Every finding on record at Life Care Center of the Willows

Based on record review and interview, the facility failed to ensure residents who were dependent on staff for activities of daily living (ADL's) received bathing/showers at least twice a week for 1 of 4 residents reviewed for ADL's. (Resident C)Finding includes:Resident C's record was reviewed on 3/25/26 at 1:14 p.m. Diagnoses included, but were not limited to, dementia. A Care Plan, updated 1/7/26, indicated the resident required ADL (Activities of Daily Living) assistance. The interventions included to assist the resident with mobility and ADLs as needed.The facility Point of Care bathing task documentation, dated 2/4/26 through 3/24/26, indicated the resident was to receive showers on Thursdays and Sundays. There was no bathing documented for 3/1/26, 3/12/26, and 3/19/26.The Shower Sheets, dated 2/4/26 through 3/24/26, indicated no shower sheets had been completed on 3/1/26, 3/12/26, and 3/19/26 for Resident C.The Quarterly Minimum Data Set (MDS) assessment, dated 2/27/26, indicated the resident was cognitively impaired and required partial to moderate staff assistance with toileting hygiene, dressing, personal hygiene, and bathing.During an interview on 3/25/26 at 4:18 p.m., the Assistant Director of Nursing (ADON) indicated she was unable to find any completed shower sheets for 3/1/26, 3/12/26, or 3/19/26 for Resident C. The resident had been mistakenly left off of the shower schedule on 3/12/26 and had not received a shower.This citation relates to Intake 2960382.410 IAC (Indiana Administrative Code) 16.2-3.1-38(a)(3)410 IAC (Indiana Administrative Code) 16.2-3.1-38(b)(2)

Based on observation, interview, and record review, the facility failed to maintain comfortable water temperatures. This had the potential to affect all 67 residents who resided in the facility. Finding includes:On 1/21/26 at 11:43 a.m., Resident 9 was observed sitting on the bed in her room. The resident indicated the sink water did not get hot in her room. Her roommate was on Hospice Services and Hospice would have to heat water up in a basin in the microwave to give her roommate a bed bath. The sink water was turned on at this time and let it run for approximately a minute. The water was only slightly warm to touch.During an interview on 1/27/26 at 11:50 a.m., Hospice CNA 1 indicated the water at the facility did not get hot. When she would have to complete bed baths on the residents, she would put the water in a basin and heat it up in the microwave. She would then stir it up with her hand to test to make sure it wasn't too hot.Confidential Staff Interviews during the survey indicated the water in the residents' rooms and shower rooms did not get hot. They informed management about it a while ago and it had not been fixed.An environmental tour was completed on 1/27/26 at 1:24 p.m. with the Administrator to check water temperatures. The following water temperatures were collected. 1. [NAME] Unita. room [ROOM NUMBER]'s water temperature was 86.1 F (Fahrenheit). There were 2 residents who resided in the room.b. room [ROOM NUMBER]'s water temperature was 82.9 F. There were 2 residents who resided in the room.c. Center [NAME] Shower Room's water temperature was 84.7 F. 2. East Unita. room [ROOM NUMBER]'s water temperature was 82.2 F. There was 1 resident who resided in the room.b. room [ROOM NUMBER]'s water temperature was 80.2 F. There was 1 resident who resided in the room.c. Center East Shower Room's water temperature was 82.7 F. The water temperatures logged by Maintenance Assistant 1 were reviewed and documented as the following temperatures:1/22/26-room [ROOM NUMBER] was 91.3 F-room [ROOM NUMBER] was 93 F-room [ROOM NUMBER] was 92 F-room [ROOM NUMBER] was 91.7 F1/26/26-room [ROOM NUMBER] was 90.3 F-room [ROOM NUMBER] was 91.4 F-room [ROOM NUMBER] was 93.6 F-room [ROOM NUMBER] was 91.4 F-room [ROOM NUMBER] was 91.2 FDuring an interview on 1/27/26 at 2:05 p.m., the Administrator and Maintenance Director indicated the local water company called the facility on 1/19/26 and indicated the facility may have a water leak. The water company was supposed to have someone come out to check but they had not done it yet. Assistant Maintenance 1 did not let them know the water temperatures were below 100 F. None of the facility staff or Hospice staff had informed them the water was not getting hot. The water temperatures should be between 100 F to 120 F. 3.1-19(h)

Based on observation, record review, and interview, the facility failed to serve food under sanitary conditions related to staff touching food directly with gloved hands after touching non-food items for 1 of 1 meal service observed in the main kitchen. (Cook 1) Finding includes: On 1/22/26 at 11:52 a.m., [NAME] 1 was observed placing items on plates to prepare a lunch meal. She had on clean gloves. She turned to the prep area to prepare a grilled cheese sandwich. She opened a bag of bread using her gloved hands, reached into the bag and grabbed a piece of bread and placed it on a pan on the stove top. She proceeded to open a package of cheese, with the same gloved hands, picked up a piece of the cheese and placed it onto the bread in the pan, and then retrieved another piece of bread with the same gloved hands and placed it on top of the cheese. She prepared another tray with Super Soup and then had to prepare another grilled cheese sandwich. She repeated the above steps using the same gloved hands throughout the process. During an interview on 1/22/26 at 12:00 p.m., the Dietary Manager indicated the cooks were not supposed to touch food items directly with gloved hands after touching non-food items. 3.1-(i)(3)

Based on observation, record review, and interview, the facility failed to ensure a resident's dignity was maintained related to the resident's back side being exposed while in the hallway for 1 of 1 resident reviewed for dignity. (Resident 24)Finding includes:During a random observation on 1/22/26 at 2:12 p.m., Resident 24 was observed sitting in a shower chair in the doorway of his room. The resident was wearing a hospital gown that was open in the back. The resident's backside, including his buttocks were exposed and visible. CNA 1 was observed wheeling the resident out of his room and down the hallway into a shower room. There were a few other residents who were sitting in the hallway who could observe the resident being wheeled down the hallway with his buttocks visible. The CNA did not cover the resident with any other clothing or a blanket before wheeling him down the hallway.Record review for Resident 24 was completed on 1/22/26 at 2:15 p.m. Diagnoses included, but were not limited to, anemia, heart failure, and hypertension.The Quarterly Minimum Data Set (MDS) assessment, dated 12/24/25, indicated the resident was severely cognitively impaired.During an interview on 1/22/26 at 2:24 p.m., CNA 1 indicated she should have covered the resident up before transporting him down the hallway so his buttocks were not exposed.During an interview on 1/22/26 at 2:26 p.m., the Assistant Director of Nursing (ADON) indicated the CNA should have covered the resident up before transporting him down the hallway.3.1-3(t)

Based on record review and interview, the facility failed to ensure a resident and the resident's representative were informed of a change in treatment related to psychotropic medication for 1 of 5 residents reviewed for unnecessary medications. (Resident 48) Finding includes: Record review for Resident 48 was completed on 1/22/2 at 9:38 a.m. Diagnoses included, but were not limited to, insomnia, anemia, heart failure, end stage renal disease, and respiratory failure.The admission Minimum Data Set (MDS) assessment, dated 10/29/25, indicated the resident was moderately cognitively impaired. The resident received an antidepressant medication.A Health Status Note, dated 10/25/25 at 9:02 p.m., indicated the resident was requesting a sleep aid. The physician and resident representative were informed. The physician ordered trazodone (antidepressant medication) 50 mg (milligrams), 1 tab every night.The January 2026 Physician's Order Summary (POS) indicated an order for trazodone 50 mg, give 2 tablets at bedtime for insomnia. The record lacked any documentation the resident and the resident's representative were informed when the antidepressant medication had been increased.During an interview on 1/22/26 at 3:28 p.m., the Infection Preventionist/Wound Nurse indicated the resident had been having increased problems sleeping at night. The physician had ordered to increase the trazodone. She was unaware if the resident and the resident's representative were informed of the increase in dosage of the medication.During an interview on 1/27/26 at 10:25 a.m., the Director of Nursing (DON) indicated she could not provide any documentation the resident and the resident's representative were informed the trazodone was increased. 3.1-3(n)(2)

Based on observation, record review and interview, the facility failed to develop and implement a care plan related to a tracheostomy stoma site for 1 of 4 residents reviewed for respiratory care. (Resident 10) Finding includes:During an interview and observation on 1/20/26 at 11:31 a.m., Resident 10 indicated he was unable to speak and used a whiteboard for communication as he had a tracheostomy stoma site. He indicated he did the care for the stoma site himself every day. The stoma site appeared clean upon observation. Resident 10's record was reviewed on 1/21/26 at 11:29 a.m. Diagnoses included, but were not limited to, chronic obstructive pulmonary disease, respiratory failure, and history of cancer of larynx. The admission Minimum Data Set assessment, dated 11/6/25, indicated the resident was cognitively intact and received tracheostomy care while a resident. A Physician's Order, dated 10/31/25, indicated tracheostomy stoma care completed per resident daily and as needed. Monitor for signs and symptoms of infection or skin irritation every shift. Monitor for discoloration of sputum along with respiratory status and notify the physician of any significant changes. The record lacked any care plans related to the resident's tracheostomy stoma site. During an interview on 1/27/26 at 3:15 p.m., the Director of Nursing indicated the stoma site should have been included in the resident's care plan. 3.1-35(a)

Based on observation, record review, and interview, the facility failed to obtain orders and document treatment changes for a non-pressure skin condition for 1 of 2 residents reviewed for non-pressure skin conditions. (Resident 10)Finding includes:During an interview and observation on 1/20/26 at 11:31 a.m., Resident 10 indicated he had screws coming out of his right elbow and he was awaiting surgery to correct it. He indicated the staff changed the bandage for him. Resident 10's record was reviewed on 1/21/26 at 11:29 a.m. Diagnoses included, but were not limited to, chronic obstructive pulmonary disease, respiratory failure, and history of cancer of larynx. The admission Minimum Data Set assessment, dated 11/6/25, indicated the resident was cognitively intact, had an impairment with range of motion on one side of the upper extremity. He had surgical wound(s) that required surgical wound care and application of nonsurgical dressings other than to his feet. A Care Plan, dated 10/31/25, indicated the resident had actual impairment to the right elbow with hardware showing from a surgical site. Interventions included, but were not limited to, follow facility protocols for treatment of injury and weekly treatment documentation. A Physician's Order, initiated on 10/31/25 and discontinued on 12/13/25, indicated cleanse the right posterior upper arm surgical wound with normal saline, pat dry, apply Hydrofera Blue (antimicrobial foam dressing) to fit the wound and cover with a foam dressing three times weekly and as needed for soilage or dislodgement. A Physician's Order, dated 1/20/26 at 1:33 p.m., indicated cleanse the right elbow surgical wound with normal saline, pat dry, apply Hydrofera Blue to fit the wound and cover with a foam dressing three times weekly (day shift on Monday, Wednesday, and Friday) and as needed for soilage or dislodgement. Wound Observation Tools, dated 12/8/25, 12/15/25, 12/22/25, 12/29/25, 1/5/26, and 1/20/26, indicated the resident had a right posterior upper arm surgical wound dehiscence (closed wound reopens) with no drainage measuring 1.5 centimeters (cm) long by 1.2 cm wide by 0.2 cm deep. There was 100% necrotic tissue and hardware was exposed. The treatment plan was Hydrofera blue and dry dressing. There were no physician's orders for treatment and no documented treatments on the Treatment Administration Record (TAR) for the right elbow wound from 12/13/25 to 1/20/26. During an interview on 1/23/26 at 3:20 p.m., the Wound Care Nurse/Infection Preventionist indicated the resident received wound care three times a week. The order had been discontinued in December 2025, but she was not sure why it was discontinued. She indicated that she had been providing wound treatments three times a week. During an interview on 1/27/26 at 3:15 p.m., the Director of Nursing indicated she had no further information to provide. 3.1-37(a)

Based on observation, record review, and interview, the facility failed to provide treatment for limited range of motion related to a palm protector not in place for 1 of 1 resident reviewed for range of motion (ROM). (Resident 4)Finding includes:On 1/20/26 at 11:49 a.m., Resident 4 was observed lying in bed. Her left hand was in a fist and there was no palm protector in place. On 1/21/26 at 10:23 a.m., Resident 4 was observed lying in bed. Her left hand was in a fist and there was no palm protector in place. On 1/22/26 at 8:57 a.m., Resident 4 was observed lying in bed. Her left hand was in a fist and there was no palm protector in place. The resident's record was reviewed on 1/22/26 at 10:19 a.m. Diagnoses included, but were not limited to, type two diabetes mellitus, dementia with behavioral disturbance, and contracture of the left hand.The Quarterly Minimum Data Set (MDS) assessment, dated 12/24/25, indicated the resident was cognitively impaired and had impaired ROM to the upper and lower extremities on both sides.A Care Plan, updated 10/10/24, indicated the resident had left sided hemiparesis and was at risk for contractures. The interventions included, left palm protector.A Physician's Order, dated 1/7/25, indicated left palm protector as tolerated, check placement and skin under palm protector every shift.The Medication Administration Record and the Treatment Administration Record, dated 1/2026, indicated the left-hand palm protector had been in place as ordered. There were no documented refusals.During an interview on 1/22/26 at 4:15 p.m., the Director of Nursing and the Administrator were made aware the palm protector had not been in place as ordered. No further information was provided.3.1-42(a)(2)

Based on observation, record review, and interview, the facility failed to ensure safety was maintained related to smoking safety interventions, a smoking assessment, and fall interventions not in place for 3 of 7 residents reviewed for accidents (Residents 6, 38, and 3)Findings include:1. On 1/20/26 at 3:56 p.m. Resident 6 was observed outside smoking with staff supervision. The resident was not wearing a smoking apron. On 1/21/26 at 9:06 a.m. Resident 6 was observed outside smoking with staff supervision. The resident was not wearing a smoking apron. Record review for Resident 6 was completed on 1/22/26 at 9:21 a.m. Diagnoses included, but were not limited to, type two diabetes mellitus, vascular dementia, and major depressive disorder. The Quarterly Minimum Data Set (MDS) assessment, dated 12/18/25, indicated the resident was cognitively impaired. A Care Plan, updated 10/23/25, indicated the resident was a smoker and had a smoking incident that caused an injury on 10/20/25. An intervention, dated 10/20/25, indicated to ensure the resident had a smoking apron on at all times during smoking time. A Behavior Note, dated 10/20/25 at 4:17 p.m., indicated staff had taken the resident outside to smoke. The resident went to light her cigarette and caught a pom pom on fire. The item was on the resident briefly before she was able to toss it off of her. A singed area was noted to the top of the resident's left hand and a small area of red irritation was noted to left ring finger. A Progress Note, dated 10/20/25 at 7:25 p.m., indicated staff had taken the resident outside to smoke. As the resident went to light her cigarette, a tissue paper origami pom pom caught on fire. The resident began to swat herself and the inflamed item fell to the ground and fire was put out. Some hair was singed off the resident's left hand and a small red area to the left ring finger was noted. The resident's responsible party, the Nurse Practitioner, and Director of Nursing were made aware. A Smoking Safety Evaluation, dated 11/8/25, indicated the resident exhibited poor safety awareness when smoking and interventions must be put in place to promote smoking safety. During an interview on 1/22/26 at 4:15 p.m., the Director of Nursing and the Administrator were made aware the resident had not been using a smoking apron. No further information was provided. A facility policy, titled Smoking Use Protocol, indicated, .Residents who desire to use tobacco and or e-cigarettes will only be permitted to do so based on clinical assessment and are deemed safe to do so.Residents desiring to smoke must utilize safety equipment as deemed necessary by smoking assessment such as smoking aprons, etc. Failure to comply with the utilization of safety equipment, as necessary, will be deemed a violation of this protocol . 2. During an interview on 1/20/26 at 4:11 p.m., Resident 38 indicated he was a smoker, but was trying to quit. He had just returned inside from going out to smoke. During an interview on 1/21/26 at 9:30 a.m., Resident 38 indicated he had just returned to his room from being outside smoking. Resident 38's record was reviewed on 1/23/26 at 9:03 a.m. Diagnoses included, but were not limited to, cognitive communication deficit and personal history of mental and behavioral disorders. The resident admitted to the facility on [DATE]. The admission Minimum Data Set (MDS) assessment, dated 1/8/26, indicated the resident was moderately cognitively impaired. A Communication Note, dated 1/8/26 at 12:31 p.m., indicated the smoking policy had been discussed with the resident and the resident signed the policy form. A Care Plan, dated 1/6/26, indicated the resident was at risk for respiratory illness related to being an active smoker. There was no Smoking Safety Evaluation completed for the resident. During an interview on 1/27/26 at 3:15 p.m., the Director of Nursing indicated a smoking assessment had not been completed yet as they were not currently going out to smoke due to the cold weather, so they could not assess him while he was out smoking. It was missed upon admission. 3. Resident 3 was observed on 1/20/26 at 2:37 p.m., 1/22/26 at 10:12 a.m., and 1/23/26 at 10:12 a.m., sitting up in a Broda chair. She had a large discoloration noted to her forehead. Resident 3's record was reviewed on 1/23/26 at 10:18 a.m. Diagnoses included, but were not limited to, non-traumatic brain dysfunction, senile degeneration of brain, stroke, and non-Alzheimer's dementia. The Quarterly Minimum Data Set (MDS) assessment, dated 1/2/26, indicated the resident was severely cognitively impaired and was on hospice care. She was dependent on staff for toileting hygiene, shower/bathe, and transfers and required substantial/maximal assistance for bed mobility and eating. She had two or more falls with no major injuries. A Care Plan, dated 7/12/24, indicated the resident was at risk for falls related to dependence for activities of daily living (ADL) care, diagnoses of dementia, psychotics, depression, and anxiety, and antianxiety and antidepressant medication use. Interventions included, but were not limited to, (updated 8/26/25), Resident to be removed from the dining room when meals are not going on and placed in common areas such as nurses station or TV room. A Care Plan, dated 9/22/25, indicated the resident had actual falls with no injury on 9/21/25, 9/28/25, 10/2/25, 11/3/25, 11/25/25, 12/13/25, 1/15/26, and 1/19/26. The fall on 1/19/26 resulted in hematoma/laceration (head trauma) to the left side forehead. Interventions included, but were not limited to, assess resident's needs and meet in a timely manner, increase monitoring while in wheelchair and reposition as needed, and increase assistance during at high-risk times (dinner, early morning, and sundowners). An Event Note, dated 1/19/26 at 8:00 p.m., indicated the resident was in the dining room and the CNA was making her way back to the dining room from down the hall and found the resident in the dining room on the floor at 7:15 p.m. The CNA called another staff member into the dining room, where the resident was found lying on the floor in front of the wheelchair. One other resident was in the dining room but did not notice the resident's fall. No other people were in the room. The CNA stated she had just walked out to answer the call light, and upon return found the resident on the floor. The resident was not fidgeting in the wheelchair prior to the CNA leaving the room, but the resident did have a witnessed fall earlier in the day from her wheelchair. The resident had a laceration to the left side of her forehead with moderate amount of blood on the floor. A head-to-toe assessment was completed and there was a 3.0 centimeter by 0.2 centimeter laceration to her left side forehead. A pressure dressing was applied to stop the bleeding, which was successful. Neurochecks were initiated. 911 was called. Hospice was notified as well as the resident's family, Physician, the Director of Nursing and the Executive Director. An Event Note, dated 1/19/26 at 10:05 p.m., indicated the resident arrived back to the facility at 9:50 p.m. The resident had glue placed on the laceration and the hematoma was drained. New orders were received to keep the laceration clean and open to air. During an interview on 1/23/26 at 3:54 p.m., the Director of Nursing indicated the resident was not supposed to be left unattended in the dining room. 3.1-45(a)

Based on observation, record review, and interview, the facility failed to ensure a resident with a gastrostomy tube (g-tube, the surgical insertion of a feeding tube) received the appropriate treatment related to administration of the tube feeding for 1 of 1 resident reviewed for tube feedings. (Resident 4)Finding includes: On 1/21/26 at 10:23 a.m., Resident 4 was observed lying in her bed. The tube feeding was not connected to the resident's g-tube and the pump was off.On 1/22/26 at 8:57 a.m., Resident 4 was observed lying in her bed. The tube feeding was not connected to the resident's g-tube and the pump was off.The resident's record was reviewed on 1/22/26 at 10:19 a.m. Diagnoses included, but were not limited to, type two diabetes mellitus, dementia with behavioral disturbance, and contracture of the left hand.The Quarterly Minimum Data Set (MDS) assessment, dated 12/24/25, indicated the resident was cognitively impaired and received the majority of their nutrition by tube feeding.A Care Plan, updated 4/3/25, indicated the resident had dysphagia and a g-tube was in place to ensure adequate nutrition and hydration were received. The interventions included, nutrition and hydration via g-tube as ordered.A Physician's Order, dated 12/23/25, indicated the resident was to receive Glucerna 1.5 at 50 cubic centimeters (cc) per hour for 18 hours, on at 6 p.m. and off at 12 p.m. daily.The Medication Administration Record (MAR), dated 1/2026, indicated the tube feeding had been administered as ordered.During an interview on 1/22/26 at 4:15 p.m., the Director of Nursing and the Administrator were made aware the tube feeding had not been administered as ordered. No further information was provided.3.1-44(a)(2)

Based on observation, record review and interview, the facility failed to ensure residents received the necessary care and treatment related to oxygen administration for 2 of 4 residents reviewed for respiratory care. (Residents 51 and 74) Findings include:1.On 1/21/26 at 9:23 a.m., Resident 51 was observed in bed. She had a nasal cannula sitting next to her head. She had indicated she was not feeling well at the time and was coughing. The concentrator was set to 4 liters per minute. On 1/21/26 at 2:50 p.m., Resident 51 was observed in bed with no nasal cannula in place. On 1/22/26 at 9:53 a.m., Resident 51 was observed sitting in bed with no nasal cannula in place. On 1/23/26 at 10:12 a.m., Resident 51 was observed in bed with no nasal cannula in place. Resident 51's record was reviewed on 1/22/26 at 2:25 p.m. Diagnoses included, but were not limited to, heart failure, dementia, and respiratory failure. The Quarterly Minimum Data Set (MDS) assessment, dated 12/24/25, indicated the resident was cognitively intact. A Physician's Order, dated 1/17/26, indicated oxygen at 4 liters per minute continuously per nasal cannula. During an interview on 1/27/26 at 3:15 p.m., the Director of Nursing indicated she had no further information to provide. 2. On 1/22/26 at 2:29 p.m. and 1/23/26 at 10:12 a.m., Resident 74 was observed in bed. He had oxygen via nasal cannula at 2.5 liters per minute. Resident 74's record was reviewed on 1/27/26 at 1:19 p.m. Diagnoses included, but were not limited to, neurocognitive disorder with Lewy Bodies, schizophrenia, and chronic obstructive pulmonary disease. The admission Minimum Data Set (MDS) assessment, dated 1/21/26, indicated the resident was severely cognitively impaired and he received oxygen. The current January 2026 Physician Order Summary indicated oxygen at 3 liters per minute continuously via nasal cannula. A Care Plan, dated 1/16/26, indicated the resident had oxygen therapy related to ineffective gas exchange. Interventions included, but were not limited to, give medications as ordered by the physician, oxygen via nasal cannula at 3 liters per minute continuously with humidity as needed. During an interview on 1/27/26 at 3:15 p.m., the Director of Nursing indicated the family had been problematic with care and would change settings on the oxygen concentrator. She would provide the family with further education. 3.1-47(a)(6)

Based on record review and interview, the facility failed to ensure weights were being checked and monitored for a resident who received medications for heart failure and failed to ensure medication was not administered in an excessive dose for 1 of 5 residents reviewed for unnecessary medications and 1 of 1 resident reviewed for pain. (Residents 48 and 75)Findings include:1. Record review for Resident 48 was completed on 1/22/2 at 9:38 a.m. Diagnoses included, but were not limited to, insomnia, anemia, heart failure, end stage renal disease, and respiratory failure. The admission Minimum Data Set (MDS) assessment, dated 10/29/25, indicated the resident was moderately cognitively impaired. The resident received diuretic medication. A Care Plan, dated 10/29/25, indicated the resident had fluid overload or potential fluid volume overload related to chronic heart failure. Interventions included administer medications as ordered, observe and report sudden weight gain, and to weigh at the same time of day as ordered by the physician. The January 2026 Physician's Order Summary (POS) indicated the following orders:- Lasix (diuretic medication) 20 mg (milligrams), give 1 table every day related to heart failure- potassium chloride extended release (to lower potassium) 10 meq (milliequivalents), give 2 tablets every day related to heart failure- weights every Monday, Wednesday, and Friday related to heart failure. Call the physician for a greater than 3 pound weight gain. The January 2026 Medication Administration Record (MAR) indicated the weights were not recorded on the following dates:- 1/8, 1/12, 1/14, 1/16, 1/19, and 1/21/26. During an interview on 1/27/26 at 10:25 a.m., the Director of Nursing (DON) indicated the resident was under isolation during some of the missing dates. The staff should have checked the resident's weight but did not. 2. During an interview on 1/20/26 at 9:35 a.m., Resident 75 indicated that her pain was controlled as long as she received her scheduled pain medicine. Resident 75's record was reviewed on 01/21/2026 1:30 p.m. Diagnoses include, but were not limited to heart disease, fracture of left ischium, hypertension, osteoarthritis. The Physician's Order Summary, dated 1/2026, indicated the following pain medication order:- acetaminophen tablet 325 milligrams give 2 tablets by mouth every 4 hours for pain, not to exceed 3 grams in 24 hrs. The Medication Administration Record, dated 1/2026, indicated the resident received the scheduled pain medications six times on 1/16, 1/18, and 1/19/2026. The total dose of acetaminophen the resident received on those days was 3,900 milligrams (mg), which was greater than the 3 grams/3000 mg daily limit. On 1/20 and 1/21/2026, the resident received five doses of the scheduled pain medicine, which equalled 3,250 milligrams of acetaminophen and was greater than the 3gm/3000 mg daily limit. During an interview on 1/22/2026 at 9:58 a.m., LPN 1 indicated she would call the doctor to clarify order for pain medication. During interview on 1/22/2026 at 11:23 a.m., the Director of Nursing (DON) indicated she would review the pain medication order with the nurse and have her contact the doctor for clarification. 3.1-48(a)(1)3.1-48 (a)(3)

Based on observation and interview, the facility failed to ensure infection control practices were in place and implemented related to lack of glove changes and performing hand hygiene during wound care for 1 of 3 wound care treatments observed. (Resident 64) Finding includes:On 1/23/26 at 11:30 a.m., the Wound Nurse was observed performing dressing changes for Resident 64. The resident had a pressure ulcer to the medial side and lateral side of the left foot. The Wound Nurse washed her hands and then donned a gown and gloves. She removed the dressing to the lateral side of the foot. There was a small pressure area that she cleaned with saline and applied skin prep (provides protective film over skin). She then removed the old dressing to the medial foot, without changing gloves or performing hand hygiene. She cleansed the area with saline and applied skin prep. She removed her gloves and donned new gloves, without performing hand hygiene. She removed a dressing from the coccyx. There was a small open wound with slough observed. She washed the wound with saline, removed her gloves and donned new gloves. She did not perform hand hygiene before donning new gloves. She applied Santyl (debriding ointment) and covered the wound with a dry dressing. She removed her gown and gloves and performed hand hygiene. During an interview at the time, the Wound Nurse indicated she should have performed hand hygiene with each glove change, and she should have changed her gloves between the treatment of different wounds. 3.1-18(b)

Based on record review and interview, the facility failed to promote antibiotic stewardship by ensuring appropriate use of antibiotic therapy to reduce antibiotic resistance related to ordering an antibiotic for prophylactic (preventative) use in a resident with COPD (Chronic Obstructive Pulmonary Disease) for 1 of 1 resident reviewed for antibiotic use. (Resident 5)Finding includes:During interview on 1/20/26 at 2:46 p.m., Resident 5 indicated that he had been taking an antibiotic three times per week to keep his Chronic Obstructive Pulmonary Disease (COPD) from getting bad. Resident 5 record was reviewed on 1/23/2026 at 9:27 a.m. Diagnoses included, but were not limited to, Atherosclerotic Heart Disease, automatic implantable cardiac defibrillator, Chronic Obstructive Pulmonary Disease (COPD), peripheral vascular disease (PVD), hypertension, Diabetes Mellitus type 2, and paroxysmal atrial fibrillation. The Quarterly Minimum Data Set assessment, dated 12/24/25, indicated the resident was moderately cognitively impaired. The Physician's Order Summary, dated 1/2026, indicated Azithromycin Oral Tablet 250 mg (milligrams), give one tablet by mouth one time a day every Monday, Wednesday and Friday for COPD exacerbation prophylaxis. There was no documentation that the resident met criteria for a true infection for antibiotic use.During an interview on 1/27/26 at 3:50 p.m., the Infection Preventionist/Wound Nurse indicated it did not meet McGeer criteria for antibiotic use. The doctor had ordered the antibiotic because of the resident's history. She could not provide any documentation whether the medication use met criteria for a true infection or why the doctor had ordered the antibiotic.

Based on observation, record review, and interview, the facility failed to ensure infection control guidelines were in place and implemented, related to improper use of personal protective equipment (PPE) prior to entering and leaving a droplet precautions room and staff not knowing why a resident was in isolation for 1 of 3 residents reviewed for infection control. (Resident B) Finding includes:During a random observation on 12/4/25 at 10:01 a.m., the signage on the outside of Resident B's door indicated the resident was in enhanced barrier precautions (EBP) and droplet precautions. The wound nurse was observed inside Resident B's room providing care. She had a gown and gloves on but was not wearing a mask.During a wound observation with CNA 1 and the Wound Nurse on 12/4/25 at 10:19 a.m., both wore gowns and gloves but neither staff member wore a mask.During an interview at time, the Wound Nurse indicated Resident B was in contact isolation not droplet isolation, and she was unsure why that signage was on the door. She looked at the outside of the door and confirmed the droplet sign was up and the contact isolation sign was not.The record for Resident B was reviewed on 12/4/25 at 10:50 a.m. The diagnoses included, but were not limited to, neuromyelitis optica (inflammation of optic nerve and spinal cord), paraplegia, pressure ulcer, neuromuscular dysfunction, dysphagia (difficulty swallowing), and anemia (low iron).The Quarterly Minimum Data Set (MDS) Assessment, dated 11/18/25, indicated the resident was cognitively intact for daily decision making.A Physician's Order, dated 10/31/25, indicated EBP related to wounds and a Foley (urinary) catheter.A Physician's Order, dated 11/5/25 through 11/13/25, indicated to place the resident in contact and droplet precaution related to a Covid positive infection.A Care Plan, dated 11/21/25, indicated the resident had antibiotic use for prophylactic Clostridioides difficile (C.diff). Interventions indicated to place in contact isolation and clean all equipment before it leaves the room. During an interview on 12/4/25 at 11:52 a.m., CNA 1 indicated she had worked in the facility since February and she knew Resident B well. She did not question the sign because she knew the resident was out of isolation. She indicated the resident did have a roommate and she should have checked to ensure the resident was not recently placed in droplet isolation. She also indicated Resident B was never in droplet isolation before that she could recall and she primarily worked on the East unit where Resident B resided.During an interview on 12/4/25 at 1:55 p.m., the Executive Director indicated she understood the concern and had no additional information to provide.The facility policy titled Infection prevention and Control Program (IPCP) and Plan was provided on 12/3/25 at 2:51 p.m. by the Director of Nursing and identified as current. The policy indicated . ensure associates follow the IPCP's standards, policies and procedures (e.g., hand hygiene and appropriate use of PPE) .This citation relates to Intake 2675993.3.1-18(b)

Based on observation and interview, the facility failed to ensure the residents' environment was clean and in good repair related to dirty and discolored vents, exposed electrical wiring, and a broken baseboard heating cover for 3 of 3 units and the dining room. (East Hall, Center Hall, [NAME] Hall, and Dining Room) Findings include: During an Environmental Tour on 9/29/25 at 8:55 a.m., the following was observed: 1. East Halla. The ceiling vents were dirty and discolored throughout the hallway. 2. Center Hall a. The ceiling vents were dirty and discolored throughout the hallway.b. There was exposed electrical wiring in the hallway across from room [ROOM NUMBER].c. There were exposed electrical wiring hanging from a ceiling tile in the center hallway. 3. [NAME] Halla. The ceiling vents were dirty and discolored throughout the hallway. 4. Dining Room a. The vents in the dining room were dirty and discolored.b. The baseboard heating unit cover was not attached. During an interview on 9/29/25 at 9:49 a.m., the Maintenance Director indicated he was aware of the exposed wiring. The covers had been knocked off somehow about a week ago and he had not replaced the covers yet. He had told housekeeping to dust the vents throughout the facility and was in the process of replacing the vents in the kitchen at the time. The rest of the vents throughout the facility were in need of power washing or replacing. This citation relates to Intake 2595565. 3.1-19(f)

Based on record review and interview, the facility failed to maintain clinical records that were complete and accurately documented, related to incontinence care documentation for 3 of 3 residents reviewed for activities of daily living (ADL) care. (Residents B, C, and D) Findings include:1. Resident B's record was reviewed on 9/29/25 at 10:09 a.m. Diagnoses included, but were not limited to, high blood pressure, adult failure to thrive, and mild cognitive impairment. The admission Minimum Data Set (MDS) assessment, dated 8/11/25, indicated the resident was cognitively intact, required substantial to maximal assistance with toileting, bed mobility, and was dependent for transfers. The resident was frequently incontinent of bowel and bladder. A Care Plan, dated 8/18/25, indicated the resident had urinary incontinence. Interventions included, but were not limited to, assist with toileting and pericare as needed. The CNA (Certified Nursing Assistant) Task, B&B - Bowel and Bladder Elimination, indicated CNAs were to document at least every shift (3 times a day) incontinence care provided. Documentation included whether the resident was incontinent or continent of bowel and bladder. The task was reviewed for the previous 30 days and indicated there was no documentation of incontinence care provided during the following shifts: - Day shift: 9/5, 9/6, 9/9, 9/13, 9/14, 9/24, 9/25, and 9/26/25- Night shift: 9/6, 9/10, 9/13, 9/18, 9/20, 9/21, 9/23, 9/24, and 9/25/25During an interview on 9/29/25 at 2:45 p.m., the Regional Nurse Consultant indicated the CNAs were supposed to chart incontinence care at least three times a day on the CNA Tasks. She had no further information to provide.2. Resident C's record was reviewed on 9/29/25 at 10:38 a.m. Diagnoses included, but were not limited to, paranoid personality disorder, bipolar disorder, and hemiplegia (paralysis) affecting the right dominant side. The admission Minimum Data Set (MDS) assessment, dated 8/18/25, indicated the resident was moderately cognitively impaired, was dependent on staff for toileting hygiene, and was occasionally incontinent of bowel and bladder. A Care Plan, dated 9/16/24, indicated the resident had a self-care deficit in performing daily care tasks. Interventions included, but were not limited to, resident required assist with transfers and toileting. The CNA (Certified Nursing Assistant) Task, B&B - Bowel and Bladder Elimination, indicated CNAs were to document at least every shift (3 times a day) incontinence care provided. Documentation included whether the resident was incontinent or continent of bowel and bladder. The task was reviewed for the previous 30 days and indicated there was no documentation of incontinence care provided during the following shifts: - Day shift: 9/4, 9/6, 9/9, 9/24, and 9/26/25- Evening shift: 9/8- Night shift: 9/6, 9/7, 9/10, 9/24, and 9/25/25During an interview on 9/29/25 at 2:45 p.m., the Regional Nurse Consultant indicated the CNAs were supposed to chart incontinence care at least three times a day on the CNA Tasks. She had no further information to provide.3. Resident D's record was reviewed on 9/29/25 at 11:09 a.m. Diagnoses included, but were not limited to, alcohol-induced persisting dementia and cognitive communication deficit. The Quarterly Minimum Data Set (MDS) assessment, dated 8/27/25, indicated the resident was severely cognitively impaired, required substantial to maximal assistance for toileting hygiene, and was frequently incontinent of bowel and bladder. A Care Plan, dated 1/19/24, indicated the resident had occasional urinary incontinence. Interventions included, but were not limited to, assist with toileting and pericare as needed.The CNA (Certified Nursing Assistant) Task, B&B - Bowel and Bladder Elimination, indicated CNAs were to document at least every shift (3 times a day) incontinence care provided. Documentation included whether the resident was incontinent or continent of bowel and bladder. The task was reviewed for the previous 30 days and indicated there was no documentation of incontinence care provided during the following shifts: - Day shift: 9/1, 9/4, 9/8, 9/10, 9/13, and 9/14/25- Evening shift: 9/10, 9/12, 9/16, 9/20, 9/21, 9/24, and 9/25/25- Night shift: 9/3, 9/4, 9/10, 9/12, 9/13, 9/14, 9/15, 9/16, 9/19, 9/20, 9/23, and 9/27/25 During an interview on 9/29/25 at 2:45 p.m., the Regional Nurse Consultant indicated the CNAs were supposed to chart incontinence care at least three times a day on the CNA Tasks. She had no further information to provide.A facility policy titled, Critical Notes, received on 9/29/25 at 2:55 p.m. and noted as current from the Regional Nurse Consultant, indicated, Incontinence management, urinary, long-term care.perform hand hygiene, put on gloves and other personal protective equipment.clean the perineal area.remove personal protective equipment, perform hand hygiene, and document the procedure.This citation relates to Intake 2595565.3.1-50(a)(2)

Based on observation and interview, the facility failed to ensure resident's privacy was maintained related to the electronic medication record left open and unlocked in the hallway during medication pass for 2 of 5 residents observed during medication pass. (Residents 113 and 6) Finding includes: On 11/8/24 at 8:15 a.m., LPN 1 was observed passing medications to Resident 113. She prepared the medications in the hallway on the East Hall cart using the electronic medication record on the computer. She then took the medications to the resident in his room. The computer screen was left open and on, leaving the residents medications and personal information available to view. At 8:25 a.m., LPN 1 returned to the East Hall cart and prepared medications for Resident 6. She then took the medications to the resident in his room and again left the computer screen open and unlocked with personal information available to view in the hallway. During an interview on 11/8/24 at 8:37 a.m., LPN 1 indicated she should have locked the screen but didn't know how to unlock it. During an interview on 11/8/24 at 8:44 a.m., the Director of Nursing indicated that computer screens should be locked when the nurse walked away and she would speak to the nurse. 3.1-3(p)(2)

Based on record review and interview, the facility failed to ensure care plans were implemented for 1 of 19 resident care plans reviewed. (Resident 9) Finding includes: Resident 9's record was reviewed on 11/8/24 at 10:20 a.m. Diagnoses included, but were not limited to, senile degeneration of the brain and dementia. The Quarterly Minimum Data Set (MDS) assessment, dated 10/14/24, indicated the resident was severely cognitively impaired for daily decision making. She required maximal to total dependence on staff for activities of daily living (ADL) care. She received antipsychotic, anti-anxiety, antidepressant, and opioid medications. She was on hospice care. The November 2024 Physician Order Summary indicated Resident 9 received morphine sulfate (opioid pain medication) 20 milligram/milliliter (mg/ml), 5 mg by mouth every two hours as needed. The resident was to be observed for opioid medication side effects every shift. There were no care plans related to pain and opioid use. During an interview on 11/12/24 at 3:50 p.m., the Director of Nursing indicated there were no care plans for pain and opioid use in the current care plan for the resident. 3.1-35(c)(1)

Based on observation, record review, and interview, the facility failed to ensure a resident with a pressure ulcer received the necessary treatment and services to promote healing related to a treatment not provided as ordered for 1 of 3 residents reviewed for pressure ulcers. (Resident 39) Finding includes: On 11/8/24 at 10:40 a.m., wound care for Resident 39 was observed with the Infection Prevention (IP) Nurse. The resident had a stage 4 pressure ulcer to her sacrum. She was in bed and turned onto her right side. The nurse removed the old dressing and cleansed the wound with wound wash, patted the area dry and checked measurements. She then applied skin prep to the skin surrounding the wound and applied an antimicrobial gel to the wound bed. She then packed the wound with calcium alginate and covered the area with an island border dressing. The resident's record was reviewed on 11/7/24 at 3:31 p.m. Diagnoses included, but were not limited to, diabetes mellitus, adult failure to thrive, and a stage 4 pressure ulcer to sacral region. The Quarterly Minimum Data Set assessment, dated 8/1/24, indicated the resident had significant cognitive impairment, required substantial assistance for bed mobility, and had a stage 4 pressure ulcer present on admission. A Physician's Order, dated 7/18/24, indicated wound care to coccyx was to be provided three times weekly. Cleanse coccyx with wound wash and pat dry. Apply skin prep to periwound. Apply a thin layer of germ shield to the wound bed, apply one packet of collagen to wound bed, cover wound bed with silver alginate, and apply a small foam dressing. During an interview on 11/8/24 at 11:14 a.m., the IP Nurse indicated she had just reviewed the Physician Orders and she would redo the treatment for the resident. 3.1-40(a)(2)

Based on record review and interview, the facility failed to ensure residents received treatment and care in accordance with professional standards for 2 of 3 residents reviewed for quality of care, related to not obtaining a neurological consult for a cerebrospinal shunt assessment for a resident experiencing increased seizures and behaviors resulting in the resident being transferred to the hospital after a Grand Mal seizure and found to have a malfunctioning shunt in the brain a which then required emergency surgery and not following up timely on laboratory results which required changes in the resident's seizure medications. (Resident B) The facility also failed to monitor blood sugar levels and administer insulin as ordered by the Physician. (Resident D) Findings include: 1. Resident B's closed record was reviewed on 4/18/23 at 9:24 a.m. The diagnoses included, but were not limited to, cerebral palsy, epilepsy, and cerebrospinal fluid drainage device (shunt, used to drain excess fluid from the brain). The admitted into the facility was 12/7/21. An Annual Minimum Data Set (MDS) assessment, dated 12/13/22, indicated long and short term memory problems, no behaviors, dependent on staff for all activities of daily living, required a feeding tube, which supplied 51% or more of calories and over 501 cc's of fluids. a. A Care Plan, dated 3/29/22, indicated seizure precautions were required. The interventions included seizure medications would be administered as ordered, seizure activity would be reported to the Charge Nurse, Facility Management, and the Physician and would be followed up as indicated. The Nurses' Progress Notes indicated the following: There were behaviors of restlessness, hollering, biting at arms and hands on 2/16/23 at 1:41 a.m. and 2/16/23 at 10:47 a.m. On 2/17/23 at 2:42 p.m., the behaviors of scratching self, disconnecting the feeding tube, and sticking her fingers down her throat were present. On 2/18/23 at 6:41 a.m., the behaviors of restlessness, intermittent yelling out and biting of hands were present. The biting of the hands continued per the Nursing Progress Note on 2/18/23 at 1:50 p.m. On 2/20/23 at 4:32 a.m., high pitched noises and banging were heard in the resident's room. She was observed having a grand mal seizure and was immediately turned to the side. She had uncontrolled fluttering of the eyes and jerking movements of the body for 3 1/2 to 4 minutes. On 2/24/23 at 3:45 p.m., she was found having tonic/clonic seizures continually (Grand Mal) and the Emergency Management System (EMS) was notified for transfer to the emergency room . A Care Plan Conference was held with the Co-Guardian on 2/17/23. It was reported the resident was doing well. The Co-Guardian had asked that the functioning of the shunt be checked and was informed a Neurologist would need to be notified. There was no documentation that indicated the Primary Care Physician and/or a Neurologist was notified for the request of the shunt to checked for proper functioning. A Neurosurgeon's Surgery Note, dated 2/25/23, indicated the resident had shunt dependent hydrocephalus and had been having increased seizure activity with increased behaviors. The shunt was found disconnected to the shunt catheter and the brain imaging revealed enlarged ventricles. This had been considered a neurosurgical emergency and an emergent cerebral spinal fluid (CSF) diversion was indicated. There had been no CSF flow through the old catheter and the CSF was noted around the catheter. There had been a slight adherence of the catheter and once out, a large amount of CSF fluid flowed out of the catheter tract. The final diagnosis indicated a longstanding VP (ventriculoperitoneal) shunt with VP shunt malfunction. A Hospital Discharge Summary, dated 2/26/23, indicated a CT scan of the head showed asymmetry of the lateral ventricle and a shuntogram series showed the shunt drain was disconnected. Emergency surgery was completed by the Neurosurgeon and the resident developed intraventricular hemorrhage and an external ventricular drain that assisted with the drainage was placed. She was intubated and transferred to the Intensive Care Unit (ICU). The CT of the head indicated intraventricular hemorrhage post revision of the ventriculostomy drainage system. She was transferred to a Neurology ICU at another hospital. During an interview on 4/18/23 at 11:45 a.m., the Director of Nursing (DON) indicated the Primary Care Physician and/or Neurologist had not been notified as requested for the status of the shunt to be checked. b. The Physician ordered Tegretol and Lamictal (antiseizure medications) levels and a comprehensive metabolic panel laboratory test on 2/20/23 at 6:11 a.m. for Resident B due to an increase in seizure activity. A Nurse's Progress Note, dated 2/21/23 at 2:03 p.m., indicated the results of the laboratory tests ordered were still pending. A Nurse's Progress Note, dated 2/22/23 at 7:39 a.m., indicated the results of the laboratory test was communicated to the Physician. The Lamictal level was low at 3 (normal 3-15), the sodium level was high at 152 (normal 138-147), carbon dioxide high at 33 (20-30), glucose 118 (70-110), BUN (kidney function) 22 (5-20), and SGOT (liver function) AST 42 (9-35). The facility was waiting on a response from the Physician. There was no documentation that indicated the Physician responded or follow up with the Physician was completed in response to the abnormal laboratory test results. Documentation on the bottom of the laboratory results, dated 2/23/22 (sic -2023), indicated orders were received and noted. A Physician's Order to increase the Lamictal from 100 milligrams twice a day to 150 milligrams twice a day was written at 2 p.m. on 2/23/23. The Nurse's Progress Notes, dated On 2/24/23 at 3:45 p.m., indicated a Grand Mal seizure and she was transferred to the hospital emergency room by EMS. During an interview on 4/18/23 at 1:46 p.m., the DON indicated the results of the laboratory tests arrived at the facility on 2/22/23 at 7:39 a.m. and the Physician was made aware of the results by fax. The orders were texted to her on 2/23/23 at 8:31 a.m. The Physician indicated he had sent the orders to the facility per fax on 2/22/23. There were no orders documented on 2/22/23. There was a delay in starting the increased dosage of Lamictal. 2. Resident D's record was reviewed on 4/18/23 at 2:17 p.m. The diagnoses included, but were not limited to, anoxic brain damage, tube feeding, and diabetes mellitus. The admitted was 1/31/23. An Admission MDS assessment, indicated the cognition status was not able to be assessed, was dependent on staff for all activities of daily living, required a feeding tube, which supplied 51% or more of calories and over 501 cc's of fluids. The Care Plans, dated 1/31/23, indicated a feeding tube was present and was unable to consume food by mouth (NPO). The intervention indicated the feeding was going to be provided as ordered by the Physician. The resident had diabetes mellitus and blood sugars would be completed and medication administered per Physician's Orders. An Admission Nurse's Progress Note, dated 1/31/23 at 6:33 p.m., indicated the resident had arrived at the facility, was NPO and had a feeding tube in place for nutrition. There was no documentation the Physician had been notified for admission and/or clarification of admission orders. The Admission Physician's Orders for Resident D, dated 1/31/23, indicated Lispro insulin was to be administered 0-12 units every 6 hours for high blood sugars. The Hospital Medication Record, dated 1/25/23 through 1/31/23, indicated a sliding scale (amount given based on blood sugar level) of Lispro insulin to be given every 6 hours after the blood sugar was completed. The Physician's Order was transcribed on 1/31/23 as Lispro Insulin per sliding scale with amounts per blood sugar level to be given every 6 hours as needed, not on a schedule, for diabetes. The MAR's, dated 1/2023 and 2/2023, indicated the blood sugars and Lispro were to be completed as needed (prn) every 6 hours. There was no blood sugar level check completed from admission on 1/31/23 until the time of transfer to the emergency roiagnom on [DATE]. A Physician's Progress Note, dated 2/1/23 at 7:39 a.m., indicated an insulin sliding scale was used and no blood sugar level had been obtained yet. A Nurse's Progress Note, dated 2/3/23 at 1:36 a.m., indicated a diagnosis of hyperglycemia and an insulin sliding scale was used after a glucose check every 6 hours. The resident was receiving prednisone, which might have contributed to the hyperglycemia. The DON indicated on 4/18/23 at 3:08 p.m., all admission orders should have been clarified with the Physician and she was unable to find documentation the orders were clarified. At 3:42 p.m., she indicated there were no blood sugar levels obtained until 2/4/23 prior to being transferred to the emergency room . During an interview on 4/21/23 at 8:33 a.m., the DON indicated she had spoken with LPN 1 (Admission Nurse). LPN 1 could not remember everything, but remembered she had faxed the orders to the Physician. She had not called the Physician. She had reported to the oncoming nurse the orders needed to be clarified. A signed and undated statement from LPN 1 indicated the medications were entered into the computer and another nurse reviewed the orders. The discharge medication list was sent to the Physician's office for review and she reported to the oncoming nurse to clarify the orders given from the hospital. During an interview on 4/21/23 at 8:51 a.m., LPN 2 (oncoming nurse) indicated she had not spoken to the Physician and everything had been completed on the admission already when she came in to work. She was informed the water flush order needed to be clarified. She had not clarified the water flush and had passed it on to the day shift nurse to clarify. During an interview with LPN 1 on 4/21/23 at 10:59 a.m., she indicated she had faxed the orders to the Physician's Office for clarification. The Physician was not in the office in the evening and she would normally call the Physician, but knew he was going to be in the building the next morning and could clarify the orders then. She informed the Night Shift Nurse the orders needed to be clarified. The prn sliding scale for the insulin was written from the admission paperwork. Every order written was from the hospital paperwork. It was difficult to remember everything, however, due to the amount of time that had passed. This Federal tag relates to Complaint IN00406256. 3.1-37(a)

Based on record review and interview, the facility failed to provide sufficient fluid intake to maintain proper hydration and health related to lack of timely follow up on laboratory results which required changes in the feeding tube water flushes and failure to clarify and implement correct Physician's admission orders which contributed to the residents being admitted /readmitted into the hospital with severe dehydration for 2 of 3 residents reviewed for quality of care. (Residents B & D) Findings include: 1. Resident B's closed record was reviewed on 4/18/23 at 9:24 a.m. The diagnoses included, but were not limited to, cerebral palsy, epilepsy, and cerebrospinal fluid drainage device (shunt, used to drain excess fluid from the brain). The admitted into the facility was 12/7/21. An Annual Minimum Data Set (MDS) assessment, dated 12/13/22, indicated long and short term memory problems, no behaviors, dependent on staff for all activities of daily living, required a feeding tube, which supplied 51% or more of calories and over 501 cc's of fluids. The Physician ordered Tegretol and Lamictal (antiseizure medications) levels and a comprehensive metabolic panel laboratory test on 2/20/23 at 6:11 a.m. due to an increase in seizure activity. A Nurse's Progress Note, dated 2/21/23 at 2:03 p.m., indicated the results of the laboratory tests ordered were still pending. A Nurse's Progress Note, dated 2/22/23 at 7:39 a.m., indicated the results of the laboratory test was communicated to the Physician. The sodium level was high at 152 (normal 138-147), carbon dioxide high at 33 (20-30), glucose 118 (70-110), BUN (kidney function) 22 (5-20), and SGOT (liver function) AST 42 (9-35). The facility was waiting on a response from the Physician. There was no documentation that indicated the Physician responded or follow up with the Physician was completed in response to the laboratory test results. Documentation on the bottom of the laboratory results, dated 2/23/22 (sic -2023), indicated orders were received and noted. A Physician's Order, dated 2/23/23, indicated the water flushes for the feeding tube were to be increased from 244 cubic centimeters (cc's) every 4 hours to 300 cc's every 4 hours. The Nurse's Progress Notes, dated 2/24/23 at 3:45 p.m., indicated a Grand Mal seizure and she was transferred to the hospital emergency room by EMS. The emergency room Physician Notes, dated 2/24/23 at 6:15 p.m., indicated a critical sodium level at 171 and a high BUN of 64. She had a seizure in the emergency room . The diagnoses included, sepsis likely due to a urinary tract infection and possible left lower lobe pneumonia, seizure disorder, and severe hypernatremia likely due to severe dehydration. During an interview on 4/18/23 at 1:46 p.m., the DON indicated the results of the laboratory tests arrived at the facility on 2/22/23 at 7:39 a.m. and the Physician was made aware of the results by fax. The orders were texted to her on 2/23/23 at 8:31 a.m. The Physician indicated he had sent the orders to the facility per fax on 2/22/23. There were no orders documented on 2/22/23. There was a delay in starting the increased dosage of Lamictal and the increase in the water flush. 2. Resident D's record was reviewed on 4/18/23 at 2:17 p.m. The diagnoses included, but were not limited to, anoxic brain damage, tube feeding, and diabetes mellitus. The admitted was 1/31/23. An Admission MDS assessment, indicated the cognition status was not able to be assessed, was dependent on staff for all activities of daily living, required a feeding tube, which supplied 51% or more of calories and over 501 cc's of fluids. The Care Plans, dated 1/31/23, indicated a feeding tube was present and was unable to consume food by mouth (NPO). The intervention indicated the feeding was going to be provided as ordered by the Physician. The resident had diabetes mellitus and blood sugars would be completed and medication administered per Physician's Orders. An Admission Nurse's Progress Note, dated 1/31/23 at 6:33 p.m., indicated the resident had arrived at the facility, was NPO and had a feeding tube in place for nutrition. There was no documentation the Physician had been notified for admission and/or clarification of admission orders. A Hospital Dietary Order, dated 1/14/23, indicated a NPO diet with tube feeding of Glucerna 1.5 continuous at 47 cc's per hour with a water flush of 30 cc's every 6 hours. The current feeding amount met the caloric and protein needs of the patient. The free water flush was to be increased to 175 cc's every 6 hours to better meet the patient's fluid needs. The After Visit Summary Physician's Orders (Admission Orders), dated 1/31/23, indicated diet instructions of Glucerna at 47 cc's per hour with a water flush of 175 cc's every 6 hours. The order did not indicate Glucerna 1.5 was to be administered. The Facility Physician's Orders, indicated an order on 1/31/23 for 230 cc's of water to be provided every hour per feeding pump. The Medication Administration Record (MAR), dated 1/2023, indicated this was transcribed on 1/31/23 at 3:34 p.m. then it was discontinued at 8:35 p.m. The times the order was scheduled for were 5 a.m., 8 a.m., 12 p.m., 3 p.m., 7 p.m., 10 p.m. and was documented as completed at 7 p.m. Other Physician's Orders, dated 1/31/23, indicated 30 cc's of water was to be provided per the feeding pump every hour and another order indicated Glucerna 1.5 at 47 cc/hour per pump with a flush with 30 cc's water every 6 hours. The MAR's dated 1/2023 and 2/2023, indicated both orders were being followed. There was no documentation of the amount of fluid intake per shift to determine how much fluids were being administered. A Nurse's Progress Note, dated 2/1/23 at 7:23 a.m., indicated the Physician visited the resident. There was no documentation of a clarification of the feeding type and water flush per the feeding tube. The Interdisciplinary Team (IDT) Notes, dated 2/1/23 at 11:09 a.m., indicated she received Glucerna 1.5 at 47 cc's and hour with scheduled water flushes. There was no clarification of the amount of water flushes she received or the type of feeding she was to receive. A Nurse's Progress Note, dated 2/3/23 at 1:36 a.m., indicated Glucerna 1.5 was being administered at 47 cc's per hour with a 30 cc's of water flush every 6 hours. A Nurse's Progress Note, dated 2/4/23 at 11:10 a.m., indicated around 10:30 a.m. she was diaphoretic and hyperpneic (fast breathing), blood pressure 74/46, pulse 110, blood sugar 203. The lung sounds were congested in the bilateral upper fields. The nebulizer treatment per Physician Orders was administered. The Physician was notified and the resident was transferred to the emergency room . The emergency room Physician's Notes, dated 2/4/23, indicated the differential diagnosis included dehydration and electrolyte imbalance. Sodium was elevated at 162 with a potassium of 6.3 and the BUN was 33. The white blood cells were high at 21.5. The impression and plan indicated the diagnoses of hypoxia, sepsis, and pneumonia. During an interview on 4/18/23 at 3:27 p.m., the DON indicated the water flush was 30 cc's every 6 hours and the Hospital Dietician had recommended to increase the water to 175 cc/hour. She indicated the dietary orders on the admission indicated Glucerna not Glucerna 1.5. During an interview on 4/21/23 at 8:51 a.m., LPN 2 (night shift nurse) indicated she had not spoken to the Physician and everything had been completed on the admission when she came in to work. She was informed the water flush order needed clarified. She had not clarified the water flush and had passed it on to the day shift nurse to clarify. During an interview with LPN 1 on 4/21/23 at 10:59 a.m., she indicated she had faxed the orders to the Physician's Office for clarification. The Physician was not in the office in the evening and she would normally call the Physician, but knew he was going to be in the building the next morning and could clarify the orders then. She informed the Night Shift Nurse the orders needed to be clarified. She indicated she had seen the water flush for the feeding tube to be 30 cc's every 6 hours on the paperwork. She had not seen the order for 175 cc's of water flush every 6 hours. Every order written was from the hospital paperwork. It was difficult to remember everything, however, due to the amount of time that had passed. This Federal tag relates to Complaint IN00406256. 3.1-46

Based on record review and interview, the facility failed to ensure a resident received adequate assistance to prevent accidents, related to a resident who was dependent on two staff members for transfers being transferred by one staff member. The resident fell from a mechanical lift, which resulted in fractures of the left leg and pain for 1 of 3 residents reviewed for accidents. (Resident B) Finding includes: Record review for Resident B was completed on 12/28/21 at 9:54 a.m. Diagnoses included, but were not limited to, [CONDITION(S)], anxiety, [CONDITION(S)], and muscle weakness. The resident was admitted to the facility on [DATE]. The Admission Minimum Data Set (MDS) assessment, dated 9/22/21, indicated the resident was cognitively impaired. The resident required an extensive 2+ person assist for transfers and toilet use. A Progress Note, dated 11/13/21 at 6:29 p.m., indicated at approximately 1:51 p.m., CNA 1 called the nurse into Resident B's room. The resident was sitting on the floor in front of her wheelchair next to the Sabina lift (sit to stand mechanical lift). The CNA indicated the resident had slipped out of the harness and slid down to the floor. A full body assessment was completed with 3 scratches noted to her back and the resident was moaning and wincing in pain when her hips were assessed. The Nurse Practitioner was updated and ordered to obtain an x-ray of the pelvis and both hip joints and to give a one time dose of [MEDICATION(S)] (narcotic pain medication) for pain. A Physician's Note, dated 11/13/21 at 7:43 p.m., indicated the x-rays showed no definitive fracture. The physician ordered another dose of [MEDICATION(S)] for nighttime and to have a CT (computerized tomography) (series of x-rays images that provide more detailed information than plain x-rays) in the morning if the pain was not better or worsened. A Physician's Note, dated 11/14/21 at 10:53 p.m., indicated the resident had a fall the day before. X-rays of bilateral hips and pelvis did not demonstrate definitive fracture, however it was not unusual for a fracture to not show up on initial radiographs. Given progression of pain they wound send the resident to the ER for a CT scan to rule out acute fracture. A Progress Note, dated 11/14/21, indicated the hospital was called for an update on the resident. The resident had been admitted with a fracture to the left femur (thigh bone) and compression fracture of the medial tibial plateau (shin bone that connects with the thigh bone). An Indiana Department of Health Reportable Incident was completed on 11/14/21. The report indicated that on 11/13/21 at 2:01 p.m., the resident had a fall during a Sabina lift transfer. An investigation was initiated. The resident had a left femur fracture and a compression fracture to the medial tibial plateau. The follow up to the investigation on 11/19/21, indicated CNA 1 did not follow policy for mechanical lift transfers. All nursing staff had been in-serviced and completed mechanical lift education and competencies. Managerial staff would observe 3-5 transfers requiring a mechanical lift and any issues would have been addressed immediately. Mechanical lift skills validations were reviewed and completed by all nursing staff after the incident. There was no record the facility had completed ongoing audits to ensure the staff were performing mechanical lifts appropriately after the skills validations in-service. A Witness Statement Form, dated 11/13/21, was completed by LPN 1. She indicated the CNA called her into Resident B's room. The resident was sitting on her buttock in front of her wheelchair. The Sabina lift was in front of the resident. The CNA indicated that when she was attempting to stand the resident up with the Sabina lift, the resident slid down to the floor. The Sabina lift was still in the raised position. The LPN reminded the CNA that a mechanical lift must always be used with two staff members. The CNA indicated that she was aware of the rules, but that she could not find another staff member at the time. The LPN told the CNA that she would need to wait to transfer until another staff member was available. The CNA indicated she did not have time to wait. A Root Cause Analysis Form: Falls, dated 11/13/21, indicated: Problem: resident slipped out of Sabina belt while CNA was changing her. Landed on floor, sitting in front of her wheelchair. Scratch noted on back. Environment: -Expected: Sabina lift 2 staff members, Sabina belt properly around resident waist, legs on Sabina spread. -Actual: Sabina lift 1 staff member, Sabina belt not properly placed around her waist and secured to the Sabina, legs on Sabina spread Process: -Expected: Sabina belt properly placed on residents and properly secured on Sabina. 2 CNAs stand her up, change her brief and place her back in the wheelchair. -Actual: Sabina belt was not properly placed around resident and secured to the Sabina. 1 CNA raised her up and she slid to the floor. Nurse called to room, checked resident and they put her in her wheelchair. Differences observed: -there was only 1 CNA in the room. The belt was not properly attached to the resident and Sabina lift. Resident was lifted up and the resident slid to the floor. Actions agreed: -CNA did not properly place the belt on the resident and attach to the Sabina. CNA proceeded to attempt to lift the resident alone which is against policy. CNA is suspended until until she completes lift competency again. A Body Mechanics/Transfer Training Demonstration Checklist, dated 10/26/21, was signed by CNA 1 and a section was marked yes that she felt she needed further instruction in transfers/body mechanics. The checklist include mechanical lift transfers. The CNA had completed the training demonstration during orientation. The CNA started working on 11/1/21 and completed 5 days training with other CNAs before starting to complete care on her own with residents on 11/10/21. During the 5 days of training, the facility could not find documentation the CNA was checked off on transfer training since the demonstration checklist on 10/26/21. A Corrective Action Form, signed by CNA 1, Director of Nursing (DON), and Administrator, on 11/19/21, indicated: -Current incident description and supporting details: The nursing assistant placed a resident into a Sabina lift and attempted to stand the resident up so she could change her brief. The resident was stood up and slid to the floor of her wheelchair. The nurse was called to examine the resident and to assist with helping her back to her chair. A scratch was noted on her back. Resident assessed for pain- did not appear to be in pain. The resident's representative, physician and DON was notified. The resident continued to have pain and was sent to the hospital for a CT scan which revealed that the resident had fractures. -Supervisor comments: explained to associate that policy must be followed. If there was not a CNA immediately available go and get the nurse, she/he had been trained in lifts. It was the staffs job to keep the residents safe. -Associate comments: On 11/13/21 when she took care of the resident she had taken over for another staff member. There was [sic] no CNA's available to help. She proceeded to do the job herself. After the accident she reported to the nurse on duty. Interview with the Administrator and DON on 12/28/21 at 10:15 a.m., indicated the CNA should not have attempted to transfer the resident with the mechanical lift on her own and it was against facility policy. They had completed mechanical lift in-service and skills validation checklist with all nursing staff after the incident. They did not document any ongoing audits after the incident to ensure staff were performing safe mechanical lift transfers. Interview with the Health Information Manager (HIM), who was also the CNA preceptor, on 12/28/21 at 10:29 a.m., indicated she had completed a skills validation checklist with all nursing staff related to mechanical lifts after the incident. She indicated she was out on the floor every day to assist staff if they needed it, but did not document any ongoing audits that staff were being observed after the incident to make sure they were safely and appropriately using the mechanical lifts. A follow up interview with the HIM indicated the CNA had mechanical lift training during orientation on 10/26/21. She started working on the floor training with other CNAs for 5 days on 11/1/21-11/5/21. She would have completed more mechanical lift training during that time. She could not provide any skills validation checklist that had been completed with mechanical lift transfers since the CNA was in orientation on 10/26/21 and had signed that she needed further instruction in transfers/body mechanics before the incident on 11/13/21. Interview with CNA 2 on 12/28/21 at 11:19 a.m., indicated she had worked on the day of the incident. CNA 1 did not ask her for assistance in transferring Resident B. She had asked CNA 1 why she did not ask for help and CNA 1 replied, she didn't want to bother the other CNAs working to come help her with the lift. She further indicated she had trained CNA 1 prior to the incident and told her that she always had to transfer the residents who required mechanical lifts with 2 staff members. CNA 1 did not tell her that she needed more training with mechanical lifts. A facility policy titled, Mechanical Lifts and received as current from the Administrator on 12/28/21, indicated, .The use of mechanical lifts requires a minimum of two associates This deficient practice was corrected by 11/20/21 after the facility implemented a systemic plan that included the following actions: Assessment of all residents for assistance needed with transfers, audit and update of care sheets for residents, corrective action for CNA involved in transfer, and in-servicing education to staff related to providing proper transfer of a resident including a skills check off and the observations of staff participating in transfers. This Federal tag relates to Complaint IN 165. 3.1-45(a)(2)

Based on record review, observation, and interview, the facility failed to provide adequate supervision while toileting a resident resulting in the resident falling and obtaining a hip fracture for 1 of 1 residents reviewed for falls. (Resident #31) Finding includes: Resident #31's record was reviewed on 12/8/15 at 1:30 PM. [DIAGNOSES REDACTED]. A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #31 was cognitively intact and required an extensive one person physical assist for transfers and toileting. Review of Progress Notes indicated the following: - 10/31/15 11:40 AM: Writer (LPN #2) was informed by nurse (LPN #1) while I was on break my resident had fallen . 10:50 AM ambulance called for transfer for resident to emergency room to eval (evaluate) and treat - 11/5/15 6:47 PM: Resident arrived to east wing . post left hip fx. (fracture) . Left hip dressing dry and intact . per Dr (Surgeon's name) resident is to follow up with him in his office in a week for dressing change and removal of staples. Do not remove dressing Review of care plans indicated Resident #31 was at risk for injuries from falls related to CVA with [DIAGNOSES REDACTED], neuropathy (numbness and/or weakness of the extremities), diuretic use, and may try to transfer self and must have staff assist. A State reportable dated 11/1/15 and facility investigation for Resident #31 was reviewed on 12/8/15 at 12:00 p.m. The reportable indicated the following: Incident date: 10/31/15; Incident time: 9:35 AM Diagnosis: [REDACTED]. Brief Description of Incident: (Resident #31) who is alert x 3 and an assist of 1 was being assisted in his bathroom by CNA. (Resident #31) was standing and holding onto the grab bar and states his knees gave out and he fell . The CNA was right there and witnessed the event. The facility was notified by ER that x-ray revealed a fractured left hip and resident was being admitted for treatment. Type of Injury: left hip fracture Immediate Action Taken: The attending CNA immediately got assistance from the nurse. The first responder nurse assessed (Resident #31) in the bathroom and then with the help of other CNAs assisted (Resident #31) into bed for further assessment. (Resident #31) had no immediate complaints. When the regular hall nurse returned from break she too assessed (Resident #31) and he complained of left hip pain. Dr was notified and order to send to ER for evaluation was received. (Resident #31) is his own responsible party and has no immediately family to notify. Preventative Measures Taken: Will evaluate upon (Resident #31's) return from hospital. CNA who was with (Resident #31) at the time of fall was educated to use a gait belt and due to being a new CNA was also educated on transfers by the ADON and the restorative CNA. Follow up: 11/4/15 Resident still remains in the hospital The facility investigation completed by the former Director of Nursing (DON) included statements from CNA #1, LPN #1 who originally assessed the resident, and LPN #2 who was the regular hall nurse. The written statement dated 10/31/15 from CNA #1 regarding Resident #31's fall indicated, I, a new CNA, was instructed to get the resident for a shower. Upon entering the resident's room, the resident informed me that he had to use the restroom very badly. Because he stated that he had to go right away, I helped him myself instead of calling for help. Everything went fine until the resident had to be wiped. The resident bad taken a large BM (bowel movement) which required extensive wiping to clean so that he would not get a rash. The brief he was wearing had gotten soiled in the process; so I turned to get another brief. The resident fell in this moment, I immediately ran to get help to lift him back up. He fell on his elbow and left hip. The written statement regarding Resident #31's fall from LPN #2 indicated, Writer asked (Resident #31) what had happened. Resident that's alert & oriented x 3 with clear speech stated 'I was on the toilet, had bowel movement, stood up with assist of CNA, holding bar in bathroom being cleaned when my knees got weak. Next thing I know I'm falling. I landed on my left side. That hurts . The typed root cause analysis of Resident #31's fall completed by the former DON indicated the following: Problem: (Resident #31) fell in bathroom while being toileted and fractured left hip. (Resident #31) has DX (diagnoses) of CVA with left [DIAGNOSES REDACTED]. Why: He had an extra-large bowel movement that needed more time to be cleaned up by CNA. Why: new CNA was slower than normal CNA's in cleaning him up and got BM on his new brief and had to get another one from the room. Why: Extra briefs are kept in the closet in the rooms due to no cabinet space in bathroom Why: He was standing holding onto the grab bar to {sic} long while she cleaned him up and got a new brief Why: (Resident #31) states his knees gave out and he fell . CNA went to the resident room to assist him to the shower room and (Resident #31) stated he had to use the bathroom immediately. She did not want him to have an accident and therefore assisted him into his bathroom to use the toilet. (Resident #31) is a one assist and she transferred him onto the toilet. When he was finished she assisted him to a standing position to clean him up after his extra-large bowel movement. (Resident #31) was standing and holding onto the grab bar directly in front of him with his right hand. She was taking her time and cleaning him thoroughly when BM got on his new brief. She stepped out of the bathroom to obtain a new brief from his closet and it was during that time that (Resident #31's) knees gave out and he fell . CNA was educated by ADON who set up an in-service with the Restorative Aide and she was trained on use of gait belt, transfers 1 assist - where to stand, how to lift, how to work with people with [DIAGNOSES REDACTED] and then also re-trained on lifts both Sabina and hoyer. She had previously been through lift training during orientation. CNA stated that this training help {sic} her immensely and she now feels more comfortable. A termination form for CNA #1 provided by the Administrator by her own request on 12/8/15 at 2:45 PM, indicated CNA #1 was terminated by the facility on 11/18/15. The form indicated, Employee still in her 90 day probation period. Employee has been educated and orientation has been extended. Employee still unable to keep up with the work load as a CNA. Her performance at this time is not what the Willows feels is safe for the residents or the employee at this time. Consequence to the facility: Potential safety issues and state tags, resident care issues, employee safety. Reason for termination: Unable to perform CNA duties in a skilled facility at this time safely for the residents or the employee On 12/8/15 at 2:18 PM, the DON provided a copy of Life Care Centers of America, Restorative Nursing Guidelines Manual, Chapter Two, Body Mechanics and Transfers as the facility's guidelines for proper resident transfers by staff and deemed the document as current. The document stated, F. Sit to Stand to Chair . 2. Place the gait belt around the resident Resident #31 was observed on 12/8/15 at 12:40 PM wheeling himself down the hallway in his wheelchair. His left hand was secured on a platform and his left foot had on a padded boot. He was interviewed at that time regarding his fall on 10/31/15. He indicated he had been standing in the bathroom holding onto the grab bar across from the toilet with his right hand while the CNA helped clean him up when she said she'd be right back and left him standing there for awhile. He further indicated his knees got weak from standing so long, he called out for help, and then he fell , breaking his left hip. Resident #31 also indicated no one else had ever left him alone in the bathroom before and he had not been wearing a gait belt at the time. He indicated no one from the facility had come to talk to him specifically about what had happened during his fall since he returned from the hospital. Interview with the current DON on 12/8/15 at 12:51 PM, indicated she was the Assistant DON (ADON) at the time of the fall and CNA #1 no longer worked at the facility. She further indicated CNA #1 was partway through her first week of orientation on the floor and had received transfer training prior to being out on the floor. She further indicated CNA #1 had not used a gait belt for Resident #31 during the transfer, would have been given a gait belt to use during orientation, and should have used a gait belt for transferring a resident. CNA #1 was given an extended orientation after the incident and ended up leaving the facility before her probation period was completed. Interview with LPN #2 on 12/8/15 at 1:21 PM, indicated she was at lunch when Resident #31 fell on [DATE] and she came into the resident's room shortly after he had been placed back in bed. At the time, he complained about pain to his affected L (left) leg when he normally can't feel anything there. Resident #31 indicated to her he had just had a BM, CNA #1 was helping him while he was hanging on to the bar across from the toilet when his knees just gave out and he fell . He didn't say anything to her about CNA #1 leaving him alone in the bathroom at that time. She immediately called the Physician and sent the resident to the ER for evaluation. After he was taken to the hospital, she asked CNA #1 and nurse responder LPN #1, to write up statements. She further indicated briefs for him were usually kept right on the sink since he uses them frequently and resident supplies were restocked in the rooms at the beginning of every shift. Phone interview with the former DON on 12/8/15 at 1:47 PM, indicated she conducted the investigation for Resident #31's fall on 10/31/15. She indicated after his return from the hospital, she welcomed him back, asked if he had any concerns, and the resident said no. She indicated she did not specifically ask what happened to cause his fall, since it was on the written statement of LPN #2. She further indicated she had talked directly to CNA #1, who reported that she had only gone to the closet area in his room to get another brief and that's when the resident fell . CNA #1 indicated she had a gait belt with her at the time but did not use it. 3.1-45(a)(2)

Based on record review and interview, the facility failed to ensure a resident received supervision and assistance to prevent accidents, related to not transferring an extensive care resident correctly, leaving the resident, who was a fall risk, unattended in the bathroom, and transferring a resident off the floor after a fall without a nurse assessing the resident for 1 of 4 residents reviewed for falls. (Resident #64). The resident had increased complaints of pain and bruising of the left leg and was diagnosed with [REDACTED]. Findings include: Resident #64's record was reviewed on 12/16/13 at 1:55 p.m. The resident's [DIAGNOSES REDACTED]. The resident was admitted into the facility on [DATE] from another nursing facility and readmitted to the facility from an acute care facility on 09/19/13. The Admission Minimum Data Set Assessment, dated 8/7/13, indicated the resident required extensive assistance of 2 or more staff for transfers and toilet use, was not steady and was only stable with human assistance when moving from seated to standing and moving on and off toilet, and had no pain. Fall Risk Assessments, dated 07/31/13 and 09/14/13, indicated the resident was a high risk for falls with scores of 21 (10 or higher is at risk). The interventions indicated the resident had a low bed and alarms on her wheelchair and bed. A care plan, dated 08/08/13, indicated the resident was at risk for injuries from falls. The interventions included, alarm to w/c and bed. A care plan, dated 08/08/13, indicated the resident needed staff assistance with activities of daily living. The interventions included, 08/29/13 transfer with Sabina (stand up lift) lift. The Care Directive (care card for CNA's), dated 08/19/13 and received from the Director of Nursing (DoN), indicated the resident required assistance of two and the Sabina lift for transfers. A Nurses' Note, dated 09/14/13 at 11:38 p.m., indicated, "09/14/13 3-11 (p.m.):...At approx (approximately) 4 p.m. CNA was toileting resident, and resident slid off toilet on to floor on buttocks. Resident with AROM (active range of motion) in all extremities, denied c/o (complaints) pain or discomfort at time. Resident c/o #9 (pain rating with #10 being the worse) pain to the left knee/hip at 5 p.m., adm. (administered) PRN (as needed) Norco (narcotic pain medication) as ordered, c/o #4 pain to hip/knee at 6 p.m., adm. tylenol (sic) as ordered with positive results. (Physician's Name) informed of incident, resident's c/o pain, ordered X-ray to left hip, femur, and knee. (X-ray company) called, they will be in first thing in a.m...." There was a lack of documentation to indicate what time the resident's Physician was notified. On 12/17/13 at 9:30 a.m., the East Unit Manager indicated the x-ray company was notified of the need for an x-ray on 09/14/13 at 8:16 p.m. A Nurses' Note, dated 09/15/13 at 6:48 a.m., indicated, "Resident c/o #8 pain to left knee at 12:40 a.m. Bruising noted to left knee/leg; no bruising noted at 6 p.m. when PRN tylenol (sic) given. Resident able to move left leg from side to side...Resident woke up and requested PRN pain med (medicine) again at 6:50 a.m., PRN Norco adm. Bruising noted to be more extensive than at 12:50 p.m., will inform 7-3 nurse bruising must be measured..." A Nurses' Note, dated 09/15/13 at 10:54 a.m. indicated, "...Bruise to left leg purple/blue in color. C/o pain to left leg given PRN pain medications. Awaiting x-ray to be done." A Nurses' Note, dated 09/15/13 at 2:30 p.m., indicated "Resident had x/ray done to right leg (should be left leg) results show acute proximal fracture to tibial (sic) and fibular. (Physician's Name) notified received orders to send to (Hospital Name)..." The Pain Flow Sheet, dated 09/13, indicated the resident received Norco 5-325 mg (milligrams) on 09/14/13 at 5 p.m. for pain rated at #9 (on a scale of 1-10 with 10 being the worse), 09/15/13 at 4:30 a.m. for pain rated at #8, and 09/15/13 at 1 p.m. for pain rated at #8. The Medication Adminsitration Record, dated 09/13, indicated the resident received acetaminophen (Tylenol) 325 mg, two tablets on 09/14/13 at 6 p.m. A Radiology Report, dated 09/15/13, indicated the resident had an acute fracture of the left proximal tibia and fibular (left lower leg) metaphyses. A Consultation Report from the hospital, dated 09/15/13, indicated, "...the patient has a history of being unsteady and is at risk for multiple falls. The nursing home did not seem to take too much concern with her fall yesterday;although, she was having difficulty bearing weight due to the pain and she was brought to the emergency department today for further evaluation, and x-rays were taken and she had a left proximal tibia and fibular fracture, and we were then consulted on further management of this patient..." A Fall investigation written by the East Wing Unit Manager, received from the DoN, dated 09/16/13, indicated she had received a phone call on 09/15/13 at approximately 3 p.m. to inform her the resident had fallen on 09/14/13 and the resident had received a x-ray and was sent to the hospital with a fracture of the tibia and fibula. The note indicated CNA #7 had informed her the resident was sliding off the toilet and she and CNA #8 lowered the resident to the floor. She indicated CNA #7 had said she and CNA #8 had transferred the resident to the toilet and they had not used the Sabina lift. A Fall Investigation, received from the DoN, dated 09/16/13, indicated LPN #9 was interviewed by telephone, and during the interview, LPN #9 (no longer employed at facility) indicated: CNA #8 came and told her Resident #64 was on the floor. LPN #9 arrived at Resident #64's room and observed her sitting on her buttocks with her legs stretched out in front of the toilet. She stated she asked the resident if she had any pain and the resident denied pain, she checked the resident's range of motion, and assessed for bruising and there was none noted. She indicated CNA #7 and CNA #8 then transferred the resident into the wheelchair, she finished her assessment and left the resident's room. Continued investigation in person on 09/17/13 with LPN #9 indicated LPN #9 had asked the resident if she was in any pain and the resident had stated she was ok. LPN #9 indicated she had came to the room approximately five minutes after notification and she had told the CNA's to transfer the resident into the wheelchair and bring her to the Nurses' Station. She indicated an assessment had been completed while the resident was still on the floor. A Fall Investigation, received from the DoN, dated 09/16/13, indicated CNA #8 was interviewed, and during the interview, CNA #8 indicated: CNA #7 came up to the Nurses' Station and asked her for help. CNA #8 went to the resident's room and CNA #7 asked her to help transfer Resident #64 off the floor and back into the wheelchair. CNA #8 told CNA #7 they had to get a nurse then she went to tell LPN #9 and LPN #9 said she would be right there. After a few minutes LPN #9 had not come to the room so CNA #7 went to get LPN #9. CNA #7 returned and said LPN #9 said to just go ahead and get her up. CNA #7 and CNA #8 then lifted the resident off the floor using the under the arm and under the thigh technique and transferred the resident into the wheelchair and then to bed. A continued investigation with CNA #8 on 09/17/13, indicated LPN #9 had not came into the room to assess the resident until after the resident had been transferred into her bed and the Sabina lift was not in the Bathroom A Fall Investigation, received from the DoN, dated 09/17/13 at 5:25 p.m., indicated, CNA #7 was interviewed and during the interview, CNA #7 indicated she transferred Resident #64 with one assistance to the toilet. CNA #7 then indicated she had left the room to answer a call light for another resident (leaving the resident alone in the bathroom) and when she returned, Resident #64 was sliding off the toilet. CNA #7 indicated she slid Resident #64 to the floor. CNA #7 indicated the resident was screaming. CNA #7 indicated she called for CNA #8 to assist her. CNA #7 told CNA #8 to go and get the Nurse (LPN #9). She indicated CNA #8 asked the resident what she did and the resident just kept yelling. CNA #8 went to get LPN #9 them came back to the room and they waited 10 minutes and LPN #9 did not come to the room. Then CNA #7 went to get LPN #9. CNA #7 indicated LPN #9 asked her if the resident had hit her head and CNA #7 told her no. CNA #7 indicated LPN #9 asked her if she had any bruises and CNA #7 told her no. CNA #7 indicated LPN #9 told her to get the resident off the floor. CNA #7 and CNA #8 then lifted the resident to the wheelchair and then to bed. CNA #7 indicated LPN #9 arrived at the room approximately five minutes after the resident was in bed. During an interview with the DoN on 12/16/13 at 4:35 p.m., the DoN indicated the resident was a fall risk, used wheelchair and bed alarms, and should not have been left by herself in the bathroom. She indicated the Sabina lift should have been used for the transfer and there should have been two staff helping with the transfer. She indicated CNA #7 transferred the resident by her self and without the Sabina lift. She indicated CNA #7's conflicting information on how the resident was transferred was because the CNA was scared. She indicated LPN #9 had said she went into the room to assess the resident while she was still on the floor, but both CNA's had said she did not go into the room until after the resident was back into bed. She indicated LPN #9 had not returned to the facility to work after the investigation on 09/17/13. She indicated LPN #9 should have assessed the resident before she was moved off the floor and the CNA's knew not to move the resident. An undated facility policy, received by the DoN on 12/17/13 at 10:28 a.m. as current, titled, "Falls Management", indicated, "...Residents who experience a fall will receive prompt medical attention. Immediate needs will be quickly assessed and responded to...When a resident has a fall, the charge nurse will be notified immediately. b. The charge nurse will provide prompt medical attention as needed...The charge nurse will assess for injuries prior to moving the resident...The responsible party and physician are promptly notified of the occurrence and status of the resident...3. Follow-up for Falls:...The charge nurse or designee will update the physician and family as necessary of the resident's progress and response to the fall..." The Indiana State Department of Health, Core Curriculium for Nurse Aide Training Program, dated July 1998, Topic 22: Transferring, indicated, "...Have at least one co-worker assist when using a mechanical lift..." 3.1-45(a)(2)