could see was someone with a hat on, couldn't see their face, but you could tell they (aide and resident) were in one of our bathrooms. It took me a while to figure out whose hat it was, but I figured out it was [name of Resident B]. The ED indicated NA 3 had completed the CNA training, but has not taken her written exam yet. She indicated NA 3 had been employed by the facility since March, 2023. I know I personally do the new staff orientation for the abuse prevention portion and I go over the no pictures or video portion of the training, as well as reporting [guidelines]. [Name of NA 3] told me the phone that the video was on was one that she had given to a friend of hers and the video was under her memories, but the video had been taken by her. She said the person who she gave the phone to was the person who actually posted the video on social media, not her. I don't know how well she understood the training conducted from orientation about pictures and social media .I did terminate her, due to her not following our policies about not taking pictures of residents without written consent to do so and having her phone with her on the floor. In an interview with Resident B on 6-26-23 at 12:05 p.m., she indicated she is treated well by the facility staff and feels safe there. She indicated she does not recall ever being photographed with a camera or phone at the facility without her permission. In 15 staff interviews conducted on 6-26-23, none indicated they had ever witnessed other staff members using their cell phones or mobile devices to photograph residents. In a review of the facility's post-incident investigation, it indicated 0 of 29 staff members interviewed had witnessed NA 3 using her phone to take pictures or videos of residents and 0 of 12 residents indicating they had witnessed any staff using their phone to take pictures or videos of residents. In a review of NA 3's employee file, her hire dated was listed as 4-21-23. Her Nurse Aide In-Training Class File indicated her class start date as 4-23-23. A criminal background check indicated she did not have any criminal record. She had two references, one personal and one professional, verified by the Business Office Manager. Her General Orientation, document was signed as completed on 4-21-23. The training with this document included, but was not limited to, Resident Rights, Resident Abuse and Reporting, Elder Justice education and receipt of the employee handbook. It indicated she had completed six hours of dementia education by 4-27-23. An Employee Communication Form, indicated an incident on 6-12-23, included a violations of the facility's mobile device policy, social media and associated abuse policy. Administrator was sent of video of employee in [name of facility] bathroom [abbreviation for with] resident on the toilet. Suspended pending investigation. Post investigation termination 6-19-23. This document signed by NA 3, the Assistant Director of Nursing and the ED. On 6-26-23 at 10:30 a.m., the ED provided a copy of a policy entitled, Abuse Prohibition, Reporting, and Investigation. This policy had a revision date of January, 2023, and was indicated to be the policy utilized by the facility. This policy indicated, It is the policy of American Seniors Communities to provide each resident with an environment that is free from abuse, neglect, misappropriation of resident property, and exploitation. This includes but is not limited to verbal abuse, sexual abuse, physical abuse, mental abuse, corporal punishment, and involuntary seclusion .American Senior Communities will prohibit employees from taking pictures or recordings in any manner which would demean or humiliate a resident(s) and/or from taking unauthorized photographs .Mental abuse also includes what is facilitated or caused by staff taking or using photographs or recordings in any manner that would demean, humiliate, or dehumanize a resident(s). This includes any type of equipment (cameras, smart phones, or other electronic devices) to take, keep, or distribute photographs and recordings. Demeaning or humiliating photographs or videos include nudity, sexual and intimate relations, bathing, showering, exposed body parts, or of posting examples of bodily functions such as toileting, provision of incontinence care, exposing perineal/rectal areas and/or fecal matter on body parts and/or bedding . On 6-27-23 at 12:45 p.m., the ED provided a copy of information she indicated was utilized for post-incident staff education and was located in the facility's employee's handbook. In the portion entitled, Photographs and Video or Audio Recordings, it indicated, The Company prohibits recordings which violate applicable laws. To protect the privacy of our residents and prevent wrongful disclosure of individually identifiable health information and other Confidential information .including by unauthorized photography, the use of cameras or camera phones (or any other picture taking or image generating devices) for photographing, recording or videotaping residents, or Confidential information is prohibited unless specifically authorized by the Company . This Federal tag relates to Complaints IN00410663 and IN00410764. 3.1-27(a)(1)

Based on interview and record review, the facility failed to: A. ensure abuse-related policies were implemented involving avoidance of mental abuse of 1 of 4 residents reviewed for abuse. (Resident B) B. ensure abuse-related policies were implemented for timely submit of the initial report of abuse allegations for 3 abuse allegations. (Facility Incident Numbers 196, 197 and 198) Findings include: A. On 6-26-23 at 11:23 a.m., the Executive Director (ED) provided a copy of a facility reported incident that had been reported to the Indiana Department of Health via email on 6-12-23 alleging the facility ED had received a video posted to social media depicting a staff member, NA 3, in a facility bathroom with Resident B, in the image. The report indicated the facility launched an investigation into this on 6-12-23, including statements from staff and residents. The employee was suspended, pending investigation results. The family and attending physician were notified of the incident. The report indicated the social services director would follow-up with Resident B and all residents to ensure mobile devices were not being used during care provided by staff. An addendum on 6-18-23 indicated staff re-education was conducted on the facility's abuse policy, mobile device policy and social media policy, as well as a QAPI (quality assurance improvement plan) was put into place for interviewing staff and residents regarding mobile devices and recordings. In an interview with the ED on 6-26-23 at 1:05 p.m., she indicated the manner in which she learned of the video was the ED of another facility contacted her regarding receiving the video from one of that ED's former employees. The former employee had sent the video to the other ED, thinking it was one of their employees, because of the type of uniform in the video worn by the staff member. The ED indicated the video had been placed on a social media platform. She sent it to me thinking it might be one of our employees and it was. What I saw on the video was of the aide taking a selfie and kind of turned the camera just a little bit and all you could see was someone with a hat on, couldn't see their face, but you could tell they (aide and resident) were in one of our bathrooms. It too took me a while to figure out whose hat it was, but I figured out it was [name of Resident B]. The ED indicated NA 3 had completed the CNA training, but has not taken her written exam yet. She indicated NA 3 had been employed by the facility since March, 2023. I know I personally do the new staff orientation for the abuse prevention portion and I go over the no pictures or video portion of the training, as well as reporting [guidelines]. [Name of NA 3] told me the phone that the video was on was one that she had given to a friend of hers and the video was under her memories, but the video had been taken by her. She said the person who she gave the phone to was the person who actually posted the video on social media, not her. I don't know how well she understood the training conducted from orientation about pictures and social media .I did terminate her, due to her not following our policies about not taking pictures of residents without written consent to do so and having her phone with her on the floor. In an interview with Resident B on 6-26-23 at 12:05 p.m., she indicated she is treated well by the facility staff and feels safe there. She indicated she does not recall ever being photographed with a camera or phone at the facility without her permission. In 15 staff interviews conducted on 6-26-23, none indicated they had ever witnessed other staff members using their cell phones or mobile devices to photograph residents. In a review of the facility's post-incident investigation, it indicated 0 of 29 staff members interviewed had witnessed NA 3 using her phone to take pictures or videos of residents and 0 of 12 residents indicating they had witnessed any staff using their phone to take pictures or videos of residents. In a review of NA 3's employee file, her hire dated was listed as 4-21-23. Her Nurse Aide In-Training Class File indicated her class start date as 4-23-23. A criminal background check indicated she did not have any criminal record. She had two references, one personal and one professional, verified by the Business Office Manager. Her General Orientation, document was signed as completed on 4-21-23. The training with this document included, but was not limited to, Resident Rights, Resident Abuse and Reporting, Elder Justice education and receipt of the employee handbook. It indicated she had completed six hours of dementia education by 4-27-23. An Employee Communication Form, indicated an incident on 6-12-23, included a violations of the facility's mobile device policy, social media and associated abuse policy. Administrator was sent of video of employee in [name of facility] bathroom [abbreviation for with] resident on the toilet. Suspended pending investigation. Post investigation termination 6-19-23. This document signed by NA 3, the Assistant Director of Nursing and the ED. On 6-26-23 at 10:30 a.m., the ED provided a copy of a policy entitled, Abuse Prohibition, Reporting, and Investigation. This policy had a revision date of January, 2023, and was indicated to be the policy utilized by the facility. This policy indicated, It is the policy of American Seniors Communities to provide each resident with an environment that is free from abuse, neglect, misappropriation of resident property, and exploitation. This includes but is not limited to verbal abuse, sexual abuse, physical abuse, mental abuse, corporal punishment, and involuntary seclusion .American Senior Communities will prohibit employees from taking pictures or recordings in any manner which would demean or humiliate a resident(s) and/or from taking unauthorized photographs .Mental abuse also includes what is facilitated or caused by staff taking or using photographs or recordings in any manner that would demean, humiliate, or dehumanize a resident(s). This includes any type of equipment (cameras, smart phones, or other electronic devices) to take, keep, or distribute photographs and recordings. Demeaning or humiliating photographs or videos include nudity, sexual and intimate relations, bathing, showering, exposed body parts, or of posting examples of bodily functions such as toileting, provision of incontinence care, exposing perineal/rectal areas and/or fecal matter on body parts and/or bedding . On 6-27-23 at 12:45 p.m., the ED provided a copy of information she indicated was utilized for post-incident staff education and was located in the facility's employee's handbook. In the portion entitled, Photographs and Video or Audio Recordings, it indicated, The Company prohibits recordings which violate applicable laws. To protect the privacy of our residents and prevent wrongful disclosure of individually identifiable health information and other Confidential information .including by unauthorized photography, the use of cameras or camera phones (or any other picture taking or image generating devices) for photographing, recording or videotaping residents, or Confidential information is prohibited unless specifically authorized by the Company . B. On 6-27-23 at 1:45 p.m., the Executive Director (ED) provided copies of the facility's three (3) most recent abuse allegations investigations and their associated email confirmation forms for Facility Incident Numbers 196, 197 and 198. Facility Incident Number 196 email confirmation form indicated the Actual or Identified Date and Time of incident as 6-12-23 at 11:30 a.m., and the date and time of submission to IDOH as 6-12-23 at 6:48 p.m. It indicated this incident was submitted by the ED. Facility Incident Number 197 email confirmation form indicated the Actual or Identified Date and Time of incident as 6-13-23 at 3:01 p.m., and the date and time of submission to IDOH as 6-13-23 at 6:02 p.m. It indicated this incident was submitted by the ED. Facility Incident Number 198 email confirmation form indicated the Actual or Identified Date and Time of incident as 6-18-23 at 4:01 p.m., and the date and time of submission as to IDOH 6-18-23 at 10:11 p.m. It indicated this incident was submitted by the ED. In an interview with the ED on 6-27-23 at 2:20 p.m., during the exit conference, she indicated it is very difficult to get the initial report of an abuse allegation submitted to IDOH State within the two hour time frame as there is so much information that needs to be included in that, especially if it happens to be on a weekend. On 6-26-23 at 10:30 a.m., the ED provided a copy of a policy entitled, Abuse Prohibition, Reporting, and Investigation. This policy had a revision date of January, 2023, and was indicated to be the policy utilized by the facility. This policy indicated, It is the policy of American Seniors Communities to provide each resident with an environment that is free from abuse, neglect, misappropriation of resident property, and exploitation. This includes but is not limited to verbal abuse, sexual abuse, physical abuse, mental abuse, corporal punishment, and involuntary seclusion .It is the responsibility of the Administrator/Director of Nursing to report the abuse, or allegations of abuse, immediately, within 2 hours to the Indiana State Department of Health via the IDOH (Indiana Department of Health) gateway system .An incident report will be initiated within 2 hours of the allegation, following the guidelines for Unusual Occurrence Reporting via ISDH gateway portal .The Executive Director will ensure that if the alleged violation involves abuse or results in serious bodily injury, it must be reported immediately but no later than 2 hours [sic] to the Long Term Care Division of the Indiana State Department of Health via the Gateway Portal. This Federal tag relates to Complaints IN00410663 and IN00410764. 3.1-28(a)

Based on interview and record review, the facility failed to report an allegation of mental abuse to the State Survey Agency, the Indiana Department of Health's Long-Term Care Division (IDOH), within two (2) hours of becoming aware of the abuse allegation for 3 of 3 allegations of abuse. (Facility Incident Numbers 196, 197 and 198) Findings include: On 6-27-23 at 1:45 p.m., the Executive Director (ED) provided copies of the facility's three (3) most recent abuse allegations investigations and their associated email confirmation forms for Facility Incident Numbers 196, 197 and 198. Facility Incident Number 196 email confirmation form indicated the Actual or Identified Date and Time of incident as 6-12-23 at 11:30 a.m., and the date and time of submission to IDOH as 6-12-23 at 6:48 p.m. It indicated this incident was submitted by the ED. Facility Incident Number 197 email confirmation form indicated the Actual or Identified Date and Time of incident as 6-13-23 at 3:01 p.m., and the date and time of submission to IDOH as 6-13-23 at 6:02 p.m. It indicated this incident was submitted by the ED. Facility Incident Number 198 email confirmation form indicated the Actual or Identified Date and Time of incident as 6-18-23 at 4:01 p.m., and the date and time of submission as to IDOH 6-18-23 at 10:11 p.m. It indicated this incident was submitted by the ED. In an interview with the ED on 6-27-23 at 2:20 p.m., during the exit conference, she indicated it is very difficult to get the initial report of an abuse allegation submitted to IDOH State within the two hour time frame as there is so much information that needs to be included in that, especially if it happens to be on a weekend. On 6-26-23 at 10:30 a.m., the ED provided a copy of a policy entitled, Abuse Prohibition, Reporting, and Investigation. This policy had a revision date of January, 2023, and was indicated to be the policy utilized by the facility. This policy indicated, It is the policy of American Seniors Communities to provide each resident with an environment that is free from abuse, neglect, misappropriation of resident property, and exploitation. This includes but is not limited to verbal abuse, sexual abuse, physical abuse, mental abuse, corporal punishment, and involuntary seclusion .It is the responsibility of the Administrator/Director of Nursing to report the abuse, or allegations of abuse, immediately, within 2 hours to the Indiana State Department of Health via the IDOH (Indiana Department of Health) gateway system .An incident report will be initiated within 2 hours of the allegation, following the guidelines for Unusual Occurrence Reporting via ISDH gateway portal .The Executive Director will ensure that if the alleged violation involves abuse or results in serious bodily injury, it must be reported immediately but no later than 2 hours [sic] to the Long Term Care Division of the Indiana State Department of Health via the Gateway Portal. This Federal tag relates to Complaints IN00410663 and IN00410764. 3.1-28(c)

Based on observation, interview and record review the facility failed to implement a treatment for two diabetic ulcer toes for 9 days for 1 of 1 resident reviewed for non-pressure skin (Resident 27). Finding include: Review of the record of Resident 27 on 5/8/22 at 2:30 p.m., indicated the resident's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was admitted to the facility on [DATE]. The diabetic ulcer assessment for Resident 27, dated 5/24/22, right second toe measuring 2 centimeters (cm) by 2 cm. The wound tissue was necrotic with 100 % eschar. The diabetic ulcer assessment for Resident 27, dated 5/3122, right second toe measuring 2 centimeters (cm) by 2 cm. The wound tissue was necrotic with 100 % eschar. The diabetic ulcer assessment for Resident 27, dated 6/7/22, right second toe measuring 2 centimeters (cm) by 2 cm. The wound tissue was necrotic with 100 % eschar. The diabetic ulcer assessment for Resident 27, dated 5/24/22, right third toe measuring 2 centimeters (cm) by 2 cm. The wound tissue was necrotic with 100 % eschar. The diabetic ulcer assessment for Resident 27, dated 5/3122, right third toe measuring 2 centimeters (cm) by 2 cm. The wound tissue was necrotic with 100 % eschar. The diabetic ulcer assessment for Resident 27, dated 6/7/22, right third toe measuring 2 centimeters (cm) by 2 cm. The wound tissue was necrotic with 100 % eschar. The Admission Minimum Data Set (MDS) assessment for Resident 27, dated 5/31/22, indicated the resident had a diabetic foot ulcer. The wound doctor orders for Resident 27, dated 6/1/22 at 10:45 a.m., indicated the resident was ordered [MEDICATION(S)]- iodine solution to the right foot second and third toe daily. The Treatment Administer Record (TAR) for Resident 27, dated May 2022 and June 2022, indicated the resident did not receive any treatment to his right foot diabetic ulcers on the second and third toe until 6/2/22. During an interview with the Director of Nursing (DON) on 6/9/22 at 11:02 a.m., indicated Resident 27 did not have a treatment on his right foot second and third necrotic toes when he was admitted . The Wound Nurse discovered he did not have a treatment on 5/31/22 and scheduled him to go to the Wound doctor on 6/1/22 and now he had a treatment. The DON indicated the admitting nurse was responsible to call the physician when Resident 27 admitted to obtain a treatment order for the diabetic ulcers. During an observation on 6/9/22 at 12:40 p.m., LPN 6 applied [MEDICATION(S)]-iodine solution swab sticks to the second and third toe on the right foot of Resident 27. Both toes were black and necrotic. The resident indicated he had pain in both toes but could not feel it when the [MEDICATION(S)]-iodine swabs were applied. The skin management program provided by the DON on 6/9/22 at 2:20 p.m., indicated alterations in skin integrity would be reported to the physician/Nurse Practitioner and a treatment order would be obtained from the physician or Nurse Practitioner. 3.1-37(a)

Based on observation, interview and record review the facility failed to implement fall interventions for a resident at high risk for falls for 1 of 3 residents reviewed for accidents (Resident 17). Finding include: During an observation on 6/8/22 at 11:52 a.m., CNA 3 and CNA 5 assisted Resident 17 from the bed to the wheelchair using a gait belt. The resident had leaned over posture, stiff and required extensive assistance with the transfer. The resident did not have hipsters on and did not have a dycem on the top of his wheelchair cushion or under his wheelchair cushion. The resident was transported from his room to the dining room. Review of the record of Resident 17 on 6/8/22 at 1:35 p.m., indicated the resident's diagnoses included, but were not limited to, [CONDITION(S)] with behavioral disturbance, [CONDITION(S)], type 2 diabetes mellitus with unspecified complications, muscle weakness (generalized) and history of falling. The Quarterly Minimum Data Set (MDS) assessment for Resident 17, dated 5/11/22, indicated the resident was severely cognitively impaired for daily decision making and required extensive assistance of two people for transfers. The resident had a history falls and had fell in the last 2-6 months. The plan of care for Resident 17, dated 5/26/22, indicated the resident was at risk for falls related to impaired mobility and a history of falls. The interventions included, but were not limited to, cushion would be placed in the wheelchair with a dycem on top and under the cushion (2/14/22) and hipsters to be worn at all times (1/17/22). The fall risk assessment for Resident 17, dated 6/1/22 at 2:36 p.m., indicated the resident was at high risk for falls. During an observation on 6/08/22 2:05 p.m., Resident 17 was in bed asleep. The resident did not have on hipsters and did not he have a dycem on top of his wheelchair cushion or underneath the wheelchair cushion. During an interview and observation with the Director of Nursing (DON) on 6/8/22 at 3:39 p.m., verified Resident 17 did not have on hipsters and did not have a dycem on top or under his wheelchair cushion. The DON indicated it was the CNA's responsibility to ensure these fall interventions were in place. The CNAs were communicated to what fall interventions were to be in place by the CNA assignment sheet. The DON indicated she would locate the hipsters and the dycem pads and put them in place. The CNA assignment sheet provided by the DON on 6/9/22 at 2:20 p.m., indicated Resident 17's fall interventions included, but were not limited to, dycem on top of wheelchair cushion and underneath the wheelchair cushion and hipsters to be worn at all times. The fall management program provided by the DON on 6/9/22 at 2:22 p.m., indicated the facility must implement comprehensive, resident-centered fall prevention plans for each resident at risk for falls or with a history of falls. Residents who are categorized as moderate to high risk should have fall interventions implemented based on the resident specific risk factors. 3.1-45(a)

Based on observation, interview, and record review, the facility failed to ensure a dignity bag was present over a urinary catheter bag for 1 of 1 resident reviewed for urinary catheters. (Resident 22) Findings include: The clinical record for Resident 22 was reviewed on 6/9/22 at 10:00 a.m. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The following observations were conducted to where Resident 22's urinary catheter bag was noted without a dignity bag and a yellow substance was observed from the entryway of Resident 22's room: 6/7/22 at 11:33 a.m., 6/7/22 at 12:37 p.m., 6/7/22 at 1:15 p.m., & 6/7/22 at 2:04 p.m. A urinary catheter care plan, start date of 12/20/21, listed an approach to provide catheter care every shift and cover the catheter drainage bag. An interview conducted with the Director of Nursing (DON), on 6/10/22 at 11:03 a.m., indicated a resident with an indwelling catheter should have a dignity bag over their drainage bag. A policy titled Bowel, Bladder, Urinary Indwelling Catheter Programs, revised 12/8/21, was provided by the DON on 6/9/22 at 2:22 p.m. The policy indicated catheter bags should be stored in a dignity bag. 3.1-41(a)(2)

Based on observation, interview, and record review, the facility failed to ensure insulin pens were labeled with an open date for 3 insulin pens observed in 1 of 2 medication carts observed. (Resident 16, 21, and 27) Findings include: An observation conducted of the back medication cart with Registered Nurse (RN) 2, on 6/7/22 at 10:42 a.m., noted 3 [MEDICATION(S)] pens that were opened but did not have an open date listed on the pen for Resident 16, Resident 21, or Resident 27. RN 2 indicated she worked day shift and [MEDICATION(S)] was typically administered in the evening time. She would not be the one to date or label those insulin pens in question. An interview with the Director of Nursing (DON), on 6/10/22 at 11:03 a.m., indicated there should be an open date and/or label on the insulin pens when they are opened. A policy titled Storage and Expiration of Medications, Biologicals, Syringes and Needles, revised 10/31/16, was provided by the DON on 6/10/22 at 12:45 p.m. The policy indicated the following, .5. Once any medication or biological package is opened, Facility should follow manufacturer/supplier guidelines with respect to expiration dates for opened medications. Facility staff should record the date opened on the medication container when the medication has a shortened expiration date once opened 3.1-25(j) 3.1-25(k)(6)

Based on observation, interview, and record review, the facility failed to ensure hand hygiene was performed after making direct contact with an antigen test for a staff member without the use of gloves. Findings include: An observation was conducted at the nurses' station with Registered Nurse (RN) 2, on 6/7/22 at 10:45 a.m., of her picking up what appeared to be an antigen test for COVID-19 testing that was lying flat on the surface of the desk at the nurses' station. RN 2 was commenting on why it was lying there as she had it in her hands without gloves on. She laid it back down on the desk and proceeded to open the front medication cart to show writer the contents of the medication cart and then went to open the back medication cart without performing hand hygiene after handling medications in the top drawer of each medication cart. RN 2 went back to the nurses' station and picked up the antigen test again and indicated, to writer, that the test had Dietary Staff 4's name on it. She gets tested on a regular basis. The test appeared negative. An interview with the Director of Nursing (DON), on 6/10/22 at 11:03 a.m., indicated the COVID tests should not just be out in the open where people can come in contact with it. A policy titled Hand Hygiene Policy, revised 12/2021, was provided by the DON on 6/10/22 at 12:45 p.m. The policy indicated the following, .Procedure .Healthcare personnel should use an alcohol-based hand rub or wash with soap and water for the following clinical indications .After contact with blood, bodily fluids, or contaminated surfaces 3.1-18(l)

Based on interview and record review, the facility failed to properly prevent and/or contain COVID-19 by failing to ensure a staff member who was ill was appropriately screened and sent home for 1 of 3 staff reviewed for infection control this had the potential to effect 35 of 35 residents residing in the facility (CNA 1) Finding include: During an interview with CNA 1 on 9/2/21 at 1:34 p.m., indicated on 8/14/21 she came to work at the facility and did not feel well. The CNA indicated she had a scratchy throat and [MEDICATION(S)] drainage. The CNA indicated when she arrived to the facility she told the hospitality aide who was completing the screening that she was ill and had symptoms and the screener marked it on the screening questions form. The nurse working on 8/14/21 told CNA 1 that she could go ahead and work because on 8/12/21 she had been tested for COVID 19 and was negative. The CNA indicated the nurse instructed the hospitality aide to change the screening questions to not ill and no symptoms and the hospitality aide changed it. Review of the employee screening tool - fit for duty for CNA 1, dated 8/14/21 at 9:50 a.m., the question Are you currently ill ? had a check mark for yes that had been white out and check mark placed on no and the question Do you have symptoms of fever, cold, cough, shortness of breath or temporarily lost your sense of taste or smell ? Do you have symptoms of nausea/vomiting or diarrhea ? also had a check mark for yes with white out and a check mark on no. CNA 1 indicated a COVID 19 rapid test was not completed on 8/14/21. The screening form in bold letters at the bottom of the questions indicated If you are feeling ill, you should not report for duty. Review of the schedule provided by the Director Of Nursing (DON) on 9/3/21 at 9:04 a.m., indicated CNA worked at the facility on 8/14/21 from 10:00 a.m. to 6:00 p.m. and there were 35 residents residing in the building on 8/14/21. During an interview with the DON on 9/3/21 at 10:55 a.m., indicated she was not aware that CNA 1 was ill on 8/14/21 and still worked. The DON indicated she was not aware that on 8/14/21 CNA 1's screening questions had been changed, the DON agreed that the screening questions check marked had been white out and changed. The DON indicated the facility should have called her and reported the CNA's symptoms on 8/14/21 when CNA 1 was ill and CNA 1 should have had a COVID 19 rapid test completed also. During an interview with the DON on 9/3/21 at 12:05 p.m., indicated on 8/14/21 CNA 1 was assigned to care for 12 residents. CNA 1 had the potential to come into contact with all 35 residents residing in the facility due to meal passing trays, answering call lights and assisting other CNA's with resident care that day. During an interview with the Administrator on 9/3/21 at 2:55 p.m., indicated she called and talked with the hospitality aide that worked on 8/14/21, the hospitality aide indicated that CNA 1 came to work and reported she was ill. The hospitality aide reported it to the nurse on duty and the nurse instructed her to change the screening questions and that CNA 1 could work because she had tested negative for COVID 19 on 8/12/21. The employee COVID 19 testing policy provided by the DON on 9/3/21 at 9:50 a.m., indicated All staff, regardless of vaccination status should be tested if they are experiencing any symptoms of COVID 19 virus: Fever, cough, sore throat, loss of taste, loss of smell, difficulty breathing, etc. This Federal tag relates to Complaint IN 663. 3.1-18(a)

Based on observation, interview and record review the facility failed to implement [CONDITION(S)]-[CONDITION(S)] Deterrent (TED) hose recommended by the physician for a resident experiencing [CONDITION(S)] (swelling) of her left lower extremity for 1 of 3 residents sampled for assessment (Resident C). Finding include: During an interview with Resident C's family member on 9/2/21 at 11:30 a.m., indicated the resident had been experiencing swelling in her lower legs and had a knot on her left leg. The family member indicated she reported it to a nurse and the nurse indicated the physician was aware. The facility was suppose to be putting TED hose her legs and this had not been done. During an observation on 9/2/21 at 3:10 p.m., Resident C was sitting in her wheelchair, the resident's left lower leg was swollen. The resident did not have on TED hose. During an observation on 9/3/21 at 9:45 a.m., Resident C was sitting in her wheelchair, the residents left lower leg was swollen. The resident did not have on TED hose. During an observation and interview on 9/3/21 at 2:40 p.m., Resident C was laying in bed and indicated the staff had not put any type of hose on her legs. The resident lifted up both of her pants legs and showed me that she had regular socks on. The resident indicated the facility staff had never put hose, she would wear them if they did. The resident's left lower leg was swollen. Review of the record of Resident C on 9/2/21 at 3:20 p.m., indicated the resident's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The progress note for Resident C, dated 8/20/21 at 2:55 p.m., indicated the physician examined the resident's [CONDITION(S)] and blister on her left lower extremity. The physician recommended that the facility attempt to implement TED hose for the resident. The progress note for Resident C, dated 8/24/21 at 2:26 p.m., indicated the resident continued to have non pitting [CONDITION(S)] to both legs. The progress note for Resident C, dated 8/25/21 at 12:54 p.m., indicated the resident continued to have bilateral lower legs [CONDITION(S)]. During an interview with the Director Of Nursing (DON) on 3:07 p.m., indicated the nurse that the physician talked to about implementing TED hose for Resident C should have wrote an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . This Federal tag relates to Complaint IN 663. 3.1-37(a)

Based on observation, interview, and record review, the facility failed to ensure food was stored properly related to undated, unlabeled, and expired food of 7 food items. Findings include: 1. A tour of the kitchen was conducted with the Dietary Manager (DM) on [DATE] at 10:15 a.m. The main refrigerator was observed with the following: A bag containing sliced beef bologna with a use or freeze by date of [DATE] and a written date of [DATE], Five clear cups containing fruit with no date, One clear cup that contained pudding with no date, One bag containing multiple cheese slices with no date, A package of dinner rolls with best by date of [DATE], & A package of hot dog buns with best by date of [DATE]. An interview with the DM, on [DATE] at 10:30 a.m., indicated she did not prepare the fruit and/or pudding in the clear containers while she was working on [DATE]. She was unsure when they were prepared. There should have been dates on the prepared food stored in the fridge for when the item was prepared or opened. The beef bologna was expired. There was no system in place to store the bread items by a date of use. She just puts the designated items in the bread compartments depending on what they are. 2. An observation of the medication storage room containing a nutrition refrigerator was conducted on [DATE] at 2:48 p.m. with RN (Registered Nurse) 4. There were 6 cartons of orange boost breeze with an expiration date of [DATE] on all 6 cartons. RN 4 indicated the cartons of orange boost breeze were expired and removed them from the refrigerator to throw away in the trash. A policy titled Refrigerated Storage, revised [DATE], was provided by the Executive Director (ED) on [DATE] at 12:28 p.m. The policy indicated the following, .PROCEDURE .4. Raw meats, poultry, and fish will be wrapped, dated, and labeled .7. All foods will be properly wrapped and/or stored in sealed containers and dated and labeled. Food will be discarded within appropriate shelf life A policy titled Date Marking, revised [DATE], was provided by the ED on [DATE] at 12:28 p.m. The policy indicated the following, .All prepared foods that are stored will be properly dated to ensure food safety .PROCEDURE .1. Date marking is an identification system that identifies when foods were prepared and when they need to be discarded .3. When to discard .C. The expiration date with which the manufacturer guarantee the food will no longer meet quality standards .4. Expiration dates: The date with which the manufacturer guarantees the food will meet its quality standards .8. Items will be marked with both the date opened or prepared and the use-by date 3.,d+[DATE](i)(2) 3.,d+[DATE](i)(3)

Based on interview and record review, the facility failed to ensure a discharge summary was completed for 1 of 1 resident's reviewed for discharge. (Resident 86) Findings include: The clinical record for Resident 86 was reviewed on 7/8/21 at 5:26 p.m. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 86 was admitted to the facility on [DATE] and discharged to home on 5/28/21. A care plan for discharge, dated 5/7/21, indicated the following, .I wish to return home with in [sic] the next 120 days .assist with transportation if needed at time of discharge .call meds into pharmacy of my choice .provide me info on outside referrals .set up referrals as requested A progress note, dated 5/28/21 at 3:00 p.m., indicated the following, .Discharge instructions given to resident. Home medication given to resident to take home. Son to pick her up shortly. Bed hold policy given to resident The clinical record didn't include a discharge summary for Resident 86's discharge to home on 5/28/21. There was no recapitulation of the resident's stay, reconciliation of medications and/or a post-discharge plan of care. An interview conducted with the Director of Nursing (DON), on 7/8/21 at 5:27 p.m., indicated she was unable to find discharge paperwork for Resident 86. The expectations are for a discharge summary to be filled out for each discharged resident. A document titled Post-Discharge Instructions, that was blank, was provided by the DON on 7/8/21 at 5:38 p.m. The DON indicated this was the form that the facility utilizes for discharged residents. The form included, but was not limited to, medical diagnosis, medical information, medical status measurement for vital signs, functional status, skin condition, disposition of personal belongings, special treatments and procedures, current medication therapy, resident instructions, social services, activities, dietary, laboratory data, and rehabilitation services. A policy titled Discharge/Transfer of the Resident, dated June 2004, was provided by the DON on 7/8/21 at 6:23 p.m. The policy indicated the following, .DOCUMENTATION .Discharge summary, including vital signs and a thorough description of the resident's condition upon discharge, disposition of medication, and disposition of personal items .FORMS TO SEND WITH RESIDENT .Discharging Home .Home Instruction Sheet 3.1-36(a)(1) 3.1-36(a)(2) 3.1-36(a)(3) 3.1-36(b)

Based on observation, interview, and record review, the facility failed to ensure medications were labeled with an open date for an insulin pen and purified protein derivative solution. The facility also failed to discard a pneumococcal vaccination for a resident that had passed away for 1 of 1 medication storage refrigerators 1 of 2 medication carts observed. Findings include: 1a. An observation of the medication storage room was conducted on [DATE] at 2:50 p.m. with Registered Nurse (RN) 4. There was a vial of [MEDICATION(S)] (purified protein derivative solution) that was opened, and no open date was present. The vial was in a pharmacy bottle that was dated [DATE] as a fill date. There was a pneumococcal vaccine for Resident 85 with a fill date of [DATE]. The second medication cart contained a Novolog insulin pen with Resident 26's name but no open date present. The pen was inside a pharmacy bag with a fill date of [DATE]. RN 4 indicated there should be a date marked on when the medication was opened. Sometimes the nursing staff will utilize the pharmacy bags for the insulin, but the insulin pen will be dated for a later, more current, date. 1b. The clinical record for Resident 85 was reviewed on [DATE] at 1:00 p.m. The record indicated Resident 85 passed away on [DATE]. 1c. The clinical record for Resident 26 was reviewed on [DATE] at 1:05 p.m. The diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician order, dated [DATE], indicated Resident 26 received sliding scale Novolog via [MEDICATION(S)] three times daily before meals. A policy titled Medications - Storage & Labeling, revised ,d+[DATE], was provided by the Director of Nursing (DON) on [DATE] at 12:55 p.m. The policy indicated the following, .Policy: Drugs and biologicals used in this facility will be labeled in accordance with the currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable .11. Any outdated, contaminated, or deteriorated drugs, or those in containers that are cracked, soiled, or without secure closures must be removed from stock and destroyed according to the drug destruction policy .LABELING OF MEDICATIONS AND BIOLOGICALS .1. The medication label at a minimum shall include the medication name .the expiration date when applicable A policy titled Medication Disposition, revised ,d+[DATE], was provided by the DON on [DATE] at 12:55 p.m. The policy indicated the following, .GUIDELINES .Any medication for which there is no active order shall be disposed of as soon as possible but no later than seven (7) days of becoming inactive .Such medications may include discontinued drugs, outdated drugs, and drugs for residents who are deceased or who have been discharged 3.,d+[DATE](j) 3.,d+[DATE](o)

Based on observation, interview and record review, the facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessment in regards to the risk for pressure ulcer development for 1 of 3 residents reviewed for pressure ulcers. (Resident D) Findings include: The clinical record of Resident D was reviewed on 4-22-19 at 3:40 p.m. His [DIAGNOSES REDACTED]. His most recent quarterly MDS assessment, dated 4-12-19, indicated he was severely cognitively impaired, was able to ambulate with limited assistance of one person with a walker, had no pressure ulcers or other skin issues and was not at risk for pressure ulcers. His most recent annual MDS assessment, 10-12-18, also reflected he was not at risk for for pressure ulcers. He was severely cognitively impaired, was able to be mobile via the use of a wheelchair or walker with supervision of one person, had no pressure ulcers, but did have an open lesion to his foot. Care plans related to being at risk of pressure ulcer development and intact skin had been developed with initiation dates of 12-20-18, 3-3-19 and 3-12-19. His most recent risking tools for prediction of pressure ulcer development, dated 7-13-18, 10-12-18, 12-4-18, 12-11-18, 12-18-18, 12-25-18, 1-1-19 and 4-12-19, identified him as not being at risk for development of pressure ulcers. A risking tool, dated 3-11-19, identified him as being at risk of pressure ulcer development. On 4-22-19 at 11:15 a.m., the MDS Coordinator provided a copy of a report identifying Resident D as having a Stage 2 pressure ulcer which was identified on 3-3-19 to his right buttocks. This report indicated the pressure ulcer was healed as of 3-21-19. The Centers for Medicaid and Medicaid Services, Long Term Care Facility, Resident Assessment Instrument 3.0 User's Manual, version 1.16 (October, (YEAR)) defines a Stage 2 pressure ulcer as a partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed without slough or bruising. (MONTH) also present as an intact or open/ruptured blister. In interview on 4-22-19 at 4:15 p.m., with the MDS Coordinator, she indicated Resident D, did have an open area to his backside not long ago, but it healed up. I did see it last Friday and it had healed up. He does have a pressure reduction cushion for his chair. Resident D's clinical record indicated the previous Stage 2 pressure ulcer, located on the right buttocks, was identified on 3-3-19. An order was received from the attending physician for a protective skin ointment to the area two times daily until healed. On 3-5-19, Resident D was hospitalized for [REDACTED]. A skin assessment, dated 3-13-19, indicated the Stage 2 pressure ulcer had healed. In an interview with the MDS Coordinator on 4-23-19 at 8:57 a.m., she indicated, The reason I listed him as not at risk for pressure areas was that I've been taught to look at the Braden score (risking tool for prediction of pressure area development) and by it, he is not at risk, even though he has had some problems with his skin. I've never really used the 'clinical indications' as part of the risk for pressure areas. I have always looked at that question about pressure risk as having to use the 7-day look back. When (other entity) comes to do our audits, they will look at that question in terms of the 7-day look back period. The MDS Coordinator shared she had observed a new Stage 2 area to Resident D's right buttocks the prior evening after the resident had complained of his buttocks being sore. A care observation was conducted with the MDS Coordinator on 4-23-19 at 11:01 a.m. She indicated the evening prior, Resident D had reported to her his bottom was sore. She explained upon observation at that time, she noted a small open area of 0.3 cm (centimeters) by 0.3 cm area on the right lower buttocks that appeared, like dry skin, almost like a callous. She indicated the attending physician was notified and ordered a protective skin ointment to the area three times daily until healed. She then notified the family of the situation. The area was observed to appear as described by the MDS Coordinator. Resident D indicates his buttocks is sometimes sore, but was unsure if the discomfort is related to his skin issue or hemorrhoids. On 4-23-19 at 1:32 p.m., the Executive Director provided a copy of a portion of the Section M: Skin Conditions from the Centers for Medicaid and Medicaid Services, Long Term Care Facility, Resident Assessment Instrument 3.0 User's Manual, version 1.16 (October, (YEAR)) for M0100, Determination of Pressure Ulcer/Injury Risk. This document indicated, The items in this section document the risk, presence, appearance, and change of pressure ulcers/injury .It is important to recognize and evaluate each resident's risk factors and to identify and evaluate all areas at risk of constant pressure .Pressure ulcers/injuries occur when tissue is compressed between a bony prominence and an external surface. In a addition to pressure, shear force, and friction are important contributors to pressure ulcer/injury development. The underlying health of the resident's soft tissue affects how much pressure, shear force or friction is needed to damage tissue. Skin and soft tissue changes associated with aging, illness, small vessel disease, and malnutrition increase vulnerability to pressure ulcers/injuries .Steps for Assessment (include): Review the medical record, including skin care flow sheets or other tracking forms, nurses' notes and pressure ulcer/injury risk assessments. Speak with the treatment nurse and direct care staff on all shifts to confirm conclusions from the medical record review and observations of the resident .Check C if the resident's risk for pressure ulcer/injury development is based on clinical assessment. A clinical assessment could included a head-to-toe physical examination of the the skin and observation or medical record review of pressure ulcer/injury risk factors. Examples of risk factors include the following: impaired/decreased mobility and decreased functional ability; co-morbid conditions, such as [MEDICAL CONDITIONS] disease, or diabetes; impaired diffuse or localized blood flow (e.g., general [MEDICAL CONDITION] or lower extremity arterial insufficiency); cognitive impairment; healed pressure ulcers .which are more likely to have recurrent breakdown .M0150: Risk of Pressure Ulcer/Injuries: .It is important to recognize and evaluate each resident's risk factors and to evaluate all areas at risk of constant pressure .Based on the item(s) reviewed for M0100, determine if the resident is at risk for developing a pressure ulcer/injury. If the medical record reveals the resident currently has a pressure ulcer/injury, a scar over a bony prominence, or a non-removable dressing or device, the resident is at risk for a worsening or new pressure ulcers/injuries. Review formal risk assessment tools to determine the resident's 'risk score'. Review the component of the clinical assessment conducted for evidence of pressure ulcer/injury risk. Code 0, no if the resident is not at risk for developing pressure ulcers/injuries based on review of information gathered for M0100. Code 1, yes if the resident is at risk for developing pressure ulcers/injuries based on a review of information gathered for M0100. This Federal tag relates to Complaint IN 670. 3.1-31(a)

Based on observation, interview, and record review, the facility failed to ensure a resident's catheter bag or tubing did not touch the floor, for a resident with a history of urinary tract infections. This affected 1 of 2 residents reviewed for urinary catheters. (Resident 33) Findings include: Resident 33's record was reviewed on 7/10/18 at 1:59 p.m. and indicated [DIAGNOSES REDACTED]. On 7/09/18 at 1:56 p.m., Resident 33's catheter bag was observed hanging on the bed frame with the tubing and catheter bag touching the floor. On 7/10/18 at 11:18 a.m., Resident 33 was sitting in his wheelchair in the dining room and his catheter tubing was lying on the floor. On 7/10/18 at 1:16 p.m., Resident 33 was moved from the dining room to his room and his catheter was observed dragging on the floor beneath his wheelchair. physician's orders [REDACTED]. An Admission Minimum Data Set assessment, dated 6/26/18 indicted Resident 33 was severely impaired in cognitive skills for daily decision making, and had an anchored catheter in place. An admission care plan indicated: I am at risk for complications with voiding related to my [DIAGNOSES REDACTED]. I will be free from urinary complications through next review. Cath care every shift. Change (Name of) cath (catheter) 16 fr (French) with 10 ml (milliliter) balloon monthly per MD orders. Labs as ordered, Medications as ordered .Observe for decreased urine flow, increased urgency, or complaints of pain with urination and report findings to my doctor On 7/13/18 at 10:56 a.m., the Director of Nursing said the catheter tubing should not touch the floor. A policy for catheter care was provided by the Director of Nursing on 7/13/18 at 11:50 a.m. The policy indicated the purpose was to promote good hygiene and reduce the potential for infection. The procedure included, but was not limited to .Never allow bag to touch floor 3.1-41(a)(2)

Based on interview and record review, the facility failed to allow a resident a visitor of his choice for 1 of 2 residents reviewed for resident rights. (Resident 30) Findings include: On 5/15/2017 at 4:31 p.m., Resident B said he wants former CNA 1 to visit him, but the facility would not let her. He said she visited him at the hospital when he was in there and he wants her to come in and visit him now. He said she was his CNA and she took good care of him. Resident B indicated someone from the nursing home said it was their policy that she couldn't visit him. Resident B's record was reviewed on 5/16/2017 at 11:57 a.m. [DIAGNOSES REDACTED]. A quarterly Minimum Data Set (MDS) assessment, dated 3/30/17, indicated Resident B was cognitively intact, had not had an acute change in mental status, required extensive assist with activities of daily living, did not walk, and used a wheel chair for mobility. A care plan progress note, dated 7/21/16 at 2:18 p.m., indicated: SSD (Social Service Director) and DON (Director of Nursing) in to do care plan conference. resident and his mother both attend (sic) conference, residents concerns is why a CNA who was let go cannot come in to the building to see him and others. DON explained that he would have to call the cooperate (sic) number and address that with them. Resident was provided with the cooperate number. Residents mother and resident had no other concerns. SSD did ask about his discharge plans and he stated that he wants his mother to continue to try and find placement. Mother told him he just needed to stay here but she would try to find somewhere resident does not want SSD help. He wants to transfer to another facility who has the standing bed frame and more intense therapy. Review of a Resident/Family Concern Form, dated 3/7/17, indicated Description of Concern .Ombudsman (Name) visited & stated concern about former employee not able to visit 2 residents .Plan for Resolution: Informed Ombudsman that I would check with my supv. (supervisor), but as Administrator my concern was with allowing former employee who had an inappropriate relationship with a resident which had to be reported to ISDH, to allow that person to visit would go against Abuse Policy. On 5/17/2017 at 1:47 p.m., the Administrator said Former CNA 1 resigned, and the facility won't allow her to visit Resident B because of the inappropriate behavior. On 5/17/2017 at 3:43 p.m., the Social Service Director (SSD) said Resident B was saying he was going to marry Former CNA 1, so they tried to separate them. The resident said it wasn't true. The Administrator then indicated on 5/09/16 it started getting really sticky and it became evident it was a problem; that he obviously had feelings for the CNA, and that Former CNA 1 said she didn't know what he was talking about. It became a situation that needed to be documented and this was handled as a reported concern. The SSD said he only wanted Former CNA 1 to take care of him, no one else, that he was going to marry Former CNA 1. He wanted her to take care of him and they asked Former CNA 1 what they could do to help take care of him, and she said she just talked to him a lot; she took a lot of time with him every day. On 5/18/2017 at 2:58 p.m., Resident B said he didn't call the corporate office, Former CNA 1 called for him. On 5/18/2017 at 3:35 p.m., the Administrator said they could not let a person come in the facility who was abusive to a resident, and when she spoke with (Name of Ombudsman) during a visit, she probably should have not said they would limit visitation but should have said restrict the resident's visits. On 5/18/2017 at 5:30 p.m., Former CNA 1 said she spoke to the Ombudsman face to face to tell him that her and others who have worked in the building were not allowed to go back and visit residents, he told her to talk to the Administrator about visiting, and if the Administrator told her no she couldn't visit, then there was a problem with it. The Administrator told her no, and she told the Ombudsman, who said he would go in and talk to Resident B. After he spoke with Resident B, he then called her back, and the Administrator had said no that she can't let (Former CNA 1) in there. Former CNA 1 said Resident B's mother also asked the Administrator if she could visit with Resident B, and the Administrator told her no. Former CNA 1 said he doesn't have visitors if his family can't visit, and they can't always visit. She said the reason she can't go in to visit is because he likes her; when he had surgery and sat beside his hospital bed, the Administrator told her it was an inappropriate relationship and she should not have been there. She felt like she was harassed most of the time because of this, she was told she was smiling at him going down the hallway, and they wanted her as far away from him as possible. She was told to help him when there wasn't any one else to take care of him. She said she sat beside him at the hospital and the Administrator told her it was reportable to the state, so she told the Administrator she would just resign. She said the last time she talked to Resident B was in April; he called her briefly. His mom calls her on the phone and tells her she wants her to visit Resident B. She said it was not offered or arranged to have Resident B brought out to a public area for a visit. She said their issue was that he liked her and they didn't want her around him. She learned how to situate him in the chair and how to pad his chair for comfort, not let his lift pad get twisted, and take him to the bathroom. Two of staff would take care of him, they would laugh and cut up with him and they were told that was an inappropriate way to behave with a resident. He would ask for her, he would say Just go get (Former CNA 1) she knows what to do. She said she knew him well enough to anticipate his needs. A progress note dated 7/22/16 at 1:06 a.m. indicated: EMS here to pick up resident report given to them did ask resident if he contacted his mother and he said no no answer but did reach Former CNA 1 and she is aware. A document titled Hickory Creek Rules was provided by the Administrator on 5/17/17 at 9:00 a.m. The document included, but was not limited to: .Hickory Creek nursing homes are private property and Hickory Creek reserves the right to prohibit visitation rights to anyone for any reason should Hickory Creek believe the visit is disruptive to our Residents or Employees A copy of Resident Rights, provided to the resident upon admission, was provided by the Administrator on 5/17/17 at 9:00 a.m. The document included, but was not limited to: .(4) The resident has a right to receive visitors of his or her choosing at the time of his or her choosing, subject to the resident's right to deny visitation when applicable, and in a manner that does not impose on the rights of another resident .(iii) The facility must provide immediate access to a resident by others who are visiting with the consent of the resident, subject to reasonable clinical and safety restrictions and the resident's right to deny or withdraw consent at any time .(v) The facility must have written policies and procedures regarding the visitation rights of residents, including those setting forth any clinically necessary or reasonable restriction or limitation or safety restriction or limitation, which such limitations may apply consistent with the requirements of this subpart, that the facility may need to place on such rights and the reasons for the clinical or safety restriction or limitation 3.1-8(b)(9)

Based on observation, interview and record review the facility failed to implement an ambulation program for 1 of 3 residents reviewed for activities of daily living (Resident 12). Findings include: During observation on 05/16/2017 at 1:24 p.m., Resident 12 was wheeling herself down the hallway in her wheelchair. Review of the record of Resident 12 on 5/16/17 at 1:33 p.m., indicated the resident's [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) assessment for Resident 12, dated 3/13/17, indicated the resident was cognitively intact and decisions for daily decision making were consistent and reasonable. The resident required extensive assistance of one person for bed mobility, transferring, dressing, personal hygiene, use the restroom and locomotion on and off the unit. The resident required limited assistance of one person to walk in her room and corridor. The resident used the mobility device of a walker. The Annual MDS assessment for Resident 12, dated 4/26/17, indicated the resident was cognitively intact and decisions for daily decision making were consistent and reasonable. The resident required extensive assistance of two people for bed mobility, transfers, walking in her room and corridor and using the restroom. The resident did not use a walker and was using a wheelchair as a mobility device. The physical therapy discharge summary for Resident 12, dated 5/3/17, indicated the resident was able to ambulate up to 100 feet using a rolling walker on level surfaces with stand by assist. Recommended ambulation to meals and active range of motion. The resident's prognosis was good with consistent staff follow-through. During observation on 5/17/17 at 11:45 a.m., Resident 12 was sitting in the dining room at the table in her wheelchair. Interview with Resident 12 on 5/17/17 at 1:33 p.m., she was suppose to be on an ambulation program and had not been. The resident had talked to the therapist on this morning and told him that she had been sitting in a wheelchair for two weeks and she wanted to walk so she could go home. The therapist was suppose to find out why the facility was not walking with her. The resident indicated when she was discharged from therapy on 5/3/17, she was told the facility aides would be walking with her every day with a walker. The resident's goal was to go home and she had not walked since she was in therapy and felt like it was going to delay her progress to go home and set her back on her ability to walk. Interview with the Director Of Nursing (DON) on 5/17/17 at 2:01 p.m., she was unsure why Resident 12 had not started an ambulation restorative program and would investigate it. The system for restorative programs were the Therapy department was suppose to go to the MDS coordinator and set up restorative programs for residents. During interview and observation on 05/18/2017 1:02 p.m., Resident 12 was sitting in the dining room with her rollator walker sitting beside her. The resident indicated yesterday evening the staff walked with her to the dining room using her walker. The resident was happy and felt like she was one step closer to going home. During interview with the DON on 05/18/2017 1:05 p.m., Resident 12 was discharged from therapy on 5/3/17 and the therapy department is fairly new to the facility system for restorative programs, The therapist gave the MDS coordinator Resident 12's restorative program on 5/2/17, but there had not been staff training so she had given it back to the lead therapist on 5/5/17. Therapy then trained the staff on the resident's restorative program, the DON was unsure when the staff training was completed. The therapist gave Resident 12's ambulation program to the MDS coordinator on 5/12/17. The resident started the program yesterday evening (5/17/17) . The Restorative program policy provided by the DON on 5/18/17 at 1:20 p.m., indicated each resident will receive the necessary care to attain or maintain the highest practicable physical, mental and psychosocial well being. Restorative nursing includes two or more of the following activities that must be performed at least 15 minutes per day, 6 days per week in order to achieve optimal results. The restorative program included, but were not limited to, range of motion and walking training. 3.1-38(a)(2)(B)

Based on observation, interview and record review the facility failed to provide and post the correct nurse staffing information for 4 days. Finding include: During initial tour of the facility on 5/15/17 at 9:50 a.m., the nurse staff posting was dated 5/11/17. Interview with the Activity Director at this time indicated it was the Director Of Nursing (DON) was responsible to maintain the correct nurse staff posting. Interview with the DON on 5/15/17 at 9:53 a.m., the nurses that worked the weekend were responsible to change the nurse staff posting over the weekend. 3.1-13(a)

Based on observation and interview the facility failed to ensure the kitchen was clean, this had the potential to effect 31 of 31 residents in the facility. Findings include: On 5/15/17 at 10:17 a.m., an observation of the range hood a dark greasy substance with dust participles was noted and the front of the range door have areas of a dark greasy substance running down the front of the door. ON 5/16/17 at 9:24 a.m., an observation of kitchen range hood had a dark greasy substance with dust participles collected on it and on the front of the range, the oven door had areas of a dark greasy substance running down the front of the door. Review of Daily Cleaning Schedule provided by the Dietary Manager on 5/16/17 at 2:00 p.m., for March, April and May specified Range - catch pan - grill - steam tables - drip pans - change foil - ledge above stove. Monthly maintenance cleaning for January, February, March, April, May indicated clean filters and was checked as completed by Maintenance Supervisor. On 5/16/17 at 11:44 a.m., an interview with the Dietary Manager, indicated these will be cleaned tonight. 3.1-21(i)(1)(2)

Based on interview and record review, the facility failed to ensure availability of cardiopulmonary resuscitation (CPR) certified staff on each shift for residents identified as "full codes," or who wish to have full resuscitation in the event of a cardiopulmonary arrest. Additionally, the facility failed to ensure a resident, indicated as a full code, was provided with CPR when the resident became unresponsive and without a heart beat and without respirations for 1 of 1 residents reviewed who were found unresponsive. This deficient practice has the potential to adversely affect the current 4 of 26 residents identified as full codes. ( Resident #A) The Immediate Jeopardy (IJ) began on [DATE] when the Director of Nursing (DON) did not perform CPR on a resident who, identified as to be a full code, became unresponsive and without a heart beat and without respirations. The resident was found by facility staff at 3:45 p.m. and notified the DON. Record review and interview indicated only 4 of 10 licensed staff were currently certified in CPR. There was no CPR certified staff called to the aide the unresponsive resident. The Administrator was notified of the IJ on [DATE] at 11:15 a.m. The immediate jeopardy was removed on [DATE], but noncompliance remained at the lower scope and severity level of a patten, no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: Resident #A's clinical record was reviewed on [DATE] at 3:40 p.m. It indicated her [DIAGNOSES REDACTED]. The clinical record indicated she was designated as a "full code." A physician's telephone order, dated [DATE] indicated, "Code Status: full code per resident/family request." An electronic mail (email) communication, dated [DATE] at 11:32 a.m. from the DON to the resident's power-of-attorney (POA), indicated the resident had returned from a hospital stay with her code status listed as "Full Code," whereas it had previously been listed as "Do Not Resuscitate (DNR)." The DON requested clarification of the POA's desire for Resident #A's code status. In a reply via email from the POA to the DON, dated [DATE] at 11:54 a.m., the POA indicated, "Let's maintain full code." Subsequent documentation, including the August, 2013 recapitulation orders for Resident #A indicated the code status was "full code," and indicated on her care plan, most recently updated on [DATE]. Nursing notes indicated on [DATE] at 3:45 p.m., the resident was found by a facility CNA to be unresponsive and cool to touch. The CNA sought the assistance of the DON, who assessed the resident and found her to be unresponsive, without a heart beat and without respirations. Nursing notes indicated the DON notified the attending physician of her assessment and CPR had not been initiated and indicated the attending physician, "agreed that no CPR was to be initiated." In an interview with the DON on [DATE], she indicated she thought Resident #A was listed as a DNR and did not verify the resident's code status and did not initiate CPR. She indicated it was not until later that she found the full code status in the resident's clinical record. She indicated, "I simply messed up." In review of an initial incident report submitted via email on [DATE] at 1:29 p.m. by the facility to the Indiana State Department of Health (ISDH), the report indicated on [DATE] at approximately 3:45 p.m., Resident #A was found cold and unresponsive. The DON was summoned to the resident's room by staff CNA's. Upon assessment by the DON, the resident was unresponsive, pulseless, without respirations and cold to touch. She notified the attending physician of her findings and did not initiate CPR. The resident was listed as a full code. It indicated the resident expired. In review of the facility's staff with current CPR certification, 4 of 10 licensed nurses were documented as having current certification in CPR. Additionally, one part-time Occupational Therapist and one full-time CNA also provided documentation of current CPR certification. In an interview with the Administrator on [DATE] at 9:05 a.m., she indicated the Director of Nursing (DON) was responsible for tracking CPR certifications and this had not been done. She indicated, until the last week, there had been no inservice education regarding CPR or advance directives for over 6 months. At the time in which Resident #A was found unresponsive by facility staff, the only CPR certified staff person in the building was the part-time Occupational Therapist, but her time card indicated she had clocked out 1 minute after the resident was found unresponsive. Nursing notes and staff interviews did not indicate the Occupational Therapist was made aware or responded to the event. In an interview with the DON on [DATE] at 5:10 p.m., she indicated she previously had been a CPR instructor, but that certification had lapsed several years ago. In an interview with CNA #1 on [DATE] at 11:47 a.m., she indicated she was working on the afternoon shift of [DATE]. She indicated at approximately 2:30 p.m. on [DATE], while she was passing fresh ice water, Resident #A smiled at her and spoke with her. She indicated she observed Resident #A taking several sips of water at that time. She indicated the resident "seemed like her normal self." She indicated between 3:30 p.m. and 4:00 p.m., the other CNA working with her called her into Resident #A's room. She indicated she found Resident #A cool to touch, blue in color and unresponsive. She indicated the nurse working that evening was with another resident and the DON was close by and responded to her call. She indicated she observed the DON check the resident's chest with her stethoscope. She indicated the DON did not perform CPR on Resident #A. She indicated she was aware that Resident #A was a full code, "because she had a green dot on the outside of her chart (clinical record) and it was on the aide assignment sheet." She indicated she, "didn't give it much thought, I guess, about not doing the CPR because she was already cold when we found her and she (the DON) talked to the doctor about it." In an interview with RN #2 on [DATE] at 11:11 a.m., she indicated she was working on the afternoon Resident #A passed away. She indicated she was busy with another resident at the time the resident was found unresponsive and the DON responded. She indicated at the time of Resident #A's passing, the facility was not utilizing color coded stickers on the resident's doorframes, but were using them on the outside of the resident's clinical record to identify the resident's code status. She indicated the resident's code status is also included in the resident's clinical record under physician orders and advance directives. In an interview with the Occupational Therapist on [DATE] at 2:35 p.m., she indicated she was working on the afternoon of [DATE]. She indicated she was in the hallway near the nurse's station when she observed CNA #1 with a panicked look on her face. She indicated she overheard CNA #1 speak Resident #A's name to the DON. She indicated the DON went directly to Resident #A's room and closed the resident's door. She indicated she observed the DON taking her stethoscope into the resident's room. She indicated "No one told me what was going on or asked me for help." She indicated she clocked out shortly thereafter and left the facility. In an interview with CNA #2 on [DATE] at 11:30 a.m., she indicated she was aware, prior to Resident #A's passing, that she was listed as a full code because of the colored dot on the outside of the resident's clinical record, as well as that information was located on the aide assignment sheet. In an interview with RN #1 on [DATE] at 9:05 a.m., she indicated the facility had utilized a system of color coding for the outside of each resident's clinical record, as well as for doorway to each resident's room "for a long time" to identify the resident's code status. She indicated a listing of each resident's code status was routinely maintained in the front of the "Hot Charting" binder. In review of the "as worked" nursing schedule for CPR trained staff, as well as the Occupational Therapist, coverage, as for [DATE] to [DATE] was as follows: - on [DATE], there were 17 hours of CPR-certified staff coverage. - on [DATE], there were 10 hours of CPR-certified staff coverage. - on [DATE], there were 10 hours of CPR-certified staff coverage. - on [DATE], there were 10 hours of CPR-certified staff coverage. - on [DATE], there were 11 hours of CPR-certified staff coverage. - on [DATE], there were 15.25 hours of CPR-certified staff coverage. - on [DATE], there were 21 hours of CPR-certified staff coverage. - on [DATE], there were 24 hours of CPR-certified staff coverage. Each day during this time period, a minimum of one resident resided in the facility who was identified as a "full code." On [DATE] at 3:35 p.m., the Administrator provided a copy of a policy entitled, "Cardio-Pulmonary Resuscitation (CPR) for Adults." This policy was identified as the current policy in use by the facility. This policy indicated, "Cardio-Pulmonary Resuscitation (CPR) will be performed by trained personnel only. CPR will be performed on all residents, unless the physician has ordered otherwise. CPR will not be stopped for more than 5 seconds unless: the resident revives, a physician, EMT or other qualified person assumes responsibility, or you are unable to continue due to physical exhaustion and there is no trained person to relieve you...Begin CPR immediately if the resident/patient has: a) no pulse; b) no respiration; c) unresponsiveness; d) no physician order for [REDACTED]. On [DATE] at 3:35 p.m., the Administrator provided a copy of a policy entitled, "Full Code Directives." This policy was identified as the current policy in use by the facility. This policy indicated, "It is the policy of this facility that CPR (cardio-pulmonary resuscitation) will be performed on all residents who have indicated they wish to receive CPR. CPR will be initiated as soon as the nurse has assessed the resident does not have respirations or a pulse...For those residents who have designated a "full code" status (requesting CPR), the facility will utilize a colored sticker on the outside of the resident' medical record. They will also place the same colored sticker on the name plate outside the resident's room. The facility will designate the color and type of sticker to be used below. A list of residents who have a "full code" designation will also be maintained at the nurse's station and will be checked weekly by the Director of Nursing to make sure it is current...On a quarterly basis, the care plan team will review the resident's code status as part of the care plan conference...The nurse will initiate CPR immediately when he/she observes a resident who has been designated as a "full code" without respirations and pulse. "911" will be called by another staff member as directed by the nurse who is administering CPR. The physician will be notified immediately and informed of the resident's condition. CPR will be continued until a physician stops the procedure, until an EMT or someone as qualified or better qualified than the nurse relieved the nurse or until the victim regains adequate circulation and respirations...All RN's and LPN's will be CPR certified...The facility will arrange for CPR training for all nurses who are not CPR certified, or who need to have their CPR status renewed...The Director of Nursing will monitor the CPR status of each nurse by means of a tracking system..." On [DATE] at 3:35 p.m., the Administrator provided a copy of a policy entitled, "Advance Directives." This policy was identified as the current policy in use by the facility. This policy indicated, "...Nursing staff will be educated at least yearly on the facility policy regarding advance directives..." The immediate jeopardy that began on [DATE] was removed on [DATE] at 3:10 p.m. when the facility ensured all licensed nursing staff were currently CPR certified, including a tracking system for monitoring CPR certification status of all licensed nursing staff on a regular basis, an identification system was put into place to be able to identify the code status of all residents and inservice education was completed for all licensed nursing staff regarding full codes, advance directives and CPR. Post inservice interviews were conducted with 3 licensed nurses and 2 CNA's regarding identification of code status and what to do in the event of finding a resident who is unresponsive and without a heart beat and without respirations. Observation indicated each resident's clinical file and each resident's nameplate on their door was identified by the corresponding colored sticker which was in agreement with each resident's code status, as well as a listing of each resident and their code status in the front of the facility's "hot charting" or "focused charting" binder. Even though the facility's corrective action removed the IJ, the facility remained out of compliance at a reduced scope and severity level of pattern, no actual harm with potential for more than minimal harm that is not immediate jeopardy. 3XXX,[DATE](a)

Based on observation, interview and record review, the facility failed to assist a dependent resident with bed mobility in a safe manner resulting in the resident falling out of bed, acquiring a closed head wound that required 20 sutures and right side facial and eye contusions for 1 of 4 residents sampled for accidents in a total sample of 4 (Resident #A). Finding include: Review of the record of Resident #A on 4-10-12 at 10:30 a.m. indicated the resident's [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment for Resident #A dated, 3-29-12 indicated the following: bed mobility- total dependence of two people, transfer- total dependence of two people, walk in room- did not occur and toileting- total dependence of two people. The nurses note for Resident #A dated, 3-29-12 at 9:15 p.m. indicated the resident was on the floor face down with blood around the head. The resident had an laceration to the top of the head and a skin tear to the left hand. The emergency personal was called and pressure was applied to the resident's head. The nurses note for Resident #A dated, 3-29-12 at 9:25 p.m. indicated the emergency personal took the resident to the emergency room . The local hospital emergency room record for Resident #A dated, 3-29-12 at 9:50 p.m. indicated the resident was placed on an backboard and c-collar was placed on the resident's neck. The resident had a peri orbital hematoma and a head laceration. The resident's pain level was maximum at a level 10. The local hospital emergency room record for Resident #A dated, 3-29-12 at 11:05 p.m. indicated the resident had a 6 centimeter scalp laceration and an right eye orbit contusion. The resident's pain level was moderate. The interpretive imaging report for Resident #A dated, 3-29-12 indicated the history was pelvis injury and pain. The findings was no acute fracture. The Computed Tomography (CT) (x-ray procedure) of the facial bones for Resident #A dated, 3-29-12 indicated the history was head and neck injury and pain. The findings were bone window images show no fracture. There were fluid in the sphenoid sinuses. There were no mass effect, midline shift or evidence of hemorrhage. The cervical CT for Resident #A dated, 3-29-12 indicated the history was head and neck injury. The findings were no fractures or dislocations were seen. The CT of facial bones for Resident #A dated, 3-30-12 indicated the history was facial injury and pain. The findings were mucosal thickening in the left maxillary sinus. There was fluid in the sphenoid sinuses. There were no fractures seen. The local hospital physician order [REDACTED]. The [DIAGNOSES REDACTED]. The resident was ordered neurological checks every two hours for 24 hours and then discontinue if they were stable. Notify the resident's physician of the resident's fall and scalp laceration. The sutures to be removed in 10 days. The episodic care plan falls for Resident #A dated, 3-29-12 indicated the cause of the fall was slick sheets were on the bed. The assessment of other skin abnormalities for Resident #A dated, 3-29-12 indicated the resident had a 6 centimeter laceration to the top of the head, moderate amount of bleeding, sent to the emergency room for evaluation. Twenty sutures intact upon return. The care plan for Resident #A dated, 3-30-12 indicated the resident was at risk for falls. The interventions were as follows: "inform me of what you are going to do", "place hoyer sling under me", "converse with me during transfer to assure me that I am safe", "talk to hospice about assist rails for my bed", "use standard cotton sheets on my bed", "place a star outside my door to alert staff of my fall risk", do a fall risk assessment for me quarterly and as needed. The intervention added on 3-31-12 was assist rails to bilateral side of the resident's bed. The "ATTENTION NURSING STAFF" documentation for Resident #A dated, 3-30-12 included, but were not limited to, Nurses please check every two hours and document well regarding the resident's condition. The first sign of any problem, call the doctor and hospice, On first and second shift please use 3 staff for bed care, Please use a blanket roll as an extra barrier on the side of the bed away from the wall, please be mindful of the resident's soreness and get her up as tolerated, please assist the resident to use the grab bar now on her bed when turning side to side, provide plenty of reassurance due to her anxiety. The nurses notes for Resident #A dated, 3-30-12 at 1:00 a.m. indicated the resident returned by ambulance to the facility. The resident was assisted back to bed with the assist of 3 people. The resident had a large purple bruise to the right eye and the eye was swollen shut. The resident's scalp was clean. The resident had sutures in place. The left hand had an bandage on it. The resident had multiple bruising noted to the upper body. During observation on 4-10-12 at 11:15 a.m. Resident #A was laying in bed. The resident had an air mattress on the bed and had quarter grab bars on each side of the bed. The resident had bruising to the right side of the face and right ear. The resident had a large deep laceration on the right side of her head with dried dark drainage on it, the laceration had steri strips across it. The resident indicated she fell out of bed and was unable to remember what happened. The resident indicated her head was sore. During observation on 4-10-12 at 11:30 a.m. CNA #2 and CNA #3 assisted Resident #A from side to side in her bed to apply an hoyer lift pad under the resident for an transfer. Resident #A was able to grab the assist bars on her bed while being assisted with turning. Interview with CNA #2 and CNA #3 at this time indicated the resident had always had an air mattress and did not have assist bars until the resident fell out of bed. CNA #2 and CNA #3 indicated they had not had any problems with Resident #A sliding due to slick sheets. CNA #2 provided a set of sheets that the resident's family had provided, and the label on the sheets indicated 100% polyester. CNA #3 indicated she had not experienced any problems with Resident #A grabbing out for things during bed mobility until after the resident fell out of the bed. CNA #3 indicated the resident was fearful being turned from side to side now after she fell out of bed. During observation there were no roll blanket used during care. Interview with family member #1 of Resident #A on 4-10-12 at 12:50 p.m. indicated the resident had rolled out of bed. Family member #1 indicated the resident had felt insecure about being so close to the edge of the bed. Family member #1 indicated he was told by the facility the resident was reaching for something and the sheets were slick was the cause of the resident falling out of bed. Family member #1 indicated there had not been any problems brought to the family regarding the sheets they had provided until after the resident had fallen out of the bed. Family member #1 indicated the resident had been using the sheets for several months. Family member #1 indicated the resident had voiced concerns about being too close to the edge and was afraid she would fall. Family member #1 indicated he was told there were two staff and they rolled the resident to her side to clean her up and the resident reached for something and fell out of bed. Interview with Family member #2 of Resident #A on 4-10-12 at 1:15 p.m. indicated when she arrived to the hospital on 3-29-12 after the resident had fell out of bed, the resident indicated to her she had told those girls not to roll her so close to edge of the bed, that she was going to fall. Family member #2 indicated the resident's right side of her face was black and blue and her right eye was swollen shut. Family member #2 indicated the resident was not able to roll herself in bed by herself. Family member #2 indicated the resident had been using the sheets the family had bought for 8-9 months. Family member #2 indicated there had not been any problems with the sheets until after the resident fell out of bed. Interview with the Director Of Nursing (DON) on 4-10-12 at 2:25 a.m. indicated the "ATTENTION NURSING STAFF" documentation for Resident #A dated, 3-30-12 was an inservice the Administrator had done with staff after Resident #A had fell out of bed. The DON indicated the interventions should have been added to the resident's care plan. The DON indicated the blanket roll was added for support. Interview with CNA #1 on 4-10-12 at 2:30 p.m. indicated she and CNA #4 was caring for Resident #A on 3-29-12 when she fell out of the bed. CNA #1 indicated she had rolled the resident toward her so CNA #4 could clean the resident. CNA #1 indicated the resident attempted to grab for the oxygen tank and she instructed the resident to hold on to her scrub top. CNA #1 indicated the resident did hold onto her top for a minute. CNA #1 indicated the resident kept saying "I'm gonna fall" "I am gonna fall". CNA #1 indicated the resident's bed cannot be raised up for care so she was bending down trying to hold on to the resident. CNA #1 indicated she went to reposition her back from bending over and when she moved her knees, that was when the resident fell out of bed. CNA #1 indicated the resident had sheets on her bed the family had brought in and that she had told the nurses in the past the sheets were too slick. CNA #1 indicated she had told the nurses when the resident had the sheets on her bed it was too easy for the resident to move when trying to hold onto her. Interview with CNA #4 on 4-10-12 at 2:35 p.m. indicated she was assisting Resident #A on 3-29-12 when the resident fell out of the bed. CNA #4 indicated she was cleaning the resident at the time of the fall. When queried if Resident #A was close to the edge of the bed when she fell out of bed, CNA #4 indicated the resident was always kind of on the edge of the bed because of the resident's size. CNA #4 indicated the sheets did not help the situation and the resident not having side rails made the situation difficult. CNA #4 indicated she had reported the sheets were too slippery. CNA #4 indicated when she would try to hold onto the resident during care, the resident would move easily due to the sheets. CNA #4 indicated when staff would assist the resident to reposition and be pulled up in the bed, the resident would slide down because the sheets were slick. CNA #4 indicated she had reported the sheets being too slippery a few times. The CNA assignment sheet provided by the DON on 4-10-12 at 2:45 p.m. indicated Resident #A should have assist bars, blanket roll and the assistance of two people for turning. Interview with the Administrator on 4-11-12 at 1:50 p.m. indicated the staff were instructed to use three people during Resident #A's care when possible. The Administrator indicated the three staff during care and the blanket roll were immediate interventions the facility had put in place and were never added to the resident's care plan. The Administrator indicated the grab bars placed on the resident's bed were the main intervention put in place after the resident's fall on 3-29-12. This federal tag relates to complaint IN 471. 3.1-45(a)(1) 3.1-45(a)(2)