Every finding on record at Hickory Creek at Crawfordsville

Based on observation, interview, and record review, the facility failed to ensure staff (RN 4) were properly trained, monitored, and compliant with medication administration and infection control practices for 4 of 6 residents observed for medication administration (Residents B, D, E, and F). Findings include:A complaint during the survey indicated Qualified Medication Aide (QMA) 6 had not administered eye medications to Resident B according to her orders or failed to administer the eye medications but documented she had administered them. QMA 6 also was not placing lidocaine patches (used to relieve localized pain) on residents but documenting she had. Grievances logs, dated 2/11/26, 3/10/26, and 4/21/26, indicated Resident B or her representative had reported the resident had not been receiving her eye drops as ordered from QMA 6. During a random observation on 5/4/26 at 7:40 a.m., Registered Nurse (RN) 4 was presetting medications on top of a medication cart on the back hallway. There were 15 medications cups on the top of the cart with resident names written in black sharpie, and 2 medication cups already had medication in them. RN 4 indicated he rarely administered medications as that was a QMA job, and his system was to preset all the medications before administering to avoid making mistakes. 1. On 5/4/26 at 7:35 a.m., RN 4 was observed taking a preset cup of unidentified medications for Resident N from the top of a medication cart and going to the main dining room where he obtained Resident N's vital signs and then administered her medications. Preset cups of other residents' medications were left on top of the unlocked medication cart at the end of the back hallway out of sight of the RN. RN 4 was not observed to sanitize his hands before or after administering the resident's medications. 2. On 5/4/26 at 7:45 a.m., RN 4 was observed taking a preset cup of unidentified medications for Resident D from the top of a medication cart and going to her room at the opposite end of the hallway. An electronic tablet was left open on top of the medication cart displaying Resident D's medication names and administration record. RN 4 obtained Resident D's vital signs and then administered her oral medications in her room, out of sight of the medication cart. RN 4 donned gloves and administered Restasis drops into both of Resident D's eyes, then immediately instilled Systane 0.6% eye drops into both of her eyes. RN 4 was not observed to sanitize his hands before or after administering Resident N's medications. Resident D's clinical record was reviewed on 5/4/26 at 10:58 a.m. Diagnoses on Resident D's profile included low back pain and dry eye syndrome. Physician's orders included, a. On 10/3/25, Lidocaine patch 4% on in the a.m. and off at night, as needed (prn) for pain.b. On 4/3/26, Restasis 0.05% (cyclosporine - prescription eye lubricant used to treat chronic dry eye syndrome) eye drops administer 1 drop in each eye twice a day.c. On 4/20/26, Systane 0.6% (over-the-counter eye lubricant used to treat dry eye symptoms) eye drops 1 drop in each eye twice a day. Drugs.com indicated to apply the lubricant drop (Systane) first to soothe the eyes, then apply the prescription drop (Restasis) later to allow it to directly contact the eye surface. It indicated to wait at least 15 minutes between applications to ensure proper absorption and prevent washing out the medication. 3. On 5/4/26 at 7:58 a.m., RN 4 was observed pulling 7 medication cards from the medication cart. RN 4 then walked to Resident B's room at the opposite end of the hallway and left the medication cards unsecured on top of the cart while he obtained Resident B's vital signs. An electronic tablet was left open on top of the medication cart displaying Resident B's medication names and administration record, and the medication cart was left unlocked. While RN 4 was out of sight, he left Resident M sitting in her wheelchair near the medication cart waiting for his return. RN 4 popped out Resident B's pills from bubble pack cards directly into his hand, then placed the pills into a medication cup. RN 4 administered Refresh Relieva 0.5-1% eye drops into both of Resident B's eyes, then immediately instilled Gentear eye ointment into the resident's right eye. RN 4 donned gloves to administer the eye drops/ointment but was not observed to sanitize his hands before or after administering the oral and eye medications. Resident B's clinical record was reviewed on 5/4/26 at 11:48 a.m. Diagnoses on Resident B's profile included pain in the left shoulder, presbyopia (age-related loss of eye flexibility causing difficulty focusing on near objects), myopia right eye (distant objects appear blurry) and hypermetropia in the left eye (farsightedness), and dry eye syndrome of bilateral eyes. Physician's orders included,a. On 12/7/25, lidocaine 5 % adhesive patch, apply 1 patch PRN (as wanted) daily.b. On 4/9/26, Refresh Relieva PF 0.5-1 % instill 1 drop every 2 hours while awake.c. On 2/12/26, Systane Nighttime (white petrolatum-mineral oil) 94-3 % ointment apply a thin amount to the right eye four times a day. 4. On 5/4/26 at 8:17 a.m., RN 4 was observed pulling medication cards from the medication cart for Resident E. RN 4 popped 4 pills into his hand and placed them into a medication cup when he stopped and indicated he needed to go get vital signs for the resident who was sitting in the main dining room. The popped medications included aspirin 81 mg (used to prevent blood clotting), Amlodipine (used to treat high blood pressure), Clopidogrel 75 mg (Plavix - a blood thinner), and Isosorbide ER 30 mg (used to prevent chest pain). An electronic tablet was left open on top of the medication cart displaying Resident E's medication names and administration record, the medication cart was left unlocked, and the 7 cards of medications and cup with popped pills were left unsecured on top of the medication cart, all out of sight of the nurse. The Director of Nursing (DON) arrived and was observed to stop RN 4 from obtaining vital signs in the main dining room and told the nurse to pick another resident to administer medications to as the resident was in the dining room. RN 4 was observed to place Resident E's partially filled cup of medications to the back of the medication cart surface and began preparing medications for Resident F. The nurse was not observed to sanitize his hands before or after preparing the oral medications. 5. On 5/4/26 at 8:22 a.m., RN 4 was observed pulling 10 medication cards from the medication cart for Resident F. The nurse then indicated he needed to go get vital signs for the resident who was lying in her bed in a room directly across the hallway from the medication cart. An electronic tablet was left open on top of the medication cart displaying Resident F's medication names and administration record, the medication cart was left unlocked, the 10 cards of medications and the cup with Resident E's popped pills were left unsecured on top of the medication cart, all out of sight of the nurse. The DON was observed approaching the medication cart as Resident P walked by and stayed until the nurse exited the resident room. The DON was observed telling RN 4 he could not preset medications, to throw away the medication cups with resident names that were on top of the cart, and that he had to lock the medication cart and electronic tablet when he was out of sight of the cart. The DON left the area as RN entered the room to administer Resident F's medications. Resident E's cup of 4 pills was left unsecured on top of the medication cart. The nurse was not observed to sanitize his hands before or after administering the oral medications. 6. On 5/4/26 at 8:50 a.m., RN 5 was observed putting a date and her initials on a medicated pain patch, then preparing to apply the patch on top of Resident G's right shoulder. An old patch, dated 5/3/26, was observed still on the resident's shoulder and had to be removed before placement of the new patch. RN 5 indicated Resident G had an order to place an Aspercreme patch daily in the morning and remove it at bedtime. Resident G's clinical record review was completed on 5/4/26 at 11:18 a.m. Diagnoses on Resident G's profile included fibromyalgia and chronic pain. A physician's order, dated 5/9/25, indicated Aspercreme (lidocaine) 4 % apply 1 adhesive to the right shoulder in the a.m. and remove in the p.m. The website, https://www.aspercreme.com, undated, indicated Aspercreme with lidocaine patch instructions for use included, .apply to clean, dry skin for up to 12 hours, and follow safety precautions to ensure effective pain relief. Do not apply to broken or irritated skin. Take the patch out of its packaging and remove the protective liner from one side of the patch. Place the sticky side of the patch directly onto the painful area. Press down firmly to ensure it adheres well.The patch can be left on for up to 12 hours. Do not apply more than 3 patches in a 24-hour period. When done using the patch, fold it in half with the sticky sides together and dispose of it safely, out of reach of children and pets. Wash the hands after applying or removing the patch to prevent accidental contact with sensitive areas. On 5/4/26 at 8:52 a.m., residents with medicated Aspercreme/lidocaine orders were interviewed with the DON, to include,a. Resident D indicated she had an order for a pain patch, but it was only for when she needed one and she had not worn one in a while.b. Resident J indicated she had been wearing a patch from the night before but had removed it herself earlier.d. Resident K indicated she had been wearing a patch from the night before but had removed it herself earlier.e. Resident B indicated the Assistant Director of Nursing (ADON) had removed a patch from her left shoulder that morning, but the patch had not yet been reapplied.f. Resident L indicated that the ADON had come into her room minutes earlier to check for her patch, and she was not wearing one that was ordered to be put on twice a day. A Job Specific Orientation list for RN 4, signed by the employee as having completed the requirements necessary to perform his duties on 3/5/26, including a clinical skills checklist and medication management. On 5/4/26 at 1:45 p.m., RN 4 indicated when administering multiple eye medications, there was a 5-minute wait time between medications. During an interview on 5/4/26 at 1:54 p.m., the DON indicated nurses were checked off for medication administration and hand hygiene competency as part of the new-hire orientation. The procedure for administering multiple eye medications included hand hygiene both before and after administration of the drops and waiting at least 5 minutes between eye drops. There were 6 residents that had physician's orders for medicated patches. A once daily patch order indicated to place a patch in the am and remove in the pm. A twice daily patch order indicated placing the first patch in the a.m. and removing and replacing with a second patch in the p.m. RN 4 should have used hand sanitizer before and after setting up each resident's medications. On 5/4/26 at 3:06 p.m., the DON provided a Suggested Medication Administration Procedures, revised 6/30/23, and indicated the policy was the one currently being used by the facility. The policy indicated, Ophthalmic medication procedure.3. Wash hands and wear gloves.9. Gently pull-down lower lid to expose conjunctival sac. 10. Eye drops: hold dropper in dominant hand approximately 1/2 - 3/4 above conjunctival sac. Do not touch dropper to eye.13. If multiple eye drops are to be administered, wait 5 minutes between medications.16. Wash hands and document dose administered. This citation relates to Intake 2994771. 410 IAC (Indiana Administrative Code) 3.1-16(q)(7)

Based on observation, interview, and record review, the facility failed to ensure staff (RN 4) washed his hands per policy before, between, and after medication administration for 5 of 6 residents observed for medication administration (Residents B, D, E, F, and N). Findings include:1. On 5/4/26 at 7:35 a.m., RN 4 was observed taking a preset cup of unidentified medications for Resident N from the top of a medication cart and going to the main dining room where he obtained Resident N's vital signs and then administered her medications. RN 4 was not observed to sanitize his hands before or after administering the resident's medications. 2. On 5/4/26 at 7:45 a.m., RN 4 was observed taking a preset cup of unidentified medications for Resident D from the top of a medication cart and going to her room at the opposite end of the hallway. RN 4 obtained Resident D's vital signs and then administered her oral medications in her room. RN 4 donned gloves and administered Restasis drops into both of Resident D's eyes, then immediately instilled Systane 0.6% eye drops into both of her eyes. RN 4 was not observed to sanitize his hands before or after administering Resident N's medications. 3. On 5/4/26 at 7:58 a.m., RN 4 was observed pulling 7 medication cards from the medication cart. RN 4 was observed to pop out Resident B's pills from bubble pack cards directly into his hand, then place the pills into a medication cup. RN 4 administered Refresh Relieva 0.5-1% eye drops into both of Resident B's eyes, then immediately instilled Gentear eye ointment into the resident's right eye. RN 4 donned gloves to administer the eye drops/ointment but was not observed to sanitize his hands before or after administering the oral and eye medications. 4. On 5/4/26 at 8:17 a.m., RN 4 was observed pulling medication cards from the medication cart for Resident E. The nurse had popped 4 pills into his hand and placed them into a medication cup when he stopped and indicated he needed to go get vital signs for the resident who was sitting in the main dining room. The popped medications included aspirin 81 mg (used to prevent blood clotting), Amlodipine (used to treat high blood pressure), Clopidogrel 75 mg (Plavix - a blood thinner), and Isosorbide ER 30 mg (used to prevent chest pain). The Director of Nursing (DON) arrived and was observed to stop RN 4 from obtaining vital signs in the main dining room and told the nurse to pick another resident to administer medications to as the resident was in the dining room. RN 4 was observed to place Resident E's partially filled cup of medications to the back of the medication cart surface and began preparing medications for Resident F. The nurse was not observed to sanitize his hands before or after preparing the oral medications. 5. On 5/4/26 at 8:22 a.m., RN 4 was observed pulling 10 medication cards from the medication cart for Resident F. The nurse then indicated he needed to go get vital signs for the resident who was lying in her bed in a room directly across the hallway from the medication cart. RN entered the room to administer Resident F's medications. The nurse was not observed to sanitize his hands before or after administering the oral medications. During an interview on 5/4/26 at 1:54 p.m., the DON indicated, nurses were checked off for medication administration and hand hygiene competency as part of the new-hire orientation. RN 4 should have used hand sanitizer before and after setting up each resident's medications. On 5/4/26 at 3:06 p.m., the DON provided a Suggested Medication Administration Procedures, revised 6/30/23, and indicated the policy was the one currently being used by the facility. The policy indicated, Ophthalmic medication procedure.3. Wash hands and wear gloves.9. Gently pull-down lower lid to expose conjunctival sac. 10. Eye drops: hold dropper in dominant hand approximately 1/2 - 3/4 above conjunctival sac. Do not touch dropper to eye.13. If multiple eye drops are to be administered, wait 5 minutes between medications.16. Wash hands and document dose administered. On 5/4/26 at 3:06 p.m., the Director of Nursing (DON) provided a Hand Hygiene Policy, revised 12/2021, and indicated the policy was the one currently being used by the facility. The policy indicated healthcare professionals should use an alcohol-based hand rub or wash with soap and water for clinical indications that included immediately before touching a resident, before performing an aseptic task, after touching a resident or the resident's immediate environment, immediately after glove or PPE (personal protective equipment i.e. gloves) removal, and before starting a medication preparation. Cross reference to Tag F726. This citation relates to Intake 2994771. 410 IAC (Indiana Administrative Code) 3.1-18(l)(2)

Based on observation, interview, and record review, the facility failed to ensure a medication error rate of less than 5%, when 2 errors were observed during 25 opportunities for errors during medication administration resulting in an error rate of 8.0% (Residents D and B). Findings include: 1. On 5/4/26 at 7:45 a.m., RN 4 was observed taking a preset cup of unidentified medications for Resident D from the top of a medication cart and going to her room at the opposite end of the hallway. RN 4 donned gloves and administered Restasis drops into both of Resident D's eyes, then immediately instilled Systane 0.6% eye drops into both of her eyes. RN 4 was not observed to sanitize his hands before or after administering Resident N's medications. Resident D's clinical record was reviewed on 5/4/26 at 10:58 a.m. Diagnoses on Resident D's profile included low back pain and dry eye syndrome. Physician's orders included, a. On 4/3/26, Restasis 0.05% (cyclosporine - prescription eye lubricant used to treat chronic dry eye syndrome) eye drops administer 1 drop in each eye twice a day.b. On 4/20/26, Systane 0.6% (over-the-counter eye lubricant used to treat dry eye symptoms) eye drops 1 drop in each eye twice a day. Drugs.com indicated to apply the lubricant drop (Systane) first to soothe the eyes, then apply the prescription drop (Restasis) later to allow it to directly contact the eye surface. It indicated to wait at least 15 minutes between applications to ensure proper absorption and prevent washing out the medication. 2. On 5/4/26 at 7:58 a.m., RN 4 administered Refresh Relieva 0.5-1% eye drops into both of Resident B's eyes, then immediately instilled Gentear eye ointment into the resident's right eye. RN 4 donned gloves to administer the eye drops/ointment but was not observed to sanitize his hands before or after administering the oral and eye medications. Resident B's clinical record was reviewed on 5/4/26 at 11:48 a.m. Diagnoses on Resident B's profile included pain in the left shoulder, presbyopia (age-related loss of eye flexibility causing difficulty focusing on near objects), myopia right eye (distant objects appear blurry) and hypermetropia in the left eye (farsightedness), and dry eye syndrome of bilateral eyes. Physician's orders included,a. On 4/9/26, Refresh Relieva PF 0.5-1 % instill 1 drop every 2 hours while awake.b. On 2/12/26, Systane Nighttime (white petrolatum-mineral oil) 94-3 % ointment apply a thin amount to the right eye four times a day. On 5/4/26 at 1:45 p.m., RN 4 indicated when administering multiple eye medications, there was a 5-minute wait time between medications. During an interview on 5/4/26 at 1:54 p.m., the DON indicated nurses were checked off for medication administration and hand hygiene competency as part of the new-hire orientation. The procedure for administering multiple eye medications included hand hygiene both before and after administration of the drops and waiting at least 5 minutes between eye drops. On 5/4/26 at 3:06 p.m., the DON provided a Suggested Medication Administration Procedures, revised 6/30/23, and indicated the policy was the one currently being used by the facility. The policy indicated, Ophthalmic medication procedure.3. Wash hands and wear gloves.9. Gently pull-down lower lid to expose conjunctival sac. 10. Eye drops: hold dropper in dominant hand approximately 1/2 - 3/4 above conjunctival sac. Do not touch dropper to eye.13. If multiple eye drops are to be administered, wait 5 minutes between medications.16. Wash hands and document dose administered. Cross Reference to Tag F726. This citation relates to Intake 2994771. 410 IAC (Indiana Administrative Code) 3.1-48(c)(1)

Based on observation, interview, and record review, the facility failed to ensure hand hygiene was completed according to infection control practices for 5 of 6 residents reviewed for medication administration (Residents E, R, S, T, and U).Findings include, On 1/13/26 at 7:50 a.m., Qualified Medication Aide (QMA) 10 was observed passing medications during breakfast service in the main dining room. QMA 10 handed Resident R a cup of medications, and while she waited for the resident to swallow her medications, she reached to remove a piece of bacon from Resident X's shirt. QMA 10 lifted her long hair from her neck, scratched her head, and ran her fingers through her hair. When Resident R had finished taking her medications, QMA 10 returned to the medication cart. QMA 10 did not wash or sanitize her hands before she started setting up medications for Resident S. On 1/13/26 at 8:11 a.m., QMA 10 was observed to spoon feed Resident S his medications crushed in applesauce. As QMA walked back to the medication cart, she tweaked the shoulder of Resident U's shirt as she joked with her. QMA 10 did not wash or sanitize her hands before she started setting up medications for Resident T. On 1/13/26 at 8:21 a.m., QMA 10 was observed administering medications to Resident E, then returned to the medication cart. QMA 10 did not wash or sanitize her hands before she started setting up medications for Resident U. On 1/13/26 at 8:27 a.m., QMA 10 was observed administering medications to Resident U. She did not wash or sanitize her hands before she started setting up the next medication. On 1/13/26 at 12:35 p.m., the Regional Nurse Consultant provided a General Dose Preparation and Medication policy, revised date 11/15/24. The policy indicated, 1. Prior to preparing or administering medications, authorized and competent facility staff should follow facility's infection control policy. 1.1 Appropriate hand hygiene should be performed before and after direct resident contact. This citation relates to Intake 2699551. 3.1-18(b)(1)

Based on observation, interview, and record review, the facility failed to ensure medications were administered by manufacturer's specifications for not altering extended release and enteric coated medications during 4 of 32 medications observed being administered (Residents S and U). Findings include:1. Observation of a medication pass in the main dining room included:On 1/13/26 at 8:11 a.m., Qualified Medication Aide (QMA) 10 was observed to spoon feed Resident S his morning medications crushed and served in applesauce. The medications included Memantine (medication used to treat symptoms of moderate to severe Alzheimer's disease). Review of Resident S's clinical record was completed on 1/13/26 at 9:41 a.m. Diagnoses on Resident S's profile included vascular dementia. Physician's orders included:a. On 11/28/24, memantine 10 milligram (mg) tablet, give 1 by mouth twice daily.b. On 4/17/25, may crush appropriate medications and mix with applesauce or other food source as needed. A quarterly Minimum Data Set (MDS), completed 12/5/25, assessed the resident as having severe cognitive impairment. The resident had signs or symptoms of difficulty or pain with swallowing. Medication reference from the Mayo Clinic website, located at http://www.mayoclinic.org, (1998-2026), indicated Memantine (oral dose) should not be crushed, chewed, or divided. Crushing the medication can cause it to release into the body too quickly, which may lead to serious side effects. 2. On 1/13/26 at 8:27 a.m., Qualified Medication Aide (QMA) 10 was observed to spoon feed Resident U her morning medications crushed and served in applesauce. The medications included Aspirin EC (enteric coated), Jardiance (film coated), and Potassium ER (extended release). Review of Resident U's clinical record was completed on 1/13/26 at 9:05 a.m. Diagnoses on Resident U's profile included cardiovascular accident (stroke) and vascular dementia. Physician's orders included:a. On 9/30/24, may crush appropriate medications and mix with applesauce or other food source as needed.b. On 10/1/24, aspirin EC (enteric coated/delayed release) 81 mg give 1 tablet daily.c. On 10/1/24, Jardiance (empagliflozin) 10 mg give 1 tablet daily.d. On 10/6/24, potassium chloride ER (extended release) 10 milliequivalents (meq) give 1 twice daily. A quarterly MDS assessment, completed on 12/12/25, assessed the resident as having severe cognitive impairment. The resident had no signs or symptoms of a possible swallowing disorder. During an interview on 1/13/26 at 10:23 a.m., QMA 10 indicated Resident S's medications were crushed and administered in applesauce because he had swallowing problems, but Resident U's medications were crushed and served in applesauce because she took them better that way. QMA 10 indicated, she always crushed all their medications and administered them mixed together in applesauce. An article from the Institute for Safe Medication Practices (ISMP) at https://www.ismp.org/sites/default/files/attachments/2018-04/LTC201704.pdf, titled Crushing or splitting the wrong tablet can be a deadly error, indicated enteric-coated (ER) medications should not be crushed or dissolved to administer. Enteric-coated pills are designed to dissolve in the small intestine, not in the stomach. Dissolving them can destroy the drug's protective coating and cause the medication to be absorbed too quickly or too slowly by the body, potentially leading to improper dosing or irritation to the mouth, throat, or stomach. Guidance from the Food and Drug Administration (FDA), dated 2014, indicated Jardiance (empagliflozin tablets) Jardiance could be crushed and mixed with soft food for administration, for people with swallowing difficulties. However, Jardiance should never be crushed, split, or chewed when combined with other medications, especially extended-release formulas, which can cause an unsafe and ineffective immediate release of the drug. Guidance from the FDA, dated 2014, indicated potassium chloride extended-release tablets (K-TAB) was a solid oral dosage form of potassium chloride in a film-coated wax matrix tablet. These formulations were intended to slow the release of potassium so that the likelihood of a high localized concentration of potassium chloride within the gastrointestinal tract was reduced. On 1/13/26 at 11:55 a.m., the Regional Nurse Consultant indicated to her knowledge the facility did not have a formal policy for crushing medications. There was, however, a list provided by the pharmacy of medications that should not be crushed. On 1/13/26 at 12:35 p.m., the Regional Nurse Consultant provided a General Dose Preparation and Medication policy, revised date 11/15/24. The policy indicated, 1. Prior to preparing or administering medications, authorized and competent facility staff should follow facility's infection control policy .2.7 Facility staff should crush oral medications only in accordance with pharmacy guidelines as set forth in Resource: Oral Dosage Forms that Should Not Be Crushed and/or facility policy. A Common Oral Dosage Forms That Should Not Be Crushed list provided by the contracted pharmacy, dated 2022, included memantine, aspirin EC, and potassium ER in the list of medications not to be crushed. Abbreviations for release characteristics of drug products included CC= coat core, CD= controlled dose, CR= controlled release, DR== delayed release, EC enteric coated, ER= extended release, LA== long acting, SR sustained release, XL= extended release, XR= extended release, and XT= extended release. This citation relates to Intake 2699551. 3.1-48(c)(2)

Based on record review and interview, the facility failed to ensure Registered Nurse (RN) coverage of at least 8 consecutive hours each day for 7 days a week, for 1 of 4 quarters of the Payroll Based Journal (PBJ-a detailed report that tracks staffing and payroll information, primarily used in the healthcare sector) report reviewed. Findings include: During the entrance conference meeting, on 6/27/25 at 9:56 a.m., review of the PBJ report indicated the facility had failed to have at least 8 consecutive hours of RN coverage on, 1/12/25, 1/17/25, 1/26/25, 2/2/25, 2/8/25, 2/9/25, 2/16/25, and 2/23/25. On 6/27/25 at 12:11 p.m., staffing sheets were provided by the Executive Director (ED). The staffing sheets indicated the following: a. The staffing sheets for 1/12/25, lacked documentation of an RN working in the facility on any shift for that date. b. The staffing sheets for 1/17/25, lacked documentation of an RN working in the facility on any shift for that date. c. The staffing sheets for 1/26/25, lacked documentation of an RN working in the facility on any shift for that date. d. The staffing sheets for 2/2/25, lacked documentation of an RN working in the facility on any shift for that date. e. The staffing sheets for 2/8/25, lacked documentation of an RN working in the facility on any shift for that date. f. The staffing sheets for 2/9/25, lacked documentation of an RN working in the facility on any shift for that date. g. The staffing sheets for 2/16/25, lacked documentation of an RN working in the facility on any shift for that date. h. The staffing sheets for 2/23/24, lacked documentation of an RN working in the facility on any shift for that date. During an interview, on 6/27/25 at 12:11 p.m., the ED indicated he was aware of the dates without RN coverage on the PBJ report for the second quarter of 2025. He was expecting the citation. The expectation was that the facility would comply with the regulation for having an RN for at least 8 consecutive hours a day. 3.1-17(a)(3)

Based on observation, record review, and interview, the facility failed to ensure a resident's nebulizer (a medical device that turns liquid medication into a fine mist, which is then inhaled through a mask or mouthpiece to deliver medication directly to the lungs) mask was maintained in a safe and sanitary manner for 1 of 2 residents reviewed for respiratory care (Resident 88). Findings include: During a random observation, on 6/30/25 at 9:54 a.m., Resident 88's nebulizer mask was observed sitting un-bagged, on the resident's bedside table. During a random observation, on 6/30/25 at 11:55 a.m., the resident's nebulizer mask was observed sitting un-bagged, on the resident's bedside table. During a random observation, on 6/30/25 at 2:11 p.m., the resident's nebulizer mask was observed sitting un-bagged, on the resident's bedside table. Resident 88's record was reviewed on 6/30/25 at 1:48 p.m. The profile indicated the resident's diagnoses included, but were not limited to, chronic obstructive pulmonary disease (COPD- a chronic lung disease that makes it hard to breathe) and acute and chronic respiratory failure with hypercapnia (hypercapnic respiratory failure occurs when the lungs cannot remove enough carbon dioxide [CO2] from the blood, leading to a buildup of CO2). A care plan, dated 6/25/25, indicated the resident had the potential for impaired gas exchange related to COPD. Interventions included, but were not limited to, administer nebulizer treatments as ordered. A physician's order, dated 6/26/25, indicated to administer 3 milliliters (ml) of 0.5 milligrams (mg)-3 mg of ipratropium-albuterol solution (a combination medication used to help control the symptoms of COPD) via nebulization (nebulizer) every 4 to 6 hours as needed. The June 2025 medication administration record (MAR) indicated the resident had received a treatment of ipratropium-albuterol, via nebulizer, on 6/30/25 at 8:58 a.m. During an interview, on 7/1/25 at 11:24 a.m., the Assistant Director of Nursing (ADON) indicated the expectation was that nebulizers should be stored in a bag when not in use. On 7/1/25 at 11:35 a.m., the Director of Nursing (DON) provided a skills competency document, with a revision date of 5/2025, titled, Nebulizer (Small Volume Nebulizer-SVN-Medicated Aerosol Therapy, and indicated it was the policy currently being used by the facility. The policy indicated, .Procedure Steps: .13. Store nebulizer tubing per facility policy. 14 .c .place nebulizer .in plastic bag 3.1-47(a)(6)

Based on observation and interview, the facility failed to ensure infection control procedures were followed to prevent possible contamination of work surfaces, with potential to affect residents for 1 of 1 glucometer (a small, portable device that measures the amount of glucose in the blood) observation. Findings include: On 6/30/25 at 10:42 a.m., observed Licensed Practical Nurse (LPN) 7 complete glucometer blood sugar assessment for Resident 13. The LPN placed the glucometer on top of the medication cart without a barrier. Once the assessment was completed the nurse removed a hand sanitizing wipe from a canister and wrapped the glucometer in the wipe and placed the glucometer into a plastic cup. On 6/30/25 at 10:45 a.m., during an interview, LPN 7 indicated the hand sanitizing wipes were the wipes she used to clean the glucometer after use. On 6/30/25 at 11:00 a.m., during an interview, the Director of Nursing (DON) indicated the nurse should use specific disinfecting wipes to clean the glucometer after use. The hand sanitizing wipes were not the approved wipes to be used to disinfect the glucometer. The DON indicated that the facility shared glucometers between residents. On 6/30/2025 at 1:17 p.m., the DON provided a document titled, Shared Glucometer Cleaning and Disinfecting, dated 1/2024, and indicated it was the policy currently being used by the facility. The policy indicated, .Policy: Shared glucometers will be cleaned and disinfected aster every use with an approved germicidal wipe .1 .b. Place clean paper towel, plastic cup, or other clean barrier on solid surface such as medication cart .c. Use a fresh approved disinfectant wipe each time the glucometer is cleaned and disinfected. d. Wipe all surfaces, top, bottom and sides of the blood glucose meter with wipe and allow the surface of the meter to remain wet for 3 minutes or recommended contact time for the disinfecting wipe. You may wrap the glucometer in the disinfecting wipe after all surfaces have been wiped to assist in the glucometer remaining wet per contact time. e. Allow to air dry on clean paper towel, in a clean plastic cup, or other clean barrier before use on the next resident 3.1-18(b)

Based on record review and interview, the facility failed to ensure a Registered Nurse was in the facility for 8 consecutive hours during a 24-hour period for 2 of 3 months of the first quarter of 2024 reviewed for sufficient staffing (10/23, 10/29, 12/3, 12/9, 12/10, 12/14, 12/16, 12/17, 12/23, 12/24, 12/25, and 12/30). Findings include: A Payroll-Based Journal (PBJ) Staffing report, for the first quarter (October 1-December 31) of 2024, indicated the facility failed to have Registered Nurse (RN) coverage for 8 consecutive hours on 10/23, 10/29, 12/3, 12/9, 12/10, 12/14, 12/16, 12/17, 12/23, 12/24, 12/25, and 12/30. During an interview on 5/22/24 at 11:37 a.m., the Regional Director of Clinical Services (RDCS) indicated they had reviewed the PBJ and she could not verify if the information on the PBJ was correct and would pull staffing reports. She indicated the facility submitted the PBJ data to the home office who reviewed and submitted it for them. During an interview on 5/22/24 at 12:14 p.m., the RDCS provided staffing schedules and indicated they did not have RN coverage for 10/23, 10/29, 12/3, 12/9, 12/10, 12/14, 12/16, 12/17, 12/23, 12/24, 12/25, and 12/30. During a record review, on 5/22/24 at 12:15 p.m., the actual worked staffing schedules indicated there was no RN coverage for 10/23, 10/29, 12/3, 12/9, 12/10, 12/14, 12/16, 12/17, 12/23, 12/24, 12/25, and 12/30. During an interview on 5/22/24 at 2:01 p.m., the RDCS indicated the reason why there was not an RN on duty for 10/23, 10/29, 12/3, 12/9, 12/10, 12/14, 12/16, 12/17, 12/23, 12/24, 12/25, and 12/30 was because they did not have a Director of Nursing Services (DNS), they had a float DNS at that time, but they were not there on those days. During an interview on 5/22/24 at 2:05 p.m., the RDCS indicated the facility did not have a policy related to RN coverage. 3.1-17(b)(3)

Based on observation, interview, and record review, the facility failed to ensure medications were labeled properly and the facility failed to ensure expired medications were disposed of for 2 of 2 medication carts reviewed for medication storage (Residents 22, 11, and 8). Findings include: 1. On 5/22/24 at 10:19 a.m., the front hall medication cart contained an undated and opened bottle of eye drop solution. The eye drops solution bottle contained a label that indicated it was for Resident 22. During an interview, on 5/22/24 at 10:20 a.m., Qualified Medication Aide (QMA) 9 indicated eye drops were good for 28 days once opened and should have an open date on the bottle when opened by staff. Resident 22's record was reviewed on 5/22/24 at 10:48 a.m. A physician order, dated 5/17/24, indicated to administer Refresh Optive Advanced (relieves dry, burning, and irritated eyes) 0.5-1-0.5%, 2 drops in each eye twice a day. 2. On 5/22/24 at 10:25 a.m., the back hall medication cart contained an undated and opened insulin pen. The insulin pen contained a label that indicated it was for Resident 11. Resident 11's record was reviewed on 5/22/24 at 11:00 a.m. The profile indicated the resident's diagnosis included, but were not limited to, type 2 diabetes mellitus with diabetic neuropathy (a complication of diabetes mellitus that occurs when high blood sugar damages the peripheral nervous system). A physician order, dated 3/25/24, indicated to administer Fiasp (insulin medication) FlexTouch 100 unit/ml (milliliter) 3ml by injecting 7 units subcutaneous (under the skin) three times a day. 3. On 5/22/24 at 10:27 a.m., the back hall medication cart contained an open insulin pen with an open date of 1/9/24. The insulin pen contained a label that indicated it was for Resident 8. During an interview, on 5/22/24 at 10:27 a.m., Licensed Practical Nurse (LPN) 6 indicated she thought insulin pens were good for 60 days once opened but she was not sure and would have to check the policy. During an interview, on 5/22/24 at 10:29 a.m., Regional Director of Clinical Services indicated insulin pens were good for 28 days once opened. Resident 8's record was reviewed on 5/22/24 at 11:10 a.m. The profile indicated the resident's diagnosis included, but were not limited to, type 2 diabetes mellitus without complications (a chronic condition that affects the way the body processes blood sugar). A physician order indicated to administer Novolog (insulin medication) FlexPen 100unit/ml (3ml) by injecting per sliding scale subcutaneously three times a day at 8:00 a.m., 12:00 p.m., and 5:00 p.m. On 5/22/24 at 10:31 a.m., the Regional Director of Clinical Services, provided a document as a current facility policy titled, LTC Facility's Pharmacy Services and Procedures Manual, revised date of 7/21/22. The policy indicated, .5.3 If a multi dose vial of an injectable medication has been opened or accessed, the vial should be dated and discarded within 28 days .5.4 When an ophthalmic solution or suspension has a manufactures' shortened beyond use date once opened, facility staff should record the date opened and the date to expire on the container On 5/22/24 at 10:52 a.m., the Regional Director of Clinical Services, provided an undated document as a currently facility policy, titled, Storage Recommendations for Injectable Diabetes Mediations. The policy indicated, .Fiasp cartridge or pen .expiration date at room temperature was 28 days .Novolog cartridge or pen .expiration date at room temperature was 28 days 3.1-25(j)

Based on interview and record review, the facility failed to ensure that personal funds were available on the weekends for 1 of 16 residents reviewed for personal funds (Resident 19). Finding includes: During an interview, on 5/17/24 at 11:36 a.m., Resident 19 indicated she was not able to get money on the weekends and hadn't been able to for a while. Resident 19's record was reviewed on 5/22/24 at 2:00 p.m. A quarterly Minimum Data Set (MDS) assessment, dated 5/1/24, indicated the resident was cognitively intact. During an interview, on 5/22/24 at 2:30 p.m., the Business Office Manager (BOM) indicated the residents could obtain their money out of their personal funds Monday through Friday. She was not at the facility on the weekends and had not been employed by the facility for very long. She wasn't aware of the procedure for the weekends. During an interview, on 5/22/24 at 2:33 p.m., the Corporate Business Office Specialist indicated a money bag should be kept at the nurse's station so the residents could obtain the money on the weekends. She was not sure where it was kept exactly at this facility. She indicated they had not had consistent business office staff at the facility for a while. Staff and residents needed to be educated on the procedure for obtaining personal funds on the weekends. During an interview, on 5/22/24 at 2:39 p.m., Licensed Practical Nurse (LPN) 6 indicated she was not aware of any money bag being at the nurse's station on the weekends for the residents to have personal funds. During an interview, on 5/22/24 at 2:41 p.m., Registered Nurse 3 indicated there had not been a money bag or cash box at the facility for personal funds. She indicated the Director of Nursing had recently purchased a cash box that she thought was for personal funds, but they had not been educated on the process yet. On 3/22/24 at 3:01 p.m., the Regional Director of Clinical Services provided an undated document titled, Resident Trust Overview, and indicated it was the policy currently used by the facility. The policy indicated, .Funds should be available to residents 24 hours a day and 7 days a week. A method for distributing funds after hours and on weekends must be established 3.1-6(a)

Based on observation, interview, and record review, the facility failed to ensure dependent residents were shaved, for 2 of 16 residents reviewed for Activities of Daily Living (ADLs- activities related to personal care) (Residents 30 and 17). Findings include: 1. During the initial observation, on 5/17/24 at 2:17 p.m., Resident 30 was observed with long facial hair. At the same time, the resident indicated he had not been shaved for quite a while. The staff had told him the facility had run out of razors. His preference was to be shaved when he received his shower. He did not wish to shave himself because of his seizure disorder and his fear of having a seizure while shaving. During a random observation. on 5/20/24 at 11:18 a.m., The resident was observed sitting in the dining room waiting on his lunch meal to be served. The resident was observed to be unshaven. Resident 30's record was reviewed on 5/23/24 at 10:11 a.m. The profile indicated the resident's diagnoses included, but were not limited to, other sequalae of cerebral infarction (damage to tissues in the brain due to a loss of oxygen to the area) and epilepsy, unspecified (brain condition that causes recurring seizures [a burst of uncontrolled electrical activity between brain cells that causes temporary abnormalities in muscle tone or movements such as twitching, stiffness, or limpness]). An admission Minimum Data Set (MDS) assessment (part of the federally mandated process for clinical assessment of all residents in Medicare and Medicaid certified nursing homes), dated 2/26/24, indicated the resident had moderate cognitive deficit, had no documented behaviors of rejection of care, and required partial to moderate assistance with bathing or showers. A care plan, dated 2/23/2024, indicated the resident required assistance with ADLs. Interventions included, but were not limited to, assist with bathing per resident preference and offer showers two times per week, with partial bath in between and assist with hygiene. A care plan, dated 2/23/2024, indicated the resident was at risk for bleeding related to use of an antiplatelet medication (medicines that stop blood cells from sticking together and forming a blood clot). A care plan, dated 2/23/2024, indicated the resident was at risk for bleeding due to the use of an anticoagulant medication (medication used to prevent and treat blood clots in blood vessels and the heart). A physician's order, dated 2/21/24, indicated to administer aspirin (antiplatelet medication), 81 milligrams (mg) chewable once a day. A physician's order, dated 2/21/24, indicated to administer Eliquis (apixaban-anticoagulant medication), tablet; 5 milligrams (mg) two times a day. Resident 30's May 2024 shower sheets indicated shaving was a part of the bathing and/or showering process. The shower sheets indicated the resident had not been shaved from 5/9/24 through 5/19/24. A shower sheet, dated 5/20/24, indicated the resident had been shaved on that date. 2. During an initial observation, on 5/17/24 at 2:18 p.m., Resident 17 was observed with long facial hair. At the same time, the resident indicated he had not been shaved for several days. The staff had told him the facility had run out of razors. He desired to be shaved regularly and did not want to have a beard. He was unable to shave himself and depended on the staff to do it for him when he received his shower or bed bath. During a random observation, on 5/20/24 at 11:22 a.m., the resident was observed in his bed watching TV. The resident's long facial hair was still observed. At the same time, the resident indicated the staff had been told that the facility had ordered razors, but they had not come in yet. During a random observation, on 5/22/24 at 12:20 p.m., the resident was observed to be clean shaven. At the same time, the resident indicated the facility had finally received some razors and he was shaved last evening. It had been 4-5 days since he had last been shaved. He again indicated that he wished to be shaved every time he gets his baths. Resident 17's record was reviewed on 5/22/24 at 1:56 p.m. The profile indicated the resident's diagnoses included, but were not limited to, hypertensive heart and chronic kidney disease with heart failure (high blood pressure and damage to the heart caused by damage to the kidneys) and type 2 diabetes mellitus with diabetic chronic kidney disease (a decrease in kidney function that occurs in some people who have diabetes [uncontrolled blood sugar levels]). A significant change Minimum Data Set MDS assessment (part of the federally mandated process for clinical assessment of all residents in Medicare and Medicaid certified nursing homes), dated 6/15/23, indicated the resident had no cognitive deficit and required total assistance with bathing and extensive assistance with personal hygiene. A quarterly MDS, dated [DATE], indicated the resident had no cognitive deficit and had no documented behaviors for rejection of care. A care plan, dated 9/2/2022, indicated the resident required assistance with ADLs. Interventions included, but were not limited to, assist with bathing per resident preference and offer showers two times per week, with partial bath in between and assist with hygiene. A care plan, dated 2/23/2024, indicated the resident was at risk for bleeding related to use of an antiplatelet medication (medicines that stop blood cells from sticking together and forming a blood clot). A physician's order, dated 5/10/24, indicated to administer aspirin (antiplatelet medication), 81 milligrams (mg) chewable once a day. Resident 17's May 2024 shower sheets indicated shaving was a part of the bathing and/or showering process. The shower sheets indicated the resident had not been shaved from 5/16/24 to 5/21/24. A shower sheet, dated 5/22/24, indicated the resident had been shaved on that date. During an interview, on 5/22/24 at 2:46 p.m., the Regional Director of Clinical Services (RDCS) indicated that it often took the facility several days to receive their supply order. She had been made aware that the facility had only 1 box of razors. She was unsure as to why the residents had not been shaved. It was possible that the facility could have gone to pick up some razors at a local store. During an interview, on 5/23/24 at 10:02 a.m., Certified Nursing Assistant (CNA) 10 indicated she was aware that there had been at least one day when the facility did not have any razors. It had been reported to the nurses so that some could be ordered. During an interview, on 5/23/24 at 10:05 a.m., the Administrator (ADM) indicated the facility had some issues with the ordering process. The Director of Nursing (DON) had taken on the process in hopes of getting the issues resolved. He had not been made aware that the facility was out of razors or of the residents not getting shaved. Someone could have gone to a local store to purchase razors to ensure the facility had them on hand for use. During an interview, on 5/23/24 at 10:19 a.m., the ADM indicated he was not able to locate a policy specific on razors or supplies being in stock. The expectation was that the facility would always have enough supplies on hand, to meet the needs of the residents. 3.1-38(a)(3)(D)

Based on observation, interview, and record review, the facility failed to ensure dining meal service was completed in a sanitary manner, for 1 of 2 dining service observations. Findings include: During the initial dining meal service observation, on 5/17/24 at 12:36 p.m., Registered Nurse (RN) 3 was observed assisting Resident 9 to cut her sandwich. The nurse was observed to hold a portion of the sandwich with her ungloved left index finger while cutting the sandwich. On 05/17/24 at 12:37 p.m., Certified Nursing Assistant (CNA) 4 was observed assisting Resident 24 with cutting her sandwich. The CNA was observed to push down on the resident's sandwich with her ungloved hand as she cut the sandwich for the resident. During an interview, on 5/22/24 at 2:50 p.m., the Regional Director of Clinical Services (RDCS) indicated it was not appropriate for staff to touch resident food items with ungloved hands. The facility would follow the Indiana retail food guidelines. Section 410 IAC 7-24-171 of the Indiana Department of Health Retail Food Establishment Sanitation Requirements, effective November 13, 2004, indicated, Preventing contamination from hands .Sec. 171 (c) Food employees shall minimize bare hand .contact with exposed food 3.1-21(i)(3)

Based on observation, interview, and record review, the facility failed to ensure appropriate infection control practices were in place to mitigate and prevent the potential for the spread of the COVID-19). This deficient practice had the potential to effect 33 of 33 residents who resided in the facility. Findings include: On 11/9/23 at 9:00 a.m., upon entrance into the facility, Resident D (who was later discovered to be COVID-19 positive) was observed seated in the main dining room with three other unidentified residents. None of them were wearing masks as the finished their breakfast meals. Several staff member, unidentified at that time, walked in and out of the dining room, past Resident D. He was not encouraged to wear a mask to return to his room. On 11/9/23 at 9:21 a.m., Housekeeper (HK) 7 was observed in a Red Room (an isolation room with a COVID-19 positive resident). She was observed to wear a surgical mask underneath an N-95 and did not have any eye protection on at that time. On 11/9/23 at 9:25 a.m., Resident C (who was later discovered to have close contact to COVID-19 as his roommate was positive) was observed as he sat in his wheelchair outside of a communal shower room, he was not wearing a mask. Certified Nursing Aide (CNA) 9, joked with him and they had a short conversation. Resident C was not encouraged to go back to his room or put a mask on. On 11/9/23 at 9:30 a.m., HK 7 entered a second Red Room. Although she removed her surgical mask from underneath an N-95, she did not put on eye protection. On 11/9/23 at 9:40 a.m., Resident D was observed as he was assisted back to his room by Occupational Therapist (OT) 5. OT 5 wore an N-95 face mask and a face shield. At that time, she indicated, Resident D was COVID-19 positive and should not have eaten breakfast in the dining room. He returned to his room with her without refusing. At his table place, his plate and utensils remained, as well as an initialed medication cup. During an interview on 11/9/23 at 9:44 a.m., the Director of Nursing Services in Training (DNS-T) indicated Resident D was COVID-19 positive, and he should not be permitted to eat in the main dining room around other COVID-19 negative residents. During an interview on 11/9/23 at 9:46 a.m., Qualified Medication Aid (QMA) 6 indicated she passed morning medications. Resident D was already in the main dining room and when she asked him to go back to his room he refused. So, she administered his medications in the dining room without donning additional personal protective equipment (PPE). On 11/9/23 at 10:00 a.m., the following Red Rooms were observed to have trash cans without lids or a covering in place which were placed outside the doors in the main hallways. They were observed to have used PPE. On 11/9/23 at 10:35 a.m., CNA 8 was observed as she placed an N-95 mask on top of a surgical mask and entered a Red Room. On 11/9/23 at 11:35 a.m., Residents E and F were observed to come out of their Red Rooms to use the communal COVID-19 bathroom, they were not wearing a mask. At that time, another resident who had not tested positive, walked past Resident E. Throughout the survey period, Resident B was observed, as he preferred and was care planned, to ambulate by crawling throughout the facility hallways and common areas on his hand and knees and he occasionally put his hands in his mouth. The staff were not observed to don shoe covering in the Red Rooms or change shoes. On 11/9/23 at 11:48 a.m., an interview was conducted with the Administrator, Interim DNS, DNS-t and the Social Service Director were present. Because there were no empty available rooms, if one resident tested positive and the roommate did not, staff were to encourage the COVID-19 negative resident to remain in their room, wear a mask upon exiting the room, and maintain social distancing with other residents. The Interim DNS indicated staff should wear all PPE including eye protection as instructional signage on the Red Room door indicated. Staff should not wear a surgical mask under the N-95 as it interfered with the N-95's integrity to create an effective seal. Further, PPE trash cans needed to be covered to reduce the potential for aerosolized spread of the virus, and shoe covering could be considered as an extra precaution to help protect Resident B. On 11/9/23 at 11:00 a.m., the Administrator provided a copy of current facility policy titled, Covid-19 Policy, revised 7/2023. The policy indicated, .This community will implement infection control practices to reduce the risk of transmission of SARS-CoV-2 (Covid-19) . face covering or mask . in accordance with CDC guidance and based on the Infection Preventiont's assessment of the community virus transmission rates and other infection control. Instructional signage throughout the facility . staff to follow appropriate PPE use according to the Standard and Transmission Based Precautions policy . source control options for HCP include: a NIOSH-approved particulate respirator with N-95 filter or higher 3.1-18(b)(1)

Based on observation, record review, and interview, the facility failed to notify the family/responsible party of the resident's gradual dose reduction of an antipsychotic medication recommended by pharmacy for 1of 5 residents reviewed for unnecessary medications (Resident 181). Findings Include: On 3/6/2023 at 2:30 p.m., Resident 181 was observed outside of his room speaking with staff. Resident indicated to staff he wanted the code to get out of here. On 3/9/2023 at 11:48 a.m., Resident 181 was observed ambulating in hallway wandering around looking into different rooms. Resident 181's record was reviewed on 3/8/2023 at 2:30 p.m. The profile indicated the resident's diagnoses included, but were not limited to, Heart failure (a condition in which the heart doesn't blood pump as well as it should), Type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar), Dementia (a condition characterized by progressive or persistent loss of intellectual functioning) in other diseases classified elsewhere, mild with anxiety (a feeling of worry, nervousness, or unease), and Paroxysmal atrial fibrillation (an irregular and often very rapid heart rhythm that causes poor blood flow). An admission Minimum Data Set (MDS) assessment, dated 2/19/2023, indicated the resident had moderate cognitive deficit and received antipsychotic (used to treat a range of psychotic disorders) and antidepressant (used to treat depressive symptoms) medications. A care plan, dated 2/27/2023, indicated the resident received psychotropic medication, antidepressant, and antipsychotic. Interventions included, but were not limited to, administer medications as ordered, observe for effectiveness, and pharmacist to review medications routinely. A care plan, dated 02/21/2023 and revised on 03/06/2023, indicated the resident was at risk for elopement due to resident having a diagnosis of dementia and requesting a secured key code to get outside. Interventions included, but were not limited to, wander guard placed on left leg per physician order, all facility exits secured with key code pad, and provide one on one (1:1) attention and conversation as needed. A pharmacy recommendation, dated 02/14/2023, recommended to attempt a gradual dose reduction (GDR) of olanzapine (antipsychotic medication) to 2.5 milligrams (mg) every hs (bedtime) from 5 mg every hs. The record lacked documentation that family was notified of recommendation. A physician order dated 02/17/2023, indicated to change olanzapine from 5 mg every hs to 2.5 mg every hs. The March 2023 MAR (medication administration record) indicated Resident 181 received the olanzapine 2.5 mg dose on 02/18/2023, 02/19/2023, 02/20/2023, and 02/21/2023. Review of progress note, dated 02/17/2023 at 7:23 p.m., indicated the psychiatric NP (nurse practitioner) was in the facility on that date. A new order was obtained to discontinue olanzapine 5 mg and start olanzapine 2.5 mg orally (by mouth) every hs. Review of progress note, dated 02/18/2023 at 3:06 p.m., indicated resident had increased confusion and was pointing down the hallway asking for assistance to his car in the ditch so that he could go home. Review of progress note, dated 02/21/2023 at 12:06 a.m., indicated resident was confused and exit seeking. Resident 181 had been in several different rooms searching for a way to get out. Review of progress note, dated 02/21/2023 at 1:18 a.m., indicated resident continued to exit seek, threatened to bust the doors down, and taunted staff to call the law and have him arrested. Review of progress note, dated 02/21/2023 at 5:32 a.m., indicated resident had been up the entire night wandering the halls and exit seeking. Continued to enter other residents' room. Resident became very frustrated and verbally abusive to staff. Review of progress note, dated 02/21/2023 at 10:44 a.m., indicated resident had been up all night wandering the hallways looking for staff in residents' rooms. Resident would become verbally aggressive and threatening. IDT (interdisciplinary team and consists of members from different disciplines working collaboratively to set goals and make decisions) met and in agreement was a failed gradual dose reduction of his olanzapine medication. Review of progress note, dated 02/21/2023 at 12:37 p.m., indicated the nurse notified resident's wife of the decrease in antipsychotic medication. Review of progress note, dated 02/22/2023 at 7:52 a.m., indicated the resident has had increased behaviors since medication had been decreased and the family was concerned. Review of progress note, dated 02/22/2023 at 2:15 p.m., indicated the NP was in the facility and increased the olanzapine back to 5 mg orally every hs. During a family interview, on 03/10/23 at 09:53 a.m., Resident 181's family member indicated they were not informed of the physician order to decrease the olanzapine medication until days later. The family had noticed the resident was having increased behaviors when they came to visit him at the facility. The family member indicated they would not have approved of the decrease in medication if they were made aware of it in a timely manner. During an interview, on 3/10/2023 at 10:57 a.m., LPN 6 indicated the family should be notified immediately of any new order or change of condition. If the family did not answer, they would leave them a message for them to return their call. On 3/10/2023 at 12:12 p.m., the Executive Director provided a document, with a revised date of 11/2018, titled, Resident Change of Condition Policy, and indicated it was the policy currently being used by the facility. The policy indicated, .3b. the nurse in charge is responsible for notification of family/responsible party prior to end of assigned shift when a significant change in the resident's condition is noted 3.1-5(a)(2)

Based on observation, interview, and record review, the facility failed to properly clean and store nebulizer (small machine that turns liquid medication into a mist that can be easily inhaled) and oxygen equipment for 3 of 4 residents reviewed for respiratory care (Residents 21, 1, and 16). Findings include: 1a. On 3/6/2023 at 1:53 p.m., Resident 21's nebulizer tubing and equipment was observed to be in a clear plastic bag and was unlabeled and not dated. The clear plastic bag was hanging from the nebulizer machine. On 3/7/2023 at 11:01 a.m., Resident 21's nebulizer tubing and equipment including mouthpiece was observed to be out of the bag sitting next to the nebulizer machine. No date noted to be on the tubing. Resident was resting in her recliner resting. The clear plastic bag for nebulizer observed to be on the floor next to side table. On 3/7/2023 at 12:00 p.m., Resident 21's nebulizer tubing and equipment including mouthpiece was observed to be out of the bag sitting next to machine. Resident was resting in her recliner. On 3/7/2023 at 12:59 p.m., Resident 21's nebulizer tubing and equipment including mouthpiece was observed to be out of the bag sitting next to machine. Resident was sitting up in wheelchair eating lunch. Clear plastic bag for nebulizer tubing was on the floor next to recliner. On 03/07/2023 at 1:56 p.m., Resident 21'a nebulizer tubing and equipment including mouthpiece was observed to be out of the bag sitting next to machine. There was a clear liquid noted to be in the chamber of the nebulizer equipment. On the floor next to the resident's recliner was an empty clear plastic bag that was unlabeled and not dated. A second clear plastic bag was observed to be on the window ledge that contained the word Nebulizer on the bag with the resident's name on it and it was dated 12/4/2022. On 03/08/23 at 1:40 p.m., Resident 21's nebulizer tubing and equipment was observed to be inside a clear plastic bag that was unlabeled and not dated hanging on the nebulizer machine. No date noted to be on the nebulizer tubing. A clear liquid was noted to be inside the chamber of the nebulizer equipment. 38767 1b. During an observation on 3/06/23 at 10:25 a.m., Resident 21 was observed sitting in her recliner receiving supplemental oxygen per a nasal cannula from an oxygen concentrator on the floor. A nebulizer machine was observed on a table next to the recliner, the mouthpiece and tubing were observed to be out of a bag next to the machine. On 3/8/23 at 11:48 a.m., Licensed Practical Nurse (LPN) 5 was observed entering the resident room to administer a nebulizer aerosol treatment to Resident 21. The nurse removed a mouthpiece from a bag hanging from the side of a bedside stand, poured medication into the nebulizer cup, turned on the nebulizer machine, and stood with the resident as she received her treatment. The nurse was then observed to turn off the nebulizer machine and place the mouthpiece back into the bag hanging from the bedside stand. The nurse was not observed to wash or rinse the remaining medication from the mouthpiece. A second observation of Resident 21's nebulizer mouthpiece on 3/08/23 at 1:42 p.m., indicated small amounts of liquid medication remained in the nebulizer cup. On 3/09/23 at 8:46 a.m., Resident 21's nebulizer mouthpiece and tubing were observed to be inside a clear plastic bag hanging from the bedside stand, the mouthpiece was observed to still contain liquid inside the nebulizer cup. On 3/09/23 at 11:44 a.m., Resident 21 was observed sitting in a wheelchair in her room after LPN 6 was observed giving her a nebulizer treatment. The nebulizer mouthpiece was observed inside a clear plastic bag on the side of a bedside stand, small amounts of liquid medication remained in the nebulizer cup. Resident 21 indicated staff changed the mouthpiece weekly, and the resident cleaned off the outside of the mouthpiece with alcohol preps. To her knowledge, no one took the mouthpiece apart and rinsed out the excess medication from the nebulizer cup after each treatment. Resident 21's record was reviewed on 3/09/23 at 8:58 a.m. Diagnoses on Resident 21's profile included, but were not limited to, chronic COPD (chronic obstructive pulmonary disease - a group of lung diseases that block airflow and make it difficult to breath) and chronic respiratory failure (develops when the lungs can't get enough oxygen into the blood). Physician's orders for Resident 21 indicated, a. On 8/9/22 change nebulizer tubing/set on Sunday 6:00 p.m. - 6:00 a.m. b. On 1/19/23 ipratropium-albuterol solution (bronchodilators used to treat and prevent wheezing and shortness of breath) for nebulization 0.5 mg (milligrams)/3 mg) per 3 ml (milliliter) give 1 vial three times a day at 6:00 a.m., 12:00 p.m., and 6:00 p.m. and as needed. A quarterly MDS (Minimum Data Set) assessment (part of the federally mandated process for clinical assessment of all residents in Medicare and Medicaid certified nursing homes), completed on 2/5/23, assessed the resident as receiving oxygen therapy. A care plans for Resident 21 indicated she was at risk for impaired gas exchange related to COPD with exacerbation with shortness of breath while lying flat, patient to have head of bed elevated. The goal was for the resident to have adequate respiratory functions as evidenced by decreased or absence of dyspnea (shortness of breath), improved breath sounds, decreased or absence of shortness of breath, and improved oximetry (non-invasive method for monitoring oxygen saturation) results. Approaches included oxygen at 3 L (liters), elevate head of bed for shortness of breath when lying flat, monitor the resident, and administer medications as ordered. An In-Service Class Attendance Record, dated 9/12/22 at 2:00 p.m., subject(s) oxygen application, tubing in bags, and observations, indicated 13 staff members signed as having received the education. On 3/10/23 at 1:50 p.m., the Executive Director (ED) provided a Respiratory Care: Competency Assessment Form: Aerosolized Medication Nebulizer Treatment, undated, and indicated the process was the one currently being used by the facility. The competency indicated, Verify physician's order. Obtain all necessary equipment and supplies .Attach one end of the tubing to the nebulizer and the other end to the compressor or oxygen source. Remove the nebulizer top, place prescribed medication into the cup, then secure the top back onto the nebulizer. Attach mouthpiece, aerosol mask, or trach mask to the nebulizer [use the reservoir tubing on the t-piece when using a mouthpiece for better medication delivery] .Once the treatment is complete, place the nebulizer in a plastic bag with the resident's name and date. Change out nebulizer weekly per facility policy . How to Clean a Nebulizer - American Lung Association (11/17/22) at www.lung.org was retrieved from the American Lung Association website. The guidance indicated cleaning a nebulizer was important to prevent the spread of germs and keep individuals from getting sick. It was recommended to wash the parts of the nebulizer after each use, including the mouthpiece or mask, top piece, and medicine cup per manufacturer's instructions. After rinsing, the mouthpiece or mask, top piece, and medication cup were to be left to air-dry in a cool, dry place. 34525 2. During the initial observation, on 3/6/23 at 2:35 p.m., Resident 16 was lying in his bed with his supplemental oxygen (O2) being administered via nasal canula (NC-a medical device to provide supplemental oxygen therapy to people who have lower oxygen levels). The resident's O2 concentrator (a medical device that provides supplemental oxygen) was observed to be dust covered. The humidification bottle (a sealed bottle of water inserted into a breathing circuit to add moisture to the breathing gases for administration) was not dated. A nebulizer (an electrically powered machine that turns liquid medication into a mist so that it can be breathed directly into the lungs through a face mask or mouthpiece) and tubing were observed in a bag which was dated 2/23/23. During a random observation, on 3/7/23 at 2:18 p.m., the resident was lying in his bed with his NC in place. The O2 concentrator was observed to be set to administer his O2 at 3 liters (L). The resident's O2 concentrator was observed to be dust covered. The humidification bottle was not dated. A O2 tubing bag, attached to the concentrator, was dated 2/23/23. The nebulizer mask was observed in a bag dated 2/23/23, and noted to have brown debris inside of the mask, near where it would be placed on the resident's mouth. During a random observation of the resident's room, on 3/8/23 at 10:55 a.m., the resident was not in the room. The O2 concentrator was turned off. The O2 concentrator was observed to be dust covered. The nebulizer mask appeared to have been changed to a new mask. No debris noted on the mask. No date noted on the bag which contained the nebulizer. The humidification bottle on the O2 concentrator was not dated. During a random observation, of the resident's room, on 3/8/23 at 11:56 a.m., the resident was not in the room. The O2 concentrator was turned off. The O2 concentrator was observed to be dust covered. The O2 NC tubing was in a bag, dated 2/23/23, hanging on the back of the concentrator. The tubing was observed to have clear fluid drops in the tubing. None of the clear fluid was noted on the inside of the bag where the tubing was placed. During a random observation on, 3/8/23 at 12:00 p.m., the resident was sitting in the dining room. The resident's supplemental O2 was being administered through a portable O2 tank. The O2 tank was set at 3 L and was being administered via NC. The NC was noted to be out of the nostrils to the left side of his nose. During a random observation, on 3/9/23 at 10:15 a.m., the resident was lying in bed with his O2 NC in place. The nebulizer tubing and mask were in an undated bag. The inside of nebulizer mask was observed to be soiled with a dust like debris and oily residue. The tubing, mask, and nebulizer chamber were dry. At the same time, the resident indicated the nurse puts the mask on and takes it off for him. Resident 16's record was reviewed on 3/8/23 at 1:50 p.m. The profile indicated the resident's diagnoses included, but were not limited to, chronic obstructive pulmonary disease (COPD-a group of diseases that cause airflow blockage and breathing-related problems). An annual Minimum Data Set (MDS-part of the federally mandated process for clinical assessment of all residents in Medicare and Medicaid certified nursing homes) assessment, dated 11/11/22, indicated the resident had severe cognitive deficit, was short of breath (SOB) when lying flat, and required supplemental O2. A care plan, dated 10/13/21, indicated the resident required supplemental O2 due to his diagnosis of COPD. Interventions included, but were not limited to, administer O2 per physician's order at 2 L per NC. A physician's order, dated 8/24/21, indicated change oxygen tubing and humidity. Clean concentrator and filter. Once A Day on Sunday. A physician's order, dated 10/13/21, indicated O2 at 2 L per NC continuously. A physician's order, dated 10/13/21, indicated change oxygen tubing and water canister (humidification bottle) every week on Sunday night shift. Label tubing with date and initials. A physician's order, dated 1/7/23, indicated ipratropium-albuterol solution (a medication used to help control the symptoms of lung diseases, such as asthma, chronic bronchitis, and emphysema) for nebulization; 0.5 milligrams (mg)-3 mg (2.5 mg base)/3 milliliters (mL). 1 vial inhalation two times a day. 3. During the initial observation, on 3/6/23 at 10:24 a.m., Resident 1 was lying in bed with supplemental oxygen (O2) being administered by nasal canula (NC-a medical device to provide supplemental oxygen therapy to people who have lower oxygen levels). The resident's O2 concentrator (a medical device that provides supplemental oxygen) was set at 2.5 liters (L). The date on O2 tubing bag was 2/23/23, and the date on the humidification bottle (a sealed bottle of water inserted into a breathing circuit to add moisture to the breathing gases for administration) was 3/5/23. During a random observation, on 3/7/23 at 10:00 a.m., the resident was lying in bed with O2 being administered at 2.5 L by NC. The date on O2 tubing bag was 2/23/23, and the date on the humidification bottle was 3/5/23. During a random observation, on 3/8/23 at 10:41 a.m., the resident was lying in bed with O2 being administered at 2.5 L by NC. The date on O2 tubing bag was 2/23/23, and the date on the humidification bottle was 3/5/23. During a random observation, on 3/9/23 at 10:00 a.m., the resident was lying in bed with O2 being administered at 2.5 L by NC. The date on O2 tubing bag was 2/23/23, and the date on the humidification bottle was 3/5/23. Resident 1's record was reviewed on 3/9/23 at 1:15 p.m. The profile indicated the resident's diagnoses included, but were not limited to, chronic obstructive pulmonary disease (COPD-a group of diseases that cause airflow blockage and breathing-related problems) and congestive heart failure (CHF-occurs when the heart muscle doesn't pump blood as well as it should). A quarterly Minimum Data Set (MDS-part of the federally mandated process for clinical assessment of all residents in Medicare and Medicaid certified nursing homes) assessment, dated 12/9/22, indicated the resident had moderate cognitive deficit, was short of breath (SOB) when lying flat, and required supplemental O2. A care plan, dated 10/13/21, indicated the resident required O2 per NC continuously related to his diagnosis of CHF and COPD. Interventions included, but were not limited to, administer O2 per physician's order order and staff to change O2 tubing and water canister (humidification bottle) every week on Sunday night shift. Label tubing with date and initials. A physician's order, dated 2/17/21, indicated O2 at 3 liters (L) per NC continuously. A physician's order, dated 12/10/22, indicated change O2 tubing and humidification bottle, clean concentrator and filter, once daily on Sunday. During an interview, on 3/10/23 at 11:57 a.m., Licensed Practical Nurse (LPN) 6 indicated, there were 4 or 5 residents who had orders for oxygen, and 2 who received nebulizer treatments. The residents must have a physician's order for oxygen use and for nebulizer treatments. Nebulizer hand piece and oxygen masks were replaced with new units weekly, and placed back into storage bags. Both oxygen and nebulizer equipment had physician's orders to be changed weekly on Sunday night shift, and to be documented in the medication administration record (MAR) in electronic medical record (EMR). Equipment should be dated when changed. If equipment was soiled in any way in between scheduled change dates the nurse would be responsible for cleaning it or changing the soiled piece of equipment. Cleaning of the nebulizer or oxygen concentrators should be cleaning at the same time the tubing, masks and bottles, to include the filter as needed. During an interview, on 3/10/23 at 12:05 p.m., LPN 6 indicated, the process for nebulizer treatments were, there must be a physician's order for medication. The resident's vital signs (respirations, oxygen saturations, listen to breath/lung sounds) should be completed. The medication would then be placed into the nebulizer hand piece. Hand the nebulizer to resident to hold. Mid way through the procedure, recheck vitals and breath sounds. When finished help resident place nebulizer in bag, and recheck vitals. On 3/10/23 at 1:50 p.m., the Executive Director (ED) provided an undated document, titled, Oxygen Therapy and Devices, and indicated it was the policy currently being used by the facility. The policy indicated, .Definition of Oxygen: 1) Oxygen is a drug which must be ordered by a physician .Initiation of Oxygen: 1) Verify physician order .7) Apply device to the patient with appropriate liter flow .Oxygen Devices: 1) Nasal Canula .e. Change out weekly and PRN (as needed). f. Place in a labeled bag when not in use 3.1-47(a)(6)

Based on record review and interview, the facility failed to ensure medications and blood sugars had been documented as administered and obtained, and they failed to ensure physician documentation addressing pharmacy recommendations for 2 of 5 residents reviewed for unnecessary medications (Residents 18 and 26). Findings include: 1. Resident 18's record was reviewed on 3/8/2023 at 10:49 a.m. The profile indicated the resident's diagnoses included, but were not limited to, Type 2 diabetes mellitus with diabetic neuropathy (a type of nerve damage caused by long term high blood sugar levels), phantom limb syndrome with pain (pain in the part of limb that is no longer there), chronic kidney disease stage 2 (mild damage to your kidneys), and unspecified atrial fibrillation (an irregular and often very rapid heart rhythm that can lead to blood clots in the heart). A quarterly Minimum Data Set (MDS) assessment, dated 2/4/2023, indicated the resident had moderate cognitive deficit and received routine insulin medications. A care plan, dated 1/14/2020, indicated the resident received insulin medication related to her diagnoses of diabetes. Interventions included, but were not limited to, blood sugar checks as ordered by physician, medication administered as ordered by physician. Review of the resident's March 2023 medication administration records (MARs) indicated the following: A physician's order, dated 12/5/2022, indicated Insulin glargine (insulin medication) 10 units, by subcutaneous (under the skin) injection at 9:00 p.m. daily. The March 2023 MAR lacked documentation of the medication having been administered at 9:00 p.m. on 3/3/2023. The record lacked documentation of resident refusal. A physician's order, dated 7/12/2022, indicated Accu check (blood sugar level) to be obtained twice daily at 6:00 a.m. and 8:00 p.m. March 2023 MAR lacked documentation of the blood sugar level was obtained at 8:00 p.m. on 3/3/2023, 3/4/2023, and 3/5/2023. The record lacked documentation of resident refusal. The resident's MAR indicated her blood sugars were running high at bedtime. On 3/1/2023 her blood sugar was 294, on 3/2/2023 was 292, on 3/6/2023 was 347, and on 3/7/2023 was 243. During an interview, on 3/8/2023 at 10:49 a.m., Licensed Practical Nurse (LPN) 5 indicated Resident 18 was on insulin injections. The resident received injections in the morning and at bedtime. During an interview, on 3/8/2023 at 11:53 a.m., Resident 18 indicated the staff often forget to check her blood sugar at bedtime. During an interview, on 3/8/2023 at 1:53 p.m., the Assistant Director of Nursing Services (ADNS) indicated she had noticed there were holes in the Resident 18's MAR. She further indicated it was an agency nurse that had worked the weekend. She was sure the nurse obtained the blood sugar and gave the insulin because she pre-sets her medication for her shift, she just forgot to sign it off. The ADNS indicated she had called the agency to see if the nurse could finish her documentation. On 3/9/2023 at 2:53 p.m., the Executive Director (ED) provided a document with a revised date of 1/1/2013, titled, 6.0 General Dose Preparation and Medication Administration, and indicated it was the policy currently being used by the facility. The policy indicated, .6.1 Document necessary medication administration/treatment information when medications are opened, when medications are given, injection site of a medication, if medications are refused. PRN medications .on appropriate forms 34525 2. Resident 26's record was reviewed on 3/8/23 at 10:07 a.m. The profile indicated the resident's diagnoses included, but were not limited to, atherosclerotic heart disease (the buildup of fats, cholesterol and other substances in and on the artery walls) and peripheral vascular disease (a slow and progressive circulation disorder). A quarterly Minimum Data Set (MDS-part of the federally mandated process for clinical assessment of all residents in Medicare and Medicaid certified nursing homes) assessment, dated 2/8/23, indicated the resident had severe cognitive deficit. The assessment lacked documentation of an anticoagulant medication (substance that hinders the clotting of blood) having been administered. A physician's order, dated 5/29/22, indicated aspirin tablet (ASA-a drug that reduces pain, fever, inflammation, and blood clotting) chewable, 81 milligrams (mg), by mouth daily. A physician's order, dated 11/10/22, indicated enoxaparin (an anticoagulant that helps prevent the formation of blood clots) syringe, 40 mg/0.4 milliliters (mL), subcutaneous (SQ-beneath, or under, all the layers of the skin), every evening for 10 days, then discontinue. For post Covid therapy. A pharmacy recommendation, dated 11/16/22, indicated the resident received ASA and enoxaparin. Recommended to consider holding the resident's ASA until the enoxaparin was no longer needed. The physician declined the recommendation. The recommendation lacked documentation of the physician's rationale to decline the recommendation. The document had been signed and dated by the physician on 11/20/22. During an interview, on 3/8/23 at 12:09 p.m., the acting Director of Nursing Services (DNS) indicated the physician was responsible for documenting a written rationale for any declined pharmacy recommendations. She was not sure why the document lacked the physician's written rationale. On 3/10/23 at 2:30 p.m., the Executive Director (ED) provided a document, dated 10/2018, titled, Medication Regimen Reviews and Pharmacy Recommendations, and indicated it was the policy currently being used by the facility. The policy indicated, .Medication Regimen Review .The consultant pharmacist recommendations will be reviewed by the Director of Nursing and the attending physician will be notified promptly of any recommendations .Pharmacy recommendations should be reviewed with follow up by the physician 3.1-48(a)(1)

Based on observation, interview, and record review, the facility failed to ensure proper handwashing for 1 of 2 kitchen observations. Findings include: The initial kitchen observation was conducted, on 3/6/23 at 10:07 a.m., with the Culinary & Nutritional Manager (Manager). On 3/6/23 at 10:09 a.m., the Manager was observed to washed hands for less than 20 seconds and touch the faucet handles, without paper towels, when turning off the water. On 3/6/23 at 10:13 a.m., the Manager was observed to wash his hands a second time. He again was observed to washed hands for less than 20 seconds and touch the faucet handles, without paper towels, when turning off the water. During an interview, on 3/6/23 at 10:24 a.m., the Manager indicated he knew better than not to use the paper towel to turn off the faucet and was unsure how long he had washed his hands for. On 3/7/23 at 11:40 a.m., the Executive Director provided a document, with a revision date of July 2022, titled, Hand Hygiene, and indicated it was the policy currently being used by the facility. The policy indicated, .Procedure Steps: Hand Hygiene with soap and water (handwashing) .6. Vigorously rub hands for at least 20 seconds .10. Use paper towel to turn off faucet 3.1-21(a)(3)

Based on record review and interview, the facility failed to ensure a resident who was prescribed anticoagulant medication was monitored for their bloods ability to timely clot (INR) for 1 of 1 resident reviewed for anticoagulant drug therapy. (Resident C) Findings include: Resident C's clinical record was reviewed on March 24, 2022 at 10:00 a.m. Resident C's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The following physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] -[MEDICATION(S)] 100 mg / commonly known as [MEDICATION(S)] (anticoagulant/blood thinner. A medication that can prolong clotting time of the blood). Inject 0.9 mL into the skin every 12 hours. Next dose due: January 07, 2022 at midnight. -[MEDICATION(S)] 4 mg tablet / commonly known as [MEDICATION(S)] (anticoagulant/blood thinner. A medication that can prolong clotting time of the blood). One tablet daily at bedtime. -INR daily or per protocol in 1 day(s). Resident C's clinical record lacked laboratory test results of INR. The Nursing Drug Handbook dated 2014 indicated, INR - International Normalized Ratio is a system established by the World Health Organization (WHO) and the International Committee on [CONDITION(S)] and Hemastasis for reporting the results of blood coagulation (clotting) tests. Abbreviated INR. Under the INR system all results are standardized. For example, a person taking the anticoagulant [MEDICATION(S)] (brand name: [MEDICATION(S)]) would regularly have blood tested to measure INR Regularly monitor INR in all patients. Consider more frequent INR monitoring in those at high risk for bleeding. The Director of Nursing was interviewed on March 24, 2022 at 2:15 p.m. In the interview the Director of Nursing indicated after having reviewed Resident C's clinical record and after communication with the facility's laboratory for blood testing Resident C's INR had not been drawn. INR testing had not been done. This Federal tag relates to Complaint IN 276. 3.1-48(a)(3)

Based on record review and interview, the facility failed to ensure a Notice of Transfer or Discharge was provided to residents with a hospitalization for 2 of 3 residents reviewed for hospitalization s (Residents 8 and 15). Findings include: 1. Resident 8's record was reviewed on 8/27/21 at 2:22 p.m. Diagnoses, included but were not limited to, acute [CONDITION(S)], severe protein-calorie malnutrition, and displaced fracture of base of neck of left femur. A significant change in status Minimum Data Set (MDS) assessment, dated 6/18/21, indicated the resident had a moderate cognitive impairment. A nursing note, dated 5/21/21 at 6:05 p.m., indicated the nurse was called to the resident's room. Resident 8 had vomited a large amount of brown/reddish liquid. The physician was notified and ordered the resident sent to the emergency room (ER). The note lacked documentation a Notice of Transfer or Discharge was provided to the resident or resident representative. During an interview, on 8/27/21 at 3:21 p.m., the Nurse Consultant indicated she was unable to find any documentation the Notice of Transfer or Discharge was provided to the resident or resident representative at the time of the hospital transfer. The notice should have been provided. 2. Resident 15's record was reviewed on 8/26/21 at 10:47 a.m. A census indicated the resident had discharged to the hospital on 8/8/21. A progress note, dated 8/8/21 at 6:00 p.m., indicated the resident had a fever and change of condition and a family member requested the resident be sent to the emergency department. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The note lacked documentation a notice of transfer or discharge was provided to the resident or responsible party. During an interview, on 8/26/21 at 11:25 a.m., the Regional Nurse Consultant indicated she was unable to find where a notice of transfer or discharge was provided to the resident or responsible party with each hospitalization when the resident was discharged to the hospital on 8/8/21. On 7/28/21 at 1:13 p.m., the Regional Nurse Consultant provided a document, revised March 2019, and titled, Transfers/Discharges, and indicated it was the policy currently being used by the facility. The policy indicated, Policy: Transfers and discharged out of the facility will occur for reasons within the federal and state regulations, with proper notice and orientation to facilities adjustment .Emergency Transfers: When a resident is temporarily transferred on an emergency basis to an acute care facility, notice of transfer may be provided to the resident and resident representative as soon as practicable .5. The form used for notice of transfers or discharges will be the form required by each individual state. For Indiana facilities, the Transfer and Discharge Form supplied by the Indiana State Department of Health must be used 3.1-12(a)(8)(D) 3.1-12(a)(9)(A) 3.1-12(a)(9)(B) 3.1-12(a)(9)(C) 3.1-12(a)(9)(D) 3.1-12(a)(9)(E) 3.1-12(a)(9)(F) 3.1-12(a)(9)(G)

Based on observation, interview, and record review, the facility failed to provide supervision to an intrusive wandering resident, and respond to residents' complaints regarding an intrusive wandering resident for 1 of 1 randomly observed wandering resident (Resident 14). This had the potential to affect 9 of 9 residents residing in the facility (Residents 3, 11, 14, 15, 17, 25, 27, 29, and 32). The immediate jeopardy began on 12/9/17 when a resident, with documented wandering behavior, wandered and woke another resident resulting in a verbal altercation. The Administrator and Director of Nursing (DON) were notified of the immediate jeopardy on 1/10/18 at 4:21 p.m. The immediate jeopardy was removed, and the deficient practice corrected on 1/12/18. Findings include: On 1/7/18 at 6:30 p.m., Resident 14 was observed picking up items belonging to a visitor, and other residents, and walking down the hallway with them. On 1/08/18 at 9:33 a.m., Resident 14 was observed wandering into the kitchen food preparation area, then around the nurse's station. On 01/08/18 at 10:16 a.m., Resident 14 was observed wandering in and out of resident rooms and open doorways, including the nurse's station, as she approached them. The record for Resident 14 was reviewed on 1/10/18 at 11:21 a.m. Resident 14's [DIAGNOSES REDACTED]. On admission 10/27/17, an Elopement Assessment indicated, Resident 14 had a history of [REDACTED]. On 12/5/17 at 10:45 a.m., a psychosocial note indicated, Resident 14 returned to the facility from an in-patient stay at Generations Psychiatric Unit. Resident was uncertain what to do or where to go, stated this was not home, was looking for her husband and asked about how to get out of the facility. On 12/7/17 at 5:21 a.m., a behavior note indicated, Resident 14 had been going into multiple unnamed residents' rooms frequently that shift. Unnamed peers had been complaining of the resident entering their rooms. Resident had been difficult to re-direct, aggressive at times, and would not stay in her own bed. Resident was out in the hallways most of the night. On 12/8/17 at 1:40 a.m., a health status note indicated, Resident 14 had been walking throughout the halls constantly that shift. She had been going into multiple rooms while unnamed residents were sleeping, and had also walked into rooms while resident care was being performed even while door was closed. Re-direction was effective only occasionally. She had been directed to bed multiple times but did not stay in it. An Indiana State Reportable Incident form, dated 12/9/17 at 4:45 a.m., indicated, Resident 14 was on her roommate's (Resident 17) side of the room, and Resident 17 called Resident 14 a foul name and told her to get back into bed. On 12/9/17 at 6:35 a.m., a behavior note indicated, Resident 14 had been up all night and had not slept. Resident had wandered the hallways and into other unnamed residents' rooms. She had been redirected several times but would wander into a different resident's room a moment later. She had been very anxious all night and required one on one care most of the time. On 12/11/17 at 10:46 p.m., a health status note indicated, Resident 14 had disturbed multiple other unnamed residents this shift. The resident went into many rooms, whether the door was open or shut, and went through other residents' things. One unnamed resident indicated Resident 14 started picking through his hair. Several unnamed residents kept asking staff why they could not have privacy if this was home to them. Many attempts were made to redirect Resident 14 including sitting and resting, and she was taken to a quiet area. She set off the door alarms multiple times. On 12/12/17 at 5:21 a.m., a health status note indicated, Resident 14 had been very difficult to redirect, and had went into multiple unnamed residents' rooms. She uncovered a few unnamed residents while they were in bed, and woke several up from a deep sleep. She was going into the nurse's station looking through papers, and had been awake most of the night. She had been directed multiple times to bed, but would not stay in it any length of time. An Indiana State Reportable Incident form, dated 12/30/17 at 8:35 p.m., indicated Resident 14 entered Resident 11's room and he yelled at her to get out. Resident 14 indicated being afraid of Resident 11. On 12/31/17 at 11:20 p.m., a health status note indicated, Resident 14 went into Resident 11's room and attempted to sit on both beds while the residents were in them, and Resident 11 yelled at her to get out. Nurse attempted to remove Resident 14 from the room without success. The resident refused to get up. An Indiana State Reportable Incident form, dated 1/1/18 at 8:30 p.m., indicated Resident 14 wandered into Resident 15's room and was going to lay down in one of the beds. She then shut the door and refused to allow Resident 15 who was returning to her room in the door. Subsequently there was a struggle between the residents. Resident 15 yelled for assistance. On 1/5/18 at 1:10 a.m., Resident 14 had been observed by staff going into another unnamed resident's room. When staff arrived to the room, Resident 14 had been sitting on the other resident's bed while the unnamed resident was on the bedpan, and the other resident was telling her to get out. Resident 14 was very combative and attempted to strike the aide as she was escorted from the room. On 1/9/18 at 3:00 p.m., during a resident counsel meeting, Resident 15 indicated Resident 14 wandered into her room and she was afraid of Resident 14. Resident 15 told staff she was afraid of Resident 14. Resident 14 had previously entered Resident 15's room and held her door so she could not get back into her room. Resident 15 had to yell for staff to help remove Resident 14. On 1/9/18 at 3:00 p.m., during a resident counsel meeting, Resident 3 indicated, recently Resident 14 had tried to get into her bed with her and wouldn't leave when asked. She led her from the room [ROOM NUMBER] times in one night, and when staff were informed they responded they would do something later about Resident 14, but there was nothing they could do at this time. Resident 3 indicated, she was afraid to go to sleep at night because Resident 14 would come into her room. Resident 3 indicated she should not have to see that Resident 14 got out of her room and staff should be watching to assure Resident 14 didn't come into other residents' rooms. On 1/10/18 at 1:30 p.m., the Social Service Director provided forms, titled, Resident/Family Concern Log, dated August 2017 through 1/9/18. The forms lacked documentation of concerns reported from other residents regarding Resident 14 or if any action was taken to resolve them. On 1/12/18 at 12:25 p.m., the Administrator provided forms, titled, Progress Notes, dated 1/11/18. The forms indicated: a. On 11/4/17, Resident 27 had voiced concerns, Resident 14 had wandered into their half of the room and it upset them. b. On 11/16/17, Resident 32 had voiced concerns, Resident 32 walked past Resident 14 as she sat on the couch and made a general statement that she was afraid of Resident 14. c. On 12/8/17, Resident 17 had voiced concerns, Resident 14 had wandered into their half of the room and it upset them. d. On 12/30/17 Resident 11 had voiced concerns, Resident 14 had wandered into their room and it upset them. e. On 1/1/18, Resident 29 had voiced concerns, Resident 14 had wandered into their room and it upset them. f. On 1/1/18, Resident 15 voiced concerns, Resident 14 had wandered into their room and it upset them. g. On 1/5/18, Resident 25 had voiced concerns, Resident 14 had wandered into their room and it upset them. A care plan, dated 10/27/17, indicated, Focus: I am at risk for elopement related to impaired decision making due to my [DIAGNOSES REDACTED]. Alarm only sounds at the nurses station, not in my room (1/2/18, revised 1/9/18) . I will be observed routinely by staff as I move about. I will be redirected by staff if observed hovering near doors leading out of the facility. If I become anxious to exit, staff will take me for a walk outside, weather permitting. If the wanderguard alarm sounds, it will be answered promptly. (1/2/18, revised 1/9/18) Alarm pad will be placed on the floor by my bed when I am in bed for the night, so staff will know when I arise and maybe in need of toileting or food/drink. Alarm only sounds at the nurse's station, not in my room. A care plan, dated 10/30/17, and updated 11/6/17, indicated, Focus: I have been noticed wandering through the building. I have been found in other resident's rooms and sleeping in other resident's beds. I have reportedly taken items from my peer's rooms when I wander throughout the building. I have a wanderguard in place. I have asked for scissors to cut my wanderguard off. Goal: I will not wander into unsafe areas or remove my wanderguard though next review. Interventions: Check my wanderguard placement each shift. Notify my MD of changes in my sleep to evaluate my sleep and potential for pain. Offer me my busy bag if I am wandering or anxious. Picking up items when wandering is likely related to my [DIAGNOSES REDACTED]. Place a floor mat alarm next to my bed that will alert nurse's station when I am getting out of bed. Redirect me if you notice me near or entering unsafe areas or in peers rooms. During an interview on 1/8/18 at 2:21 p.m., the spouse indicated, Resident 14 could no longer concentrate or participate in activities around her, he is sure she does not understands when given direction or understood right from wrong. The resident 's biggest problem was her wandering in and out of other residents' rooms doing things she should not do and taking their belongings. He worried she would have to be moved to a locked unit because of her behaviors. During an interview on 1/10/18 at 10:58 a.m., the Social Service Director indicated concerns voiced from other residents regarding Resident 14 and her wandering behaviors were not documented on the grievance/concern log as that would have been double charting. Several of the concerns were State Reportable Incidents and other residents' concerns had been documented in Resident 14's chart. On 1/10/18 at 10:58 a.m., the Administrator indicated, many interventions had been tried regarding Resident 14's wandering behaviors, and they continued to work on it. Resident 14's behaviors were discussed with the administrative team in the morning meeting daily as needed. On 1/12/18 at 12:25 p.m., the Administrator provided a policy, titled, Accident/Incident Reports, dated 7/09. The policy indicated, When an accident or incident involving a resident occurs, any witnessing staff will offer immediate assistance. An incident report and the appropriate documentation in the residents' medical record will be completed by the end of the shift .Guidelines: An incident/accident report is made out for any fall, skin tear, bruise, or any other event that occurs out of the ordinary . On 1/12/18 at 12:25 p.m., the Administrator provided a document, titled, Resident Rights, dated 11/28/16. The policy indicated, .(1) A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident .(i) Safe environment. The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safety . The immediate jeopardy that began on 1/10/12 was removed on 1/12/18 when the facility identified all residents with wandering behaviors, completed evaluations and updated assessments and care plans for wandering residents, initiated new interventions and a tracking system to identify and intervene to prevent wandering behaviors, updated the Grievance Log and followed up with all residents affected by the wandering of Resident 14, and clinical staff were in-serviced on the policy and procedures for Behavior Management and Monitoring Program, Grievance Policy, Abuse Policy, and Resident Rights. The noncompliance remained at the lower scope and severity level of no actual harm with the potential for more than minimal harm that is not immediate jeopardy because of the facility need for continued monitoring. 3.1-45(a)(1) 3.1-45(a)(2)

Based on record review and interview, the facility failed to provide adequate supervision for a resident related to fall interventions not in place resulting in a resident falling and obtaining a fibula (outer bone between ankle and knee) fracture for 1 of 1 residents reviewed for accidents. (Resident 10) Finding includes: On 2/27/17 at 9:00 a.m., the Administrator had reported to us a Reportable Incident that had occurred at the facility with Resident 10. Review of the Reportable Incident and Resident 10's record was completed on 2/27/17 at 10:16 a.m. [DIAGNOSES REDACTED]. A Brief Description of the Reportable Incident indicated on 2/20/17 the resident had a fall. She had complained of left ankle pain and an x-ray was obtained with no evidence of a fracture or dislocation. On 2/24/17 the resident started complaining of left leg pain and x-ray was obtained and there was evidence of a fibula fracture. The Quarterly MDS (Minimum Data Set) assessment, completed on 1/26/17, indicated the resident was cognitively intact. An extensive assistance of 2+ persons was needed for transferring and toilet use and she had previous falls. A Care Plan, initiated 4/27/16, indicated: The resident had a history of [REDACTED]. She would often choose not to use the call light for assistance. She had impaired mobility and balance and would often think she could do things for herself instead of requesting staff assistance. Interventions included to not leave her wheelchair at her bedside after assisting her to lay down and to place an alarm to alert staff when she attempted to get out of bed unassisted. A Progress Note, dated 2/20/17 at 2:53 p.m., indicated the resident fell attempting to transfer herself from her bed to her wheelchair. The resident was complaining of left ankle and foot hurting. An x-ray was ordered by the Physician with no significant findings. A Progress Note, dated 2/22/17 at 3:22 p.m., indicated the resident was complaining of leg pain. Tylenol wag given, will monitor. A Progress Note, dated 2/24/17 at 10:35 a.m., indicated the resident continued to complaint of pain to her left leg. The Physician was notified. A Progress Note dated 2/25/17 at 2:46 p.m., indicated a fax was received from x-ray and showed evidence of a mildly displaced fracture involving the fibula. The Physician was called and family would be informed. Interview on 2/27/17 at 12:00 p.m. with RN 2, indicated on the date of the incident, she had been walking by the resident's room and saw the resident lying on the floor next to her bed on her left side. She was lying halfway on her floor mat alarm and it was not sounding so she was unsure if the alarm was not functioning or just not turned on. The wheelchair was at the foot of the resident's bed when she found her, but the wheelchair was usually put on the other side of the curtain on the same wall farther from the bed. Interview on 2/27/17 at 12:18 p.m. with the DON (Director of Nursing), indicated the resident's alarm should have been in place and functioning and her wheelchair should not have been placed next to her bed after she was assisted into bed. 3.1-45(a)(2)

Based on observation, interview, and record review, the facility failed to ensure residents received adequate supervision and assistive devices to prevent accidents related to alarms and appropriate footwear which resulted in one resident (#7) sustaining a subdural hematoma. This deficient practice effected 3 of 5 residents with falls in a sample of 10. (Residents #7, #23, #31). Findings include: 1. On 6/13/11 at 9:45 A.M., during an initial tour with the MDS Coordinator, Resident #7 was identified as continent of bowel and bladder, being in a wheelchair, ambulatory with a walker, and having had a fall with head injury. The resident had been sent to the emergency department for evaluation after the fall. Resident #7's clinical record was reviewed on 6/15/11 at 1:10 P.M. The record indicated the resident was admitted with [DIAGNOSES REDACTED]. Review of a physician orders [REDACTED]. Further review indicated "...up with assist of walker or wheelchair and 1 person..." A Minimum Data Set (MDS) significant change assessment, dated 5/20/11, indicated the resident was independent in cognitive decision-making skills, was independent in transfers and ambulation, and required limited one-person physical assistance for toilet use. Further review indicated the resident "was not steady but able to stabilize without human assistance" for balance during transfers and walking and had one fall with no injury. A fall risk assessment, dated 5/26/11, indicated the resident had experienced 3 or more falls in the previous three months and had a balance problem when standing and walking. Further review indicated a score of 15, indicating high risk for falls. An initial care plan, dated 3/7/11, indicated "...Safety: risk for initial fall (indicated by checkmark)...history of falls (indicated by checkmark)...approach...call light in reach...reinforce safety awareness...fall risk assessment..." Nurses' notes indicated: 3/17/11 at 5:45 P.M., "Resident yelled out 'Help'. Res (resident) found sitting on floor in room. Res stated that she ambulated by herself in her room. She was using her WC (wheelchair) as a walker. It moved from her and she fell on to her buttock & (R) (right) elbow. Res assessed. No injuries present..." 3/17/11 at 10:00 P.M., "...Mod (moderate) hematoma on (L) (left) upper arm..." A "Fall Investigation Report," dated 3/17/11, indicated "...Res was walking in her room by herself holding on to WC. WC moved and resident fell on to her buttocks & (R) elbow. Res was not wearing non-skid socks...How will this incident be prevented from occurring again? Res encouraged to call for assist prior to attempting to stand or ambulate..." An "Episodic Care Plan Falls," dated 3/17/11, indicated "...Cause of fall: up s (without) assistance...approach...Keep call light & personal items within reach, Reinforce safety awareness, encourage resident to call for assist, Clear pathway in resident's normal route...Assist of #1 persons for transfers, Monitor fatigue, unsteadiness..." Nurses' notes indicated: 3/22/11 at 9:00 P.M., "Resident slightly confused this evening..." 3/23/11 at 10:10 A.M., "...confused but knows it. States 'I know I'm off today.' 'I get this way.'...will monitor." 3/24/11 at 10:45 A.M., "CNA requested nurse come to res room d/t (due to) fall. Res sitting on floor in front of closet...Res states she was reaching for clothing et (and) fell out of W/C (wheelchair)...States she is sore on rt (right) side abd (abdomen)..." 3/24/11 at 12:30 P.M., "Writer called to res room. Rt side abd c (with) abrasion from waist line down to upper (indicated by arrow) hip. Silver dollar sized light purplish raised area..." A "Fall Investigation Report," dated 3/24/11, indicated "...Res states she was getting into closet while sitting in W/C for outfit et she fell out of chair...How will this incident be prevented from occurring again? Res encouraged to call for assist when needing to reach things she need to stretch out for..." An "Episodic Care Plan Falls," dated 3/17/11 and updated on 3/28/11, indicated "...non-skid footwear..." Nurses' notes indicated: 3/28/11 at 2:00 A.M., "...Noted to have periods of confusion off & on tonite (sic)..." 3/28/11 at 4:30 A.M., "Res amb (ambulating) in hall pushing over the bed table. Yelling help, help..." 3/28/11 at 10:00 A.M., "...Incident of 3/24/11 reviewed by IDT (interdisciplinary team). Care plan reviewed et updated. Enc. (encourage) res to call for assist c (with) ADL's (activities of daily living)..." 3/29/11 at 6:00 A.M., "...Resident has required 1:1 supervision most of shift for safety...Requires extensive assist to B.R. (bathroom). Unable to re-orient mostly d/t intermittent confusion..." 3/30/11 at 2:00 A.M., "Resident yelled out, staff entered room to find resident sitting on floor. Resident stated 'I had to pee but couldn't pee!' (W) (writer) advised resident the importance of using call light. 0 (no) injury noted @ this time. (W) placed resident in front of N.S (nurses' station) in W/C for 1:1 observation...will monitor." 3/30/11 at 3:15 A.M. "Resident requested to use B.R., (W) advised that CNA would take resident shortly et that (W) couldn't d/t another resident @ N.S. station (sic) for 1:1 observation. Shortly after, resident took off down hall et fell forward before nurse could reach resident...resident did chip (R) front tooth...Resident unable to wait for assist @ x's (times)....(W) advised resident that (W) did not feel resident would be safe alone in room. (W) placed resident in W/C behind N.S. next to (W). Monitoring." A "Fall Investigation Report," dated 3/30/11 at 2:00 A.M. and 3:15 A.M., indicated "...(W) (writer) witnesses #2 fall. Resident took off out of W/C down hall, (W) run (sic) around desk toward resident but was unable to get to resident before she fell ...res confused, yelling out. Tried to get up s (without) calling for assist...How will this incident be prevented from occurring again? Alarm placed on bed et chair..." An "Episodic Care Plan Falls," dated 3/17/11 and updated 3/30/11, indicated "...bed/chair pressure alarms..." Nurses' notes indicated: 3/30/11 at 9:45 A.M., "Incidents of 3-30-2011 reviewed by IDT. Fall care plan updated. Res c (with) pressure alarms to bed et W/C. Res to be moved to room (number) closer to nursing station..." 4/2/11 at 1:30 A.M., "Resident up to BS (bedside) commode s (without) assistance..." Documentation was lacking related to the alarms being on and functioning. 4/2/11 at 2:00 P.M., "...She has been noted to be weak of all extremities..." 4/4/11 at 8:00 P.M. "CNA placed resident on bedside commode, call light in reach, CNA will check (indicated by checkmark) her..." 4/4/11 at 8:30 P.M., "Staff heard resident yell, entered resident's room, resident on floor slightly lying on (R) side, floor appears wet from water spill. Resident stated 'I was trying to get a drink of water, oh please, get me a drink.'...Resident yells out when moving lower (indicated by arrow) extremities..." The resident was transported to the hospital emergency department. A "Fall Investigation Report," dated 4/4/11, indicated "...Alarm in use...Yes (indicated by X)...If yes, what type(s) Bed alarm/Resident on bedside commode. Did it sound...No (indicated by X)...If no, why not? Resident on bedside commode...How will this incident be prevented from occurring again? All staff to be inserviced on proper use of alarms/procedures to assist resident et not leave alone..." A hospital history and physical, dated 4/4/11, indicated "...Prior to admission, apparently she got out of bed and fell down and sustained an injury to the right hip and also contusion on the chin...initial evaluation revealed a questionable fracture of the right hip and also a small subdural hematoma...admitting diagnoses...fall resulting in multiple injuries of sprained right hip to rule out fracture, contusion on the chin and subdural hematoma, very small size..." An "Episodic Care Plan Falls," dated 3/17/11, indicated documentation was lacking related to additional interventions implemented after the 4/4/11 fall. A "Physical Therapy Plan of Care," dated 4/21/11 through 5/20/11, indicated "...elevated fall risk...has fallen in the past...balance...static standing fair...dynamic standing fair -...currently demonstrates decline in transfers, safety awareness, physical function, gait, bed mobility, balance, strength...the patient has very high fear of falls. She reports that turning during the standing position leads to more fear of falls..." A "Restorative Nursing Program (FMP)" form, dated 4/29/11, indicated "...Need to assist during ambulation rolling walker...active ROM (range of motion) to bilaterall (sic) lower extremity 10 x (ten times)/3/day (three times a day). Documentation was lacking related to the restorative program having been done. Interview on 6/15/11 at 2:15 P.M., with the MDS Coordinator indicated the resident was not on a restorative program. A nurses' noted, dated 5/13/11 at 9:10 P.M., indicated "Resident calling out, found sitting on floor...c/o (complains of) bilateral knee pain that is not new..." A fall investigation was requested on 6/15/11 at 2:00 P.M., from the acting Director of Nursing but not provided for review. Interview with the acting Director of Nursing indicated an investigation had not been done. An "Episodic Care Plan Falls," dated 3/17/11, indicated documentation was lacking related to additional interventions to prevent falls being implemented after the 5/13/11 fall. Nurses' notes indicated: 5/26/11 at 5:55 P.M., "Resident fell ambulating to bathroom, res states 'my foot slipped when I tried to turn.' Res wearing non-skid slipper socks, res fell on (L) hip et elbow c (with) notable bruising point tenderness but no loss of ROM...res sent to ER (emergency room ) for assessment for possible hip fx (fracture)..." 5/26/11 8:20 P.M., "Resident returned from hospital via ambulance, dx (diagnosis) contusions...bedside commode in room for pt (patient) use, reminded res to use call light for assistance..." A "Fall Investigation Report," dated 5/26/11, indicated "...Alarm in use...No (indicated by X)...Resident was walking to bathroom, got to the halway (sic) et foot slipped as she was trying to turn...How will this incident be prevented from occurring again? Remind res to use call light et wait for someone to walk c (with) to BR (bathroom) r/t (related to) multiple pain pills..." An "Episodic Care Plan Falls," dated 5/26/11, indicated "Approach...Keep call light & personal items within reach, Reinforce safety awareness, encourage resident to call for assist, Clear pathway in resident's normal route...Monitor fatigue, unsteadiness..." Interview on 6/15/11 at 2:00 P.M., with the acting Director of Nursing indicated the resident should not have been left alone on the bedside commode. She indicated the alarms had not been applied after the resident returned from the hospital on [DATE]. The criteria for removing the alarms included not having any falls, a decrease in fall risk, or physical therapy indicated the resident was "safe." She indicated Resident #7 did not meet those criteria. 2. On 6/13/11 at 9:45 A.M., with the MDS Coordinator, Resident #23 was identified as being in a wheelchair, incontinent of bowel and bladder, and having had falls with no injuries. On 6/16/11 at 8:50 A.M., Resident # 23 was observed lying in bed in her room. There was an alarm box hanging on the side rail of her bed. There was a pressure pad under the resident. The cord from the pressure pad to the alarm box was unfastened and lying on the floor. On 6/16/11 at 9:00 A.M., with the acting Director of Nursing, Resident #23 was observed lying in bed. The alarm cord was unfastened from the alarm box and lying on the floor. QMA #1 was observed at the resident's bedside administering medications. There was no attempt by the QMA to replace the cord in the alarm box or to check the function of the alarm. Interview at the time of observation with the acting Director of Nursing indicated the alarm should be connected. Resident #23's clinical record was reviewed on 6/16/11 at 9:05 A.M. The record indicated the resident was admitted with [DIAGNOSES REDACTED]. A physician orders [REDACTED]. Further review indicated "...up ad lib (as desired) to wheelchair with 1 assist..." An MDS significant change assessment, dated 6/2/11, indicated the resident was severely impaired in cognitive decision-making skills, required extensive one-person physical assistance for transfers and toilet use, required extensive two-person physical assistance for ambulation in room, was not steady, only able to stabilize with human assistance for balance and had two falls with no injury. A fall risk assessment, dated 6/2/11, indicated the resident had intermittent confusion, had experienced 1-2 falls in the previous three months, and had balance problems. Further review indicated a score of 20, indicating a high risk for falls. A "Physical Therapy Discharge Summary," dated 2/17/11, indicated "...Balance Static sitting...Fair...Dynamic sitting...Fair-...Static standing...Poor+...Dynamic standing...Poor...elevated fall risk currently but improved from SOC (start of care)..." A resident care plan, dated 3/14/11, indicated "...I am at risk for falls...Approaches...Assist me to ambulate, Toilet me 2-3 times per shift to prevent incontinence, Provide safety cues and reminders as needed, Make sure I am wearing non-skid footwear, Make sure my call light is within reach..." A nurses' note, dated 4/13/11 at 11:00 A.M., indicated "Writer called to room by CNA @ 9:30 AM. Resident found sitting on floor in front of her WC...no injuries noted...Dtr (daughter) requested that resident have a bed/chair alarm. Alarms applied... Resident is alert and pleasantly confused..." A "Fall Investigation Report," dated 4/13/11, indicated "Type of footwear...socks...Resident confused. Resident stated 'This is the first time this has happened...Res found sitting on floor in front of W/C...How will this incident be prevented from occurring again? Staff to frequently check on res..." An "Episodic Care Plan Falls," dated 4/13/11, indicated "...Cause of fall: confusion, unsteady gait...Approach...bed & chair alarm..." Nurses' notes indicated: 4/14/11 at 9:30 A.M., "Incident of 4/13/11 reviewed by IDT. Care plan reviewed et updated. Place pressure alarm onto W/C..." 4/22/11 at 2:50 P.M., "Maintenance informed writer that resident was on floor. Writer went to (room number) found resident seated on floor beside bed..." A "Fall Investigation Report," dated 4/22/11, indicated "... Resident stated 'I was trying to get in the chair'...How will this incident be prevented from occurring again? Place bed in low position. Remind res to use call light for assist..." Documentation was lacking related to a bed alarm being in place and functioning. A nurses' note, dated 4/25/11 at 10:00 A.M., indicated "Incident of 4/22/11 reviewed by IDT...Bed to be placed in low position..." Interview on 6/16/11 at 10:35 A.M., with the acting Director of Nursing, indicated the staff should have been checking the alarm at the beginning of the shift and during care to ensure it was connected. Interview on 6/16/11 at 10:35 A.M., with the Administrator, indicated the bed alarm had not been applied before the 4/22/11 fall. 3. During initial tour on 6/13/11 at 9:45 a.m., with the MDS Coordinator, Resident #31 was identified as having had falls with no injuries and utilized a walker for ambulation. During an observation on 6/16/11 at 8:50 a.m., Resident #31 was observed lying in bed with her legs hanging over the side of the bed. The resident's feet were bare. The resident's shoes were at the end of the bed on the floor. A CNA entered the room and woke the resident up and repositioned her in the bed. She asked the resident where her socks were. The CNA assisted the resident up further into the bed and covered the resident up and left the room. During an observation on 6/16/11 at 9:17 a.m., Resident #31 was observed lying in bed on her side with no socks on her feet. The resident's shoes had been moved by staff and were sitting on top of the resident's walker, next to the resident's bed. The resident's feet were bare. A CNA assignment sheet provided by the acting Director of Nursing on 6/17/11 at 9:35 a.m., indicated the resident was alert and confused, was at high risk for falls, used a rolling walker, and low bed. Documentation was lacking to indicate the resident should have non-skid footwear in place at all times. During an interview with the Director of Nursing at the time the above form was provided she indicated the non-skid footwear should have been identified on the assignment sheet. She indicated the assignment sheet was in place at the time of the observation of the resident without non-skid footwear in place. Resident #31's record was reviewed on 6/16/11 at 9:00 a.m. [DIAGNOSES REDACTED]. An quarterly Minimum Data Set (MDS) assessment, dated 12/9/10, indicated a brief interview of mental status score equaling 7/15, indicating moderate cognitive impairment, required limited assistance of one staff for transfers and toileting, was independent with ambulation, was not steady with moving from a seated position, walking, turning around, or surface to surface transfer, but was able to stabilize without human assistance. The assessment further indicated the resident was not steady when moving on and off toilet, and was only able to stabilize with human assistance, utilized a walker, was frequently incontinent of bladder, and had a fall with injury since the last assessment. A fall risk assessment, dated 10/20/10 and updated 2/3/11, indicated the resident had intermittent confusion, 1-2 falls in the past 3 months, used an assistive device, and was taking medications that put the resident at higher risk for falls. The assessment indicated the resident's total score was 11. The assessment indicated "...if the total score is 10 or greater, the resident should be considered at HIGH RISK for potential falls. A prevention protocol should be initiated immediately and documented on the care plan...." A care plan, dated 4/16/10 and last updated with approaches on 8/9/10, indicated "...I am at risk for falls...I have poor standing balance, I walk with a rolling walker and assist. I have poor safety awareness. I have a [DIAGNOSES REDACTED]." A nurses' note, dated 2/3/11 at 10:30 (no a.m. or p.m. documented) indicated "...DE (delayed entry) for 2/3/11 @ (at) 0630- res (resident) was found on floor in BR (bathroom). Small hematoma to back of head L (left) side only injury. VS WNL (vital signs within normal limits), neuros WNL, PERRLA (pupils equal and reactive to light) MAEW (moves all extremities well). Denies pain physician, family notified...." Documentation was lacking to indicate why the resident, identified at high risk for falls, was left alone in the bathroom. A fall investigation report provided by the Director of Nursing on 6/16/11 at 10:55 a.m., dated 2/3/11, indicated the resident was found in the bathroom on floor with non-skids socks in place. The report further indicated the fall was unwitnessed and the resident required assistance of one for toileting and transfers, and the care plan was updated. The assessment further indicated "...how will this incident be prevented from occurring again? referral to therapy..." Documentation was lacking to indicate the falls care plan had been updated with the referral to therapy intervention. An annual Minimum Data Set (MDS) assessment, dated 3/3/11, indicated a brief interview of mental status score equaling 8/15, indicating moderate cognitive impairment, required limited assistance of one staff for transfers and toileting, was independent with ambulation, was not steady with moving from a seated position, walking, turning around, moving on and off toilet, or surface to surface transfer, but was able to stabilize without human assistance. The assessment further indicated the resident utilized a walker, was frequently incontinent of bladder, and had a fall with no injury and a fall with injury since the last assessment. A fall risk assessment, dated 3/3/11 and updated 5/6/11, indicated the resident had intermittent confusion, 1-2 falls in the past 3 months, had a balance problem while standing, balance problem while walking, change in gait pattern when walking through doorway, jerking or unstable when making turns, used an assistive device, and was taking medications that put the resident at higher risk for falls. The assessment indicated the resident's total score was 13. The assessment indicated "...if the total score is 10 or greater, the resident should be considered at HIGH RISK for potential falls. A prevention protocol should be initiated immediately and documented on the care plan...." The nurses' notes indicated the following: "5/6/11 9:55 A, Incident of 5/6/11 reviewed by IDT (Interdisciplinary team). Care plan reviewed et updated." 5/6/11 5 pm, Resident has had no injuries from fall. Neuro VS WNL." Documentation was lacking in the nurses' notes related to a fall having occurred, the events surrounding the fall, or an assessment of the resident at the time of the fall. A fall investigation report provided by the Director of Nursing on 6/16/11 at 10:55 a.m., dated 5/6/11 at 5:30 a.m., indicated Resident #31 had an unwitnessed fall in her room at her bedside. The assessment indicated the resident stated 'I was trying to get up and just slipped.' The assessment indicated the resident required assist of one with transfers and toileting. The assessment indicated a set of vitals and assessment of the resident had been documented on the report. The assessment indicated "...how will this incident be prevented from occurring again? Enc (encourage) res to call for assist c (with) transfers. Make sure res is wearing shoes or non-skid socks...." The report was signed as completed on 5/6/11 by the Director of Nursing, the MDS coordinator, and the Administrator. Documentation was lacking to indicate a new intervention had been initiated to prevent further falls, and the care plan had been updated with a new intervention for staff to utilize to prevent further falls. During an interview with the Director of Nursing, the Administrator, and the Director of Operations on 6/16/11 at 10:55 a.m., the Director of Nursing indicated the resident was at high risk for falls, required assist of one staff to toilet, and the resident should not have been left alone in the bathroom at the time of the 2/3/11 fall. The Administrator indicated the care plan should have been updated with the therapy screen. The Director of Nursing indicated when a fall occurs the expectation is for documentation to be placed in the nurses' notes related to the fall, the events surrounding the fall, and an assessment of the resident at the time of the fall. The Director of Nursing indicated the nurse who filled out the fall investigation report for the resident's 5/6 fall failed to document the fall in the nurses' notes. The Administrator and Director of Operations indicated new interventions should be put into place with each fall to prevent further falls for the resident. She indicated the care plan should have been updated with new interventions after the 5/6/11 fall. A policy and procedure titled "Fall prevention program," dated 11/02, last revised on 7/09, provided by the Corporate Consultant on 6/15/11 at 3:15 p.m., identified as current indicated, "...It is the policy of this facility to identify residents at risk for falls and to implement a fall prevention program to reduce the risk of falls and possible injury...Fall prevention and management is the responsibility of all staff in all departments...if the resident's fall risk score is '10' or greater and/or if the resident has a history of falls, interventions will be put into place...a fall risk prevention plan, with updated interventions, will be incorporated into the resident's comprehensive plan of care on the CNA assignment sheet...IDT will review the resident's fall risk prevention plan...the plan will be reviewed and modified as needed, after each fall to make sure that the interventions are as current as possible...The DON will review with the IDT team...to develop a fall prevention plan, including the development of new interventions or revision of existing ones...the care plan will be updated to show the resident's risk of falls and all interventions put into place to prevent falls...." 3.1-45(a)(1) 3.1-45(a)(2)