Every finding on record at Lincoln Hills of New Albany

Based on observation, record review and interview, the facility failed to ensure the kitchen was maintained in a clean and sanitary condition and the disposal of expired food. This deficient practice had the potential to affect 120 of 120 residents residing in the facility.Findings Include:During an observation of the facility kitchen, on 12/1/25 at 9:30 a.m., the following was observed: - Fifty small condiments containers were observed with ranch dressing in them. The expiration date on the containers was 11/18/25. - The kitchen floor had several black and brown dried substances on the floor tile (the floor appeared greasy) and food debris was scattered on the floor. - The knob to the oven door was missing and the Dietary Manager located it underneath the oven. the Dietary Manager indicated the knob was loose and frequently fell off. - There was a brown greasy streak running down the full length of the oven door and onto the floor. During a second observation of the facility kitchen, on 12/3/25 the following was observed: - The kitchen floor had several black and brown dried substances on the floor tile (the floor appeared greasy) and food debris was scattered on the floor. - The knob to the oven door was missing. -There was a brown greasy streak running down the full length of the oven door and onto the floor. The review of the kitchen cleaning scheduled for the month of November was reviewed. The log documentation indicated 20 out of 30 days the cleaning was not completed. During an interview, on 1/12/25 at 9:30 a.m., the Dietary Manager indicated if there were blank holes in the cleaning schedule that meant the cleaning was not done. She indicated leftover food should be disposed of after three days. 3.1-21(i)(l)(3)

Based on observation, record review, and interview, the facility failed to ensure residents' meal trays were removed in a timely manner for 6 of 7 residents reviewed for dignity. (Residents 38, 43, 104, 122, 109, and 74)Findings include: 1. During an observation and interview, on 12/1/25 at 10:00 a.m., Resident 38 was sitting up in her wheelchair with her breakfast tray sitting in front of her on the bedside table. She had not eaten any of her breakfast. She held a butter knife in her hand and indicated she was trying to get started eating her breakfast. During an interview, on 12/3/25 at 10:05 a.m., Resident 38 indicated the staff normally left the breakfast tray on her bedside table. She was asleep when they brought it. They would let her know it was there. The resident had not yet eaten any of her breakfast. She indicated she was going to eat it soon. During an observation, on 12/03/2025 12:02 p.m., Resident 38 received her lunch. As Certified Nurse Aide (CNA) 4 left the resident's room, she indicated the resident had just started eating her breakfast. Upon entering the resident's room, she was finishing her breakfast, eating the last few bites of French toast. The resident indicated she would eat her lunch afterwards, because she was paying for it. The lunch tray had been set on the bed next to the resident's bed with the plate cover over the meal. During an observation, on 12/3/25 at 12:39 p.m., the resident was pulling the bedside table up to her chair at bedside with the lunch tray on it. She sat down in front of the tray but didn't start eating. She was watching the television. She then rose from her chair and started to straighten up her bed. During an observation, on 12/3/25 at 1:29 p.m., the resident was observed eating her lunch received at 12:02 p.m. During an observation, on 12/4/25 at 9:35 a.m., the resident was starting to drink coffee from her breakfast tray. The tray was on the bedside table pushed against the opposite wall away from her bed and chair. She was standing at the tray, and she turned and sat down in the chair. She indicated she did not know what was on her tray for breakfast. She then got up from the chair and checked the meal under the plate cover. It was a breakfast sandwich with an egg, bacon, and cheese on a biscuit. She went back to her chair and sat down. The physician's order, dated 12/25/24, indicated the resident received a regular diet. The record for Resident 38 was reviewed on 12/3/25 at 1:43 p.m. The diagnoses included, but were not limited to, memory deficit following cerebrovascular disease, lack of coordination, difficulty in walking, moderate protein-calorie malnutrition, vitamin deficiency, alcohol dependence with alcohol-induced persisting dementia, encephalopathy, gastro-esophageal reflux disease, altered mental status. The Comprehensive Minimum Data Set (MDS) assessment, dated 10/30/25, indicated the resident was moderately cognitively impaired. The resident required setup or clean-up assistance with eating. During an interview, on 12/5/25 at 10:40 a.m., Licensed Practical Nurse (LPN) 5 indicated the resident slept late. She would take a while to eat her meals. The staff checked the trays in the rooms all the time. After 35 to 40 minutes, the meal trays would be removed from the resident's room. 2. During an observation, on 12/1/25 at 9:55 a.m., Resident 43 was lying in her bed leaning toward her left side. The bedside table was in front of her with her breakfast tray in front of her on the table. The breakfast tray had not been touched. The resident was attempting to remove the lid from her apple juice without success. The resident's breakfast had not been consumed. During an observation, on 12/3/25 at 12:00 p.m., the Activities Assistant 6 was overheard asking Resident 43 if she needed help cutting up her meat as she placed the meal tray on the bedside table in front of the resident. When the staff left, the resident just sat in her wheelchair without touching her meal. The meal was uncovered, and the drink cup had a lid on it. The lunch meal was a Salisbury steak, mashed potatoes, green beans were on the plate. A cupcake or roll was in a bag on the tray. The resident just looked at the tray. During an observation, on 12/4/25 at 9:35 a.m., the resident was in her room, sitting in bed with the bedside table in front of her. Her breakfast tray was in front of her and she was picking at the food. After a few minutes, she stopped eating. The record for Resident 43 was reviewed on 12/3/25 at 2:24 p.m. The resident's diagnoses included, but were not limited to, dementia with psychotic disturbance, chronic systolic congestive heart failure, atrial fibrillation, limitation of activities due to disability, mild vascular dementia with mood disturbance, anxiety and behavioral disturbance, unsteadiness on feet, history of transient ischemic attack (TIA), and cerebral infarction without residual deficits, age-related physical debility, Transient cerebral ischemic attack, lack of coordination, and the need for assistance with personal care. The Quarterly MDS assessment, dated 10/3/25, indicated the resident was severely cognitively impaired. She required setup or clean-up assistance with eating. The care plan, dated 7/18/25 and revised 11/12/25, indicated the resident was at nutritional risk related to advanced age, impaired cognition related to dementia, heart failure, debility, major depressive disorder, vitamin D deficiency, history of dehydration, hypertension, hyperlipidemia, generalized anxiety disorder, dysphagia, paranoid schizophrenia, weakness, varied appetite and complaints of pain. The interventions, dated 7/18/25, included, but were not limited to, explain the potential negative outcome of weight loss, honor the resident's food preferences, involve family in the plan of care, monitor the resident's weight, notify the physician of any significant weight changes, record meal and fluid consumption, serve the diet per physician order, and supplements as ordered. The resident's weight, on 6/2/25 at 7:09 p.m., was 173.4 pounds. The resident's current weight, on 12/1/25 at 2:39 p.m., was 163.4 pounds. The current physician's order indicated the resident received a regular diet. 3. During an observation, on 12/3/25 at 12:13 p.m., Resident 104's lunch meal tray was brought into the resident's room and placed on the bedside table. The resident was asleep and snoring. The curtain was partially closed. The plate cover was left on the resident's plate. During an observation, on 12/3/25 at 12:38 p.m., the resident was still asleep. The privacy curtain had been pulled the entire length of the bed. The meal tray was sitting on the bedside table, still covered. The resident was snoring. During an observation, on 12/3/25 at 1:28 p.m., the resident's lunch meal tray was still on the bedside table. The resident was asleep. The meal was still covered. Residents in the dining room had completed their meals and had been taken to an activity. The record for Resident 104 was reviewed, on 12/4/25 12:27 p.m. The resident's diagnoses included, but were not limited to, Parkinson's disease with dyskinesia with fluctuations, disturbances of salivary secretion, pain, palliative care, severe dementia, severe with anxiety, lack of coordination, diabetes mellitus due to underlying condition with hyperosmolarity without nonketotic hyperglycemic-hyperosmolar coma (NKHHC), restlessness and agitation, limitation of activities due to disability, memory deficit following cerebral infarction, memory deficit following cerebrovascular disease, stage 3 chronic kidney disease, and need for assistance with personal care. The Quarterly MDS assessment, dated 6/24/25, indicated the resident was moderately cognitively impaired. He required setup or clean-up assistance with eating. The resident's weight, on 3/27/25 at 5:10 p.m. was 185 pounds. The care plan, dated 8/21/25 and revised 11/25/25, indicated the resident was at nutritional risk related to advanced age, Parkinson's, dementia, weakness, chronic kidney disease, hypertension, hyperlipidemia, gastro-esophageal reflux disease, diabetes, and hypotension. The interventions, dated 8/21/25, included, but were not limited to, explain the potential negative outcome of weight loss, honor the resident's food preferences, involve family in the plan of care, monitor the resident's weight, notify the physician of any significant weight changes, record meal and fluid consumption, serve diet per physician's order, and supplements as ordered. The physician's order, dated 10/28/25, indicated the resident received a regular diet. The resident's last weight, on 11/1/25 at 4:21 p.m., was 170.8 pounds. The nurse's note, dated 11/24/25 at 9:19 a.m., indicated the resident was up in his wheelchair eating breakfast with staff. The physician's order, dated 12/1/25, indicated the resident was to receive a nutritional supplement three times daily upon rising between 7:00 a.m. and 8:00 a.m., afternoon between 11:00 a.m. and 12:00 p.m., dinner between 4:00 p.m. and 5:00 p.m. The nurse's note, dated 12/1/25 at 9:41 a.m., indicated the hospice company ordered Ensure supplemental drinks, three times daily, with meals. The nurse's note, dated 12/1/25 at 2:36 p.m., indicated the resident did not eat any lunch and was unable to understand how to open his mouth. The nutritional drink was given, and the resident drank all the drink with assistance of the nurse. The nurse's note, dated 12/2/25 at 10:39 a.m., indicated the resident was more awake this morning, but was keeping his eyes closed most of the time. The hospice nurse was at the facility at this time and was informed the resident was not taking much food in at all. He was drinking nutritional drinks with assistance of staff. The resident did eat a few bites of breakfast on this date, but it was hard to get the resident to understand how to open his mouth. 4. During an observation, on 12/3/25 at 12:14 p.m., Resident 122's lunch meal tray was sitting on his bedside table. It had a plate cover over the food and the resident was asleep. During an observation, on 12/3/25 at 12:43 p.m., the resident was still asleep, and his lunch meal tray was sitting on his bedside table covered. The food had not been touched. During an observation, on 12/3/25 at 1:32 p.m., the resident's lunch meal tray had been removed from the bedside table. The resident was still asleep in his bed and had not moved from the same position. During an observation, on 12/4/25 at 9:35 a.m., the resident arrived to his room from the dining room. He had eaten breakfast in the dining room. The record for Resident 122 was reviewed on 12/4/25 at 2:08 p.m. The resident's diagnoses included, but were not limited to, schizoaffective disorder, bipolar type, seizures, speech and language deficits following other cerebrovascular disease, dysphagia following cerebrovascular disease, restlessness and agitation, severe dementia with mood disturbance, Alzheimer's disease, protein-calorie malnutrition, hypokalemia, pain, symptoms and signs involving cognitive functions and awareness, symptoms and signs involving the musculoskeletal system. The Quarterly MDS assessment, dated 9/24/25, indicated the resident was severely cognitively impaired. The resident required setup or clean-up assistance for eating. The resident's weight, on 6/2/25 at 7:13 p.m., was 157.2 pounds. The care plan, dated 7/30/25, indicated the resident was at nutritional risk related to mechanically altered diet, advanced age, dementia, schizoaffective disorder, Alzheimer's, major depressive disorder, protein calorie malnutrition, dysphagia, iron deficiency anemia, vitamin deficiency, hypertension, pain, and diarrhea. The resident was on hospice and at risk for unavoidable weight loss related to terminal illness and end of life. The interventions, dated 7/30/25, included but were not limited to, provide assistance and encouragement as indicated for eating. The care plan, dated 11/11/25, indicated unavoidable weight loss related to terminal illness and end of life. The interventions, dated 11/11/25, included, but were not limited to diet as ordered, offer snacks between meals as tolerated, and pleasure foods as requested and tolerated. The physician's order, dated 10/23/25, indicated the resident received a mechanical soft, ground meat diet. Ice cream with lunch and dinner, 2 scrambled eggs and toast for breakfast and lunch per speech therapy, the resident could have grilled cheese sandwiches at meals. The physician's order, dated 10/31/25, indicated the resident was to receive 120 milliliters (mL) of Med Pass three times a day upon rising 7:00 a.m. to 11 a.m., afternoon 3:00 p.m. to 5:00 p.m., before bedtime 7:00 p.m. to 11:00 p.m. The nurse's note, dated 11/28/25 at 12:44 p.m., indicated the resident was in bed. He refused to go to the dining room to eat. The nurse's note, dated 11/2/25 at 1:26 p.m., indicated the resident was in the dining area and was not in his room for all meals. Staff had fed and cued the resident while he was eating meals. The resident's last weight, on 12/2/25 at 9:24 a.m., was 151 pounds. During an interview, on 12/4/25 at 9:41 a.m., CNA 7 indicated she was not sure how long the food trays could be left in a resident's room. During an interview, on 12/4/25 at 9:45 a.m., the DON indicated the food could sit in resident's rooms for as long as necessary. There was no time limit. If the resident hadn't touched the food, staff would ask if they could take it away. If the resident was not done eating after a while, the staff would ask if they could get them a fresh meal. If the meal was still with the resident and it was a half hour before the next meal arrived, staff should ask the resident if they wanted a snack. Staff should check on the resident after the meal, there was no specific time. After maybe 30 minutes, staff could remind the resident that they had the meal in their room. If the resident had fallen asleep, staff should wake the resident up and remind them of their food being present. During an interview, on 12/4/25 at 10:00 a.m., CNA 8 indicated the meal trays stay with a resident. She woke them and set them up in bed. Breakfast meals would not stay with a resident longer than an hour. During an interview, on 12/4/25 at 10:13 a.m., CNA 9 indicated she would leave a meal tray with the resident, for as long as it took them to eat. She would wake them up and set them up in bed to let them know the food was there to eat, otherwise they would go back to sleep. She would never leave the tray with them until the next meal came. She would wake them up to ask if they were going to eat or if they wanted the food warmed up. During an interview, on 12/5/25 at 10:50 a.m., the Clinical Specialist indicated the facility had no policy on how long food could be left sitting out in a resident's room. 5. During an observation, on 12/1/25 at 9:45 a.m., Resident 109 was lying in her bed. Her breakfast tray was sitting on her bedside table beside her bed. The breakfast had not been set up for the resident, and she had not eaten any of her breakfast. During a second observation, on 12/1/25 at 11:20 a.m., Resident 109 remained in her bed. Her breakfast was still sitting on her bedside table untouched. The resident had not eaten any of her breakfast. The record for Resident 109 was reviewed on 12/3/25 at 1:53 p.m. The resident's diagnoses included, but were not limited to, wedge compression fracture of the first lumbar vertebra, difficulty walking, memory deficit, attention and concentration deficit, Alzheimer's disease, anemia, and severe protein-calorie malnutrition. The admission MDS, dated [DATE], indicated the resident required assistance with setting up her meals. The resident was moderately cognitively impaired. The care plan, dated 11/6/25, indicated Resident 109 was at nutritional risk related to her advanced age, underweight, Alzheimer's, dementia, enterocolitis, anxiety disorder, severe protein calorie malnutrition, nausea, and iron deficiency anemia. The interventions included, but were not limited to, involve the family in the resident's care plan, explain the potential negative outcome of weight loss, honor the resident's food preference, supplements as needed, monitor weight and record meal and fluid consumption. During an interview, on 12/1/25 at 11:30 a.m., the Dietary Aide 11 indicated the breakfast meal was served between 7:30 a.m., and 8:00 a.m., on 12/1/25. 6. During an observation, on 12/1/25 at 9:50 a.m., Resident 74 was lying in her bed. Her breakfast tray was sitting on her bedside table. The breakfast had not been set up for the resident, and she had not eaten any of her breakfast. When an unknown CNA entered the room and asked the resident if she was going to eat her breakfast the resident indicated she wanted to eat her breakfast. The record for Resident 74 was reviewed on 12/4/25 at 5:17 p.m. The resident's diagnoses included, but were not limited to, dementia, limitations of activities, memory deficit, dysphagia, chronic pain and tremors. The admission Minimum Data Set (MDS), dated [DATE], indicated the resident required assistance with setting up her meals. The resident was severely cognitively impaired. The care plan, dated 6/27/27, indicated the resident was at nutritional risk related to mechanically altered diet, advanced age, dementia, dysphagia, depression, and anxiety disorder. The interventions included, but were not limited to, the resident would tolerate a (mechanically altered/therapeutic diet) without significant weight loss, aid and encouragement as indicated for eating, provide assistive devices as needed, monitor and report difficulties with eating, chewing and swallowing to the physician, monitor and record meal intake. During an interview, on 12/4/25 at 9:45 a.m., CNA 12 indicated staff would assist the residents if they needed assistance with eating. Once the resident received the meal tray staff should check on the resident 15 to 20 minutes later to make sure the resident was eating or needed assistance. The Resident Rights policy, dated 6/6/19, included, but was not limited to, .It is our policy that residents shall be treated with kindness, respect and dignity by associates, volunteers, contractors and visitors. 3.1-3(a)

Based on observation, record review and interview, the facility failed to ensure a resident's plan of care was revised for 1 of 3 residents reviewed for dementia care. (Resident 121)Findings include:During an observation on 12/5/25 at 11:30 a.m., the resident was seen in the hallway propelling his wheelchair to the activities room from C Hall which was not a locked unit. The resident indicated that he felt good today and was ready to be out of his room.The record for Resident 121 was reviewed on 12/2/25 at 8:30 a.m. The resident's diagnoses included, but were not limited to, personal history of traumatic brain injury, bipolar disorder, memory deficit following other cerebrovascular disease, history of falls, and chronic obstructive pulmonary disease.A care plan, dated 4/12/24, indicated the resident had a diagnosis of dementia, that negatively impacts the resident's cognition and judgement, causing the resident to require a locked, structured unit. The goal, dated 2/14/26, was for the resident to remain on locked unit until their clinical and psychosocial needs no longer required a specialized unit. The interventions, dated 4/12/24, included but were not limited to, educate the resident's family of disease process; and the resident will be encouraged to participate in activities of interest; staff to provide cues and reminders to the resident as necessary.A physician's order, dated 5/8/24, indicated the resident may reside on the secured memory unit.The resident's clinical record lacked an updated care plan and/or interventions related to the resident's improved cognition, judgement and behaviors. The resident resided on the memory unit starting on 4/11/24 and was transferred to the skilled nursing hallway on 12/27/24.The Social Service note, dated 12/30/24 at 4:27 p.m., indicated the resident was visited to follow up with his new room on the skilled nursing hall.The Quarterly Minimum Data Set (MDS) assessment, dated 10/23/25, indicated the resident's cognition was cognitively intact.During an interview, on 12/4/25 at 10:30 a.m., Certified Nurse Aide (CNA) 13 indicated that the resident did not have behaviors throughout the day when she was here. He refused care sometimes but did not attempt to wander or elope from the facility.During an interview, on 12/5/25 at 10:00a.m., the Director of Nursing indicated that changes to care plans and orders were made by the Interdisciplinary (IDT) team after a change in condition had been addressed in a resident.During an interview, on 12/5/25 at 11:00 p.m., The Clinical Specialist indicated that there were no policies on care plans or care plan revisions. The facility followed the Resident Assessment Instrument (RAI) manual for care plans.3.1-35(c)(1)

Based on interview and record review, the facility failed to ensure a plan of care was in place timely, for a resident's non-compliance with a fall intervention related to the use of hipsters for 1 of 3 residents reviewed for care plans. (Resident D) Findings include: The clinical record for Resident D was reviewed on 2/27/25 at 9:28 a.m. The resident's diagnoses included, but were not limited to, vascular dementia and abnormalities of the gait. The care plan, dated 7/22/24, indicated the resident was at risk for falls. The resident was to wear hipsters (help reduce the risk of injuries from a fall, such as hip fractures, through impact-absorbing foam pads) at all times as the resident would allow to decrease risk of injury with falls. The progress note, dated 2/20/25 at 9:24 p.m., indicated the resident was walking in the dining room and fell over onto her left hip. The residents' hipsters were not on. The nurse practitioner was notified and a new order received for an x-ray. The progress note, dated 2/21/25 at 1:26 a.m., indicated the resident was sent to the hospital due to a left hip fracture. The Interdisciplinary Team (IDT) note, dated 2/21/25 at 11:59 a.m., indicated the resident's hipsters were on her dresser. Per the staff, the resident does not like the hipsters and may remove them at times. On 2/26/25, a plan of care was implemented for non-compliance with fall interventions. The resident's plan of care lacked documentation of the resident's non-compliance with the fall intervention until 2/26/25. During an interview, on 2/27/25 at 10:53 a.m., Certified Nursing Aide (CNA) 4 indicated the resident frequently removed her hipsters and clothing and had done that for the past 2 to 3 months. The resident was able to dress and undress herself. During an interview, on 2/27/25 at 2:57 p.m., the Director of Nursing indicated the staff were aware the resident was removing her hipsters, but she was not. The resident was care planned for disrobing. During an interview, on 2/27/25 at 3:42 p.m., the Director of Nursing indicated the facility did not have a policy on care plans but they follow the Resident Assessment Instrument (RAI) manual. This Citation relates to Complaint IN00452723 3.1-35(a)

Based on observation, record review and interview, the facility failed to ensure a resident was provided the care and services to prevent the development of skin breakdown for four areas, to ensure the skin assessments identified a pressure ulcer prior to it becoming a Stage 3 wound, and the worsening of the Stage 3 pressure ulcer. This resulted in the wound worsening to a Stage 4 pressure ulcer. (Resident 18) Findings include: The record for Resident 18 was reviewed on 9/26/24 at 10:27 a.m. The resident's diagnoses included, but were not limited to, dementia, skin changes, Stage 4 pressure ulcer (full thickness ulcer with the involvement of the muscle or bone) of the left heel, limitation of activities due to disability, abnormalities of gait and mobilities, lack of coordination, Parkinsonism, hallucinations, left foot drop, neuralgia (nerve pain) and neuritis (inflammation of one or more nerves), and type 2 diabetes mellitus with diabetic nephropathy (kidney disease). The nurse's note, dated 10/16/23 at 12:15 p.m., indicated the resident arrived at the facility for admission. The physician's order, dated 10/16/23, indicated to elevate or offload the resident's heels while in bed, as tolerated. The resident was to be turned and repositioned per the plan of care. The care plan, dated 10/17/23, indicated the resident was at risk for skin breakdown related to decreased mobility, incontinence and a diagnosis of diabetes. The interventions, dated 10/26/23, included, but were not limited to, assist the resident with bed mobility as indicated, elevate heels as the resident would allow, monitor skin for signs of skin breakdown, apply a pressure reduction cushion in the wheelchair (if applicable), apply a pressure reduction mattress, turn and reposition for bed mobility, and per the resident's individual needs, and perform weekly skin assessments. The nurse's note, dated 10/18/23 at 8:00 a.m., indicated the resident's skin was assessed with scars to the bilateral knees and lower back, faded bruises on the bilateral shins, and the buttock, peri area, and heels were clean, dry and intact with dry flaky heels and feet. The Admission MDS (Minimum Data Set) assessment, dated 10/25/23, indicated the resident was cognitively intact. The resident required substantial to maximal assistance of two staff members for rolling left and right, sitting to a lying position, and lying to a sitting position. The resident had no skin breakdown upon admission or refusal of care. The resident had bilateral lower extremity impairment. The resident was at risk for skin breakdown. The physician's orders, dated 11/29/23, indicated to place a low loss air mattress on the resident's bed and the licensed nurse was to perform weekly head to toe skin inspections. If any new areas were observed, the nurse was to complete a Skin Integrity Event once a day on Wednesdays. The physician's order, dated 11/30/23, indicated staff were to off-load the resident's heels every shift. The resident's clinical record indicated on the following dates the resident acquired four areas of skin breakdown. Three of the four areas had healed, and one area had worsened. a. The Events tab report, dated 11/30/24, indicated the resident had an unstageable wound to the right heel. The wound measured 2 cm (centimeters) long by 3 cm wide by an unmeasurable depth. The wound had healed on 12/21/23. b. The Events tab report, dated 12/26/23, indicated the resident had a Stage 3 (full thickness ulcer that extends to the subcutaneous tissue) open wound to the coccyx. The wound measured 1 cm long by 0.6 cm wide by 0.1 cm deep on 11/20/23. The wound had healed on 12/20/23. c. The Events tab report, dated 11/26/23, indicated the resident had an open area to the left side of the outer ankle. No documentation of a wound or size could be found. Upon observation on 9/26/24 the wound had healed. d. The Events tab report, dated 11/26/23, indicated the resident had an open area to the left heel. The wound management note, dated 11/30/23, indicated a Stage 3 facility acquired pressure ulcer to the resident's left heel was observed, and measured 3 cm long by 3 cm wide by 0.1 cm deep. The surface area measured 9 cm square. There was a moderate amount of serous exudate (clear or pale yellow, watery, thin plasma that leaks from a wound) with granulation tissue (new connective tissue that forms in a healing wound). The dressing order indicated to apply alginate calcium daily for 30 days, cover with an ABD pad, and apply a gauze roll over the dressing. The 12/7/23 Wound Company note indicated the wound to the left heel was improving. The wound management note, dated 12/14/23, indicated the Stage 3 facility acquired pressure ulcer to the resident's left heel measured 2 cm long by 2 cm wide by 0.1 cm deep. There was a light amount of serous exudate with 50% granulation tissue and 50% necrotic tissue. The wound had improved. The care plan, dated 12/14/23, indicated the resident had a Stage 3 pressure ulcer to the left heel. The interventions, dated 12/14/23, included, but were not limited to, provide treatment and monitoring per the physician's orders in the MAR (Medication Administration Record). The nurse's note, dated 12/15/23 at 12:41 p.m., indicated the treatment to the left heel were completed as ordered with no signs or symptoms of infection. The wound management note, dated 12/21/23, indicated the facility-acquired stage three pressure injury deteriorated to an unstageable facility acquired pressure ulcer to the left heel and measured 3 cm long by 3 cm wide by 0.1 cm deep. There was a moderate amount of serous exudate with 100% eschar (dead tissue that eventually sloughs off healthy skin) tissue. The wound physician assessed the wound and indicated the wound was stable, but not at the goal of healing. She would continue to follow weekly. The Wound Company note, dated 1/11/24, indicated a wound evaluation was completed. The wound had improved with a measurement of 1.5 cm long by 1.5 cm wide by 0.1 cm deep. There was 100% thick adherent devitalized necrotic tissue and a moderate amount of serous exudate. The wound management note, dated 1/11/24, indicated the Stage 3 facility acquired pressure ulcer to the resident's left heel had improved and measured 2 cm long by 1.5 cm wide by 0.1 cm deep. There was moderate serous exudate with 80% granulation tissue and 20% necrotic tissue. The physician's order, dated 1/18/24, indicated lift boots were to be placed while the resident was in bed and to check every shift. The wound management note, dated 2/1/24, indicated the Stage 3 facility acquired pressure ulcer to the resident's left heel measured 1.2 cm long by 1 cm wide by 0.1 cm deep. There was a moderate amount of serous exudate with 50% granulation tissue and 50% necrotic tissue and had deteriorated. The wound management note, dated 3/7/24, indicated the Stage 3 facility acquired pressure ulcer to the resident's left heel measured 1.5 cm long by 1 cm wide by 0.1 cm deep. There was light serous exudate with 30% slough, 70% subcutaneous tissue and 30% slough (cast off dead tissue). The wound was improving. The IDT (Interdisciplinary Team) note, dated 3/22/24 at 1:43 p.m., indicated the resident's left heel wound remained. The nurse's note, dated 3/4/24 at 2:56 p.m., indicated wound care was completed to the bilateral heels per the treatment orders. The area was very tender during the dressing change. A small amount of bleeding was observed to the left heel. The area was cleansed as ordered and the dressing was applied as ordered. The resident denied pain when the dressing change was completed. The wound management note, dated 4/4/24, indicated the Stage 3 facility acquired pressure ulcer to the resident's left heel measured 1.5 cm long by 1.5 cm wide. There was a moderate amount of serous exudate with 60% granulation tissue, 20% slough, and 20% necrotic tissue. The wound was declining. The physician's order, dated 4/17/24, indicated to administer 30 mL (milliliters) of Active Critical Care Liquid Protein three times daily and to place the resident in enhanced barrier precautions. The wound management note, dated 5/9/24, indicated the Stage 3 facility acquired pressure ulcer to the resident's left heel measured 1.5 cm long by 1.5 cm wide by 0.1 cm deep. There was a moderate amount of serous exudate with 100% necrotic tissue and was declining. The nurse's note, dated 5/27/24 at 11:44 a.m., indicated the left heel dressing was removed with a moderate amount of yellow drainage, indicating infection. The center of the wound had a small black center surrounded by white tissue. The wound management note, dated 5/30/24, indicated the Stage 3 facility acquired pressure ulcer to the resident's left heel was documented as a deep tissue injury and measured 4 cm long by 4 cm wide by 0.1 cm deep with a moderate amount of serous exudate. There was 100% granulation tissue, and the wound was declining. The nurse's note, dated 6/4/24 at 3:52 p.m., indicated the wound care was completed to the resident's left heel. The old dressing was removed, and a large amount of thin foul smelling yellow drainage was present indicating a wound infection. The wound bed had a small amount of pink and yellow slough. The wound was tender to the touch during the wound care. The nurse's note, dated 6/8/24 at 2:40 p.m., indicated when the resident's wound care was completed to the left heel, the old dressing had a large amount of serous drainage and a slight odor. The wound management note, dated 6/12/24, indicated the unstageable facility acquired pressure ulcer to the resident's left heel measured 5 cm long by 5 cm wide by 0.1 cm deep. There was a moderate amount of serous exudate with 50% granulation tissue and necrotic tissue. The wound was declining. The nurse's note, dated 6/14/24 at 5:56 p.m., indicated when wound care was completed, the old dressing had yellow/greenish drainage, and some odor. There was no change from the assessment on the previous day. The nurse's note, dated 6/17/24 at 4:00 p.m., indicated the dressing change was completed to the resident's left heel, with decreased yellow drainage. The nurse's note, dated 6/20/24 at 11:45 a.m., indicated the resident was seen by the wound physician for the left heel ulcer. The resident indicated she had increased pain due to the procedure being done at bedside. The PRN (as needed) hydrocodone was given for the left heel pain. The dressing change was done to the left heel per the wound nurse and physician. The Wound Company evaluation, dated 6/20/24, indicated the wound to the left heel was staged as unstageable, due to the necrotic tissue. The wound measured 2 cm long by 2 cm wide by 0.1 cm deep. There was 50% thick adherent devitalized necrotic at and 50% granulation tissue. The wound was documented as improved due to the decreased surface area. The dressing was to apply Santyl daily for 9 days and to apply a Mesalt sheet daily for 22 days. Apply a gauze island with border daily for 30 days. Offload the wound and reposition per facility protocol. The wound management note, dated 6/27/24, indicated the resident's wound was now a Stage 4 facility acquired pressure ulcer to the left heel measured 2 cm long by 2 cm wide by 0.1 cm deep with moderate serous exudate. There was 50% granulation tissue and 50% necrotic tissue and was improving. The wound management note, dated 7/18/24, indicated the Stage 4 facility acquired pressure ulcer to the resident's left heel measured 2 cm long by 2.3 cm wide by 0.4 cm deep with a moderate amount of serous exudate. There was 80% granulation tissue and 20% necrotic tissue. The wound was improving. The Wound Company evaluation, dated 7/24/24, indicated the risks and benefits of using human tissue-based skin substitute graft treatment was discussed with the resident's family member. The family member and physician agreed to proceed with the placement during the subsequent wound care visit. The wound nurse's note, dated 8/5/24 at 1:16 p.m., indicated the pressure ulcer to the resident's left heel measured 2 cm long by 2 cm wide by 1 cm deep with 100% granulation and moderate serous drainage. The wound was stable with the skin substitute not intact. The physician's order, dated 8/26/24, indicated to cleanse the left heel wound with normal saline or wound cleanser and pat dry. Apply Mesalt (dressing used to help manage wounds that are discharging heavily or are infected) and cover with an ABD (abdominal pad). Wrap the dressing with rolled gauze and apply tape. Wrap the rolled gauze with an ACE wrap. Provide dressing changes as needed for soiled or dislodged dressing per physician's orders. Do not disturb the wound bed more than 6 times per day as needed. The wound nurse's note, dated 8/27/24 at 1:12 p.m., indicated during a follow-up of the left foot dressing, the dressing had been replaced. The dressing was removed over the weekend and the skin substitute was absent. The wound measured 2 cm long by 2 cm wide and had improved. The Quarterly MDS assessment, dated 7/17/24, indicated the resident had bilateral lower extremity impairment. She used a wheelchair for mobility. She required substantial or maximal assistance for putting on or taking off footwear. The wound management note, dated 8/29/24, indicated the Stage 4 facility acquired pressure ulcer to the left heel, measured 1.9 cm long by 1.5 cm wide by 0.3 cm deep with a moderate amount of serous exudate. There was 100% granulation tissue, and the wound was improving. The physician's order, dated 8/29/24, indicated the left heel wound dressing was to be left intact with the skin substitute left in place. The skin substitute was to only be replaced if soiled or dislodged as needed. Do not disturb the wound bed. The skin substitute was to be changed per the wound physician or wound nurse on Thursdays during wound rounds unless soiled or dislodged. The physician's order, dated 8/29/24, indicated to apply Mesalt to the left heel wound and cover with an ABD, wrap with rolled gauze, and apply tape. Wrap the dressing with ACE wrap. The dressing may be replaced if it became soiled or dislodged as needed. This was to be completed by the wound physician or wound nurse manager on Thursdays with the new skin substitute. The wound management note, dated 9/19/24, indicated the Stage 4 facility acquired pressure ulcer to the resident's left heel, measured 0.9 cm long by 1.2 cm wide by 0.3 cm deep with a moderate amount of serous exudate. There was 100% granulation tissue, and the wound was improving. The wound nurse's note, dated 9/24/24 at 1:35 p.m., indicated a follow-up visit by the wound physician was performed on the left heel pressure ulcer. The dressing was to be kept clean, dry and intact per the physician's orders with a skin substitute in place. The wound management note, dated 9/26/24, indicated the Stage 4 facility acquired pressure ulcer to the resident's left heel, measured 0.8 cm long by 1.2 cm wide by 0.2 cm deep with a moderate amount of serous exudate. There was 100% granulation tissue and was improving. During an interview on 9/26/24 at 8:54 a.m., the wound physician indicated the resident's wound to the left heel wasn't responding well, so a placenta membrane graft was used. After the placenta membrane graft there was a 50% reduction in the wounds size. The wound had been stagnant forever. Pressure was the cause of the wound. The resident had multiple comorbidities of dementia, obesity, and diabetes mellitus. Positioning was a big issue. Even with the boots on the resident, it was hard to get her heels offloaded. She was compliant with turning and repositioning and keeping the boots on. The wound physician had changed treatments over the last year. The skin grafts helped with hormonal stimulation. During an observation and interview on 9/26/24 at 11:00 a.m., the wound physician indicated the resident's left heel wound, measured 1.2 cm x 0.9 cm wide. The resident's oxygen saturations were acceptable now. The wound nurse indicated the resident had her pain medications and she asked the resident if she was experiencing pain. The resident indicated she still had some pain. The wound physician indicated the skin substitute had just been removed, but it would dissolve over time. The wound bed was a beefy red. The skin substitute was ordered weekly for ten weeks. The wound had improved over the last four weeks. The start date of the left heel wound was on 11/23/23. The resident's heels were offloaded, and the preventative measures were in place on 10/26/23. The resident was independent enough and could remove the preventative measures if she wanted to. The wound physician indicated the resident's left heel wound was not unavoidable, since there needed to be more indicators for that diagnosis. The Skin Assessment policy, dated 2/1/19, included, but was not limited to, . Procedure: Residents within a [corporate company] will have a head-to-toe skin assessment completed by a licensed nurse upon admission and weekly thereafter . committed to providing quality care to our residents by implementing clinical guidance and best practices for management of wounds and other skin conditions throughout a resident's stay . 3.1-40(a)(1)

Based on observation, record review and interview, the facility failed to ensure narcotics were documentated on the Controlled Drug Record of the administered narcotics for 6 of 68 residents observed for medication storage on the C and E Hall medication carts. (Residents 104, 21, 60, 26, 3, and 54) Findings include: 1. During an observation on 9/25/24 at 1:53 p.m., of the C Hall medication cart, the following were identified: a. Resident 104's oxycodone 10 mg (milligrams) Controlled Drug Record had a count of 7 tablets left. The resident's medication card contained 6 tablets of the oxycodone. The last dose signed out on the Controlled Drug Record was on 9/25/24 at 2:44 a.m. The clinical record was reviewed on 9/29/24 at 1:20 p.m., the physician's order, dated 9/20/24, indicated the resident received the oxycodone 10 mg every 4 hours as needed for pain. The resident's September MAR (Medication Administration Record) indicated the resident's last dose of oxycodone 10 mg was administered on 9/25/24 at 12:38 p.m., by LPN (Licensed Practical Nurse) 3. b. Resident 21's hydrocodone/APAP (acetaminophen) 5-325 mg Controlled Drug Record had a count of 8 tablets left. The resident's medication card contained 7 tablets of the hydrocodone/APAP. The last dose signed out on the Controlled Drug Record was on 9/24/24 at 9:00 p.m. The clincial record was reviewed on 9/29/24 at 1:24 p.m., the physician's order, dated 9/19/24, indicated the resident received the hydrocodone/APAP 5-325 mg twice a day for pain. The resident's September MAR indicated the resident's last dose of hydrocodone 5-325 mg was administered on 9/25/24 between 7:00 a.m. and 11:00 a.m., by LPN 3. c. Resident 60's Tramadol 50 mg Controlled Drug Record had a count of 18 tablets left. The resident's medication card contained 17 tablets of the Tramadol. The last dose signed out on the Controlled Drug Record was on 9/24/24 at 8:00 p.m. The clinical record was reviewed on 9/29/24 at 1:27 p.m., the physician's order, dated 9/13/24, indicated the resident received the Tramadol 50 mg twice a day for pain. The resident's September MAR indicated the resident's last dose of Tramadol 50 mg was administered on 9/25/24 between 7:00 a.m. and 11:00 a.m., by LPN 3. d. Resident 26's Clonazepam 0.5 mg Controlled Drug Record had a count of 14 tablets left. The resident's medication card contained 13 tablets of the Clonazepam. The last dose signed out on the Controlled Drug Record was on 9/24/24 at 8:00 p.m. The clinical record was reviewed on 9/29/24 at 1:29 p.m., the physician's order, dated 9/18/24, indicated the resident received the Clonazepam 0.5 mg twice a day for anxiety disorder. The resident's September MAR indicated the resident's last dose of Clonazepam 0.5 mg was administered on 9/25/24 between 7:00 a.m. and 11:00 a.m., by LPN 3 e. Resident 3's Clonazepam one half tablet of 0.5 mg (0.25 mg) Controlled Drug Record had a count of 17 tablets left. The resident's medication card contained 16 tablets of the Clonazepam. The last dose signed out on the Controlled Drug Record was on 9/24/24 at 8:00 p.m. The clincial record was reviewed on 9/29/24 at 1:32 p.m., the physician's order, dated 6/6/24, indicated the resident received the Clonazepam one half tablet of 0.5 mg (0.25 mg) three times daily for anxiety disorder. The resident's September MAR indicated the resident's last dose of Clonazepam one half tablet of 0.5 mg (0.25 mg) was administered on 9/25/24 between 7:00 a.m. and 11:00 a.m., by LPN 3. f. Resident 3's Tramadol 50 mg Controlled Drug Record had a count of 14 tablets left. The resident's medication card contained 13 tablets of the Tramadol. The last dose signed out on the Controlled Drug Record was on 9/24/24 at 8:00 p.m. The clincial record was reviewed on 9/29/24 at 1:35 p.m., the physician's order, dated 6/30/23, indicated the resident received the Tramadol 50 mg three times daily for chronic pain. The resident's September MAR indicated the resident's last dose of Tramadol 50 mg was administered on 9/25/24 between 7:00 a.m. and 11:00 a.m., by LPN 3. During an interview on 9/25/24 at 1:58 p.m., LPN 3 indicated she should have signed out each narcotic as she pulled it. 2. During an observation on 9/25/24 at 2:21 p.m., E Hall medication cart, the following was observed: Resident 54's hydrocodone/APAP 5-325 mg Controlled Drug Record had a count of 11 tablets left. The resident's medication card contained 10 tablets of the hydrocodone/APAP. The last dose signed out on the Controlled Drug Record was on 9/24/24 at 8:30 p.m. The clinical record was reviewed on 9/29/24 at 1:40 p.m., the physician's order, dated 8/28/24, indicated the resident received the hydrocodone/APAP 5-325 mg every 6 hours as needed for pain. The resident's September MAR indicated the resident's last dose of hydrocodone 5-325 mg was administered on 9/25/24 at 9:13 a.m., by LPN 4. During an interview on 9/25/24 at 2:25 p.m., LPN 4 indicated she should have signed the narcotic out after it was given. During an interview on 9/26/24 at 8:39 a.m., the DON (Director of Nursing) indicated nurses should sign narcotics out once it was given. Neither of the nurses did that. They needed to show that the count was correct and that there were no narcotic discrepancies. The current Clinical Policy and Procedure for Scheduled Drugs, included but was not limited to, . Step 2: Passing of Scheduled Drugs. Immediately after a dose of a scheduled drug is administered, the licensed nurse administering the schedule drug is to enter all of the following information on the green sheet attached hereto as Exhibit 1: Date and time of administration. Dose administered. Signature of nurse administering the dose. Remaining Doses . 3.1-25(b)(1)(c)

Based on record review and interview, the facility failed to ensure the residents received their mail on Saturdays when it was delivered to the facility. This deficient practice had the potential to affect 109 residents currently residing in the facility. Findings include: During the Resident Council meeting on 9/24/24 at 9:55 a.m., with 13 residents whom the Activities Director indicated were alert and oriented. The residents voiced that they were not receiving any mail on Saturdays. They indicated they knew it was being delivered to the facility as they had seen the mailman come in. During an interview with the Activities Director on 9/30/24 at 9:15 a.m., he indicated the mail during the week was passed by him. If the Friday mail came in late in the afternoon, he would go ahead and pass it before he left for the day. The mail was being delivered to the facility on Saturdays, but someone had to sort through it and remove the mail the residents were not supposed to receive such as bills. He did not know who did the sorting on Saturday, but any mail that came in on Saturday was not delivered until Monday when he came in. During an interview with RN 1 on 9/30/24 at 9:40 a.m., she indicated the facility did not have a policy on the mail delivery. The facility followed the State and Federal rules on Resident Rights. During an interview with the Executive Director (ED) on 9/30/24 at 3:00 p.m., she indicated that usually the residents did receive their mail on Saturdays, but they had been short a weekend receptionist on duty for a couple of weeks. The weekend receptionist was responsible for sorting the mail for Activities to then pass to the residents. During this time, the residents did not receive mail on Saturdays. 3.1-3(s)(1)

Based on record review and interview, the facility failed to promptly resolve the grievances made by the Resident Council and discussed the resolutions/responses at the next Resident Council meeting during 3 of 9 Resident Council meetings. (February, April, and August 2024) Findings include: During the Resident Council meeting on 9/24/24 at 9:55 a.m., with 13 residents whom the Activities Director indicated were alert and oriented. The residents voiced that they had the meetings and voiced their concerns, and then that was the last they heard. They never knew what the outcome was to their concerns. They indicated it was not discussed in the next month's meeting. 1. The Resident Council meeting, held on 2/2/24, indicated the following concerns were not addressed by the responsible department or resolved: - Resident 34 was missing clothes. - Residents were tired of the same menu. The kitchen needed to cut back on the salt in the food. No response to these concerns could be located. During the meeting, the residents voiced concerns about not getting their clothes back. The Director of Laundry responded on 2/2/24, that she would speak with the laundry staff and that as long as things were labeled, they would try to make sure they got to the correct residents. The residents voiced concerns that the third shift CNA (Certified Nursing Aide) on B hall needed to do a better job. On 2/2/24, the Director of Nursing (DON) responded that she would educate and discipline the staff. These concern responses were not signed by the Resident Council President. Documentation was lacking of the departments' responses being discussed in the next month's meeting. 2. The Resident Council meeting, held on 4/5/24, indicated the following concerns were not addressed by the responsible department or resolved: - Resident 34 was missing clothes. - Tired of the same menu. Needed to cut back on the salt in the food. No response to these concerns could be located. 3. The Resident Council meeting, held on 8/2/24, indicated the following concerns were not addressed by the responsible department or resolved: - Resident 62 was missing pants. - Although the food tasted good, residents would like more choices. No response to these concerns could be located. During the meeting, the residents voiced they would like the shower times and days to be the same every time and call lights needed to be answered faster. On 8/2/24, the DON responded that she would educate the staff. Documentation was lacking of the Nursing department's responses being discussed in the next month's meeting. During an interview with the Activities Director on 9/24/24 at 11:20 a.m., he indicated there was no place on the Resident Council Minutes form to write what the old business was, but that he did go over last month's concerns and resolutions with the residents at the next meeting. During an interview with RN 1 on 9/30/24 at 9:40 a.m., she indicated the facility did not have a policy on Resident Council. They followed the State and Federal rules on Resident Rights. During an interview with the Social Services Director on 9/30/24 at 9:45 a.m., she indicated the facility did not have a grievance policy. They followed the Resident Rights. During an interview with the ED (Executive Director) on 9/30/24 at 3:00 p.m., she indicated any issues raised in Resident Council meetings were written on a concern form for the responsible department to address. It was then gone over with the Resident Council President as he signed the concern forms. She was not aware the resolutions (old business) were not being brought to the Resident Council at the next meeting. The old Resident Council forms did have a place to write about old business and if there were resolutions to their concerns or it was still being worked on. She did not know why the new forms did not have this section. 3.1-3(k) 3.1-3(l) 3.1-7(a)(2)

Based on observation, record review, and interview, the facility failed to ensure a hot liquid assessment was completed for a resident with a decline in function for 1 of 4 residents reviewed for accidents. (Resident 80) Findings include: During an observation on 9/23/24 at 12:30 p.m., Resident 80's lunch tray was sitting on the table within the resident's reach. No staff were in the resident's room. The resident was able to pull the tray close to him and pick up his spoon. He attempted to pick up his peaches. Due to the resident's bilateral hand contractures, he was unable to pick up the small bowl of peaches. He attempted to pick up a peach with his spoon and was unable to do so. The record for Resident 80 was reviewed on 9/24/24 at 11:00 a.m. The resident's diagnoses included, but were not limited to, moderate intellectual disabilities, limitation of activities due to his disability, contracture of the right hand, contracture of the left hand, contracture of muscle on the right hand, contracture of the muscle on the left hand, and abnormal posture. The Quarterly Minimum Data Set (MDS) assessment, dated 7/4/24, indicated the resident was severely cognitively impaired. The resident had functional limitations in range of motion and required moderate assistance with eating. The nurse's note, dated 1/17/24 at 3:49 p.m., indicated Resident 80 was observed to have spilled soup in his lap during lunch. The resident was brought back to his room after lunch for an assessment. The resident had a red and pink area to his right inner thigh. A therapy and nursing interdisciplinary communication form was completed, related to self-feeding difficulties. The physician order, dated 1/17/24, indicated staff were to apply skin prep to the resident's burn area on the right inner thigh every shift twice a day upon rising and before bedtime. The nurse's note, dated 1/18/24 at 9:54 a.m., indicated the resident's skin was assessed by the nurse for a post event follow-up. Redness was observed to the right inner thigh measuring 4.5 cm(centimeters) long by 2.5 cm wide. The nurse's note, dated 1/21/24 at 5:59 p.m., indicated the burn area to the resident's inner thigh had healed at that time. During an interview on 9/30/24 at 9:38 a.m., the DON (Director of Nursing) indicated the resident could feed himself at times. He could pick up finger foods such as sandwiches. Staff encouraged him to eat and if he needed assistance, they would assist him. His hot liquids should be put in a cup with a lid on it. The facility did not do a hot liquid evaluation on the residents and there was no policy for hot liquids. During an interview on 9/30/24, at 10:00 a.m., OT (Occupational Therapy) 2 indicated the resident could handle finger foods. He would use two to three fingers to pick the food up due to his contractures. He had to be positioned straight up in his chair due to the potential for choking. Soups would be difficult for him to handle. The staff should put hot liquids in a cup with a lid. The resident could be impulsive at times and grabbed for his food. She was not aware he received a burn from soup, but she would have concerns giving him anything hot that was not in a cup with a lid on it. 3.1-45(a)

Based on observation, record review, and interview, the facility failed to ensure appropriate interventions, supervision, and care were provided for a resident with dementia related behaviors for 1 of 3 residents reviewed for Dementia Care. (Resident B) Findings include: The record for Resident B was reviewed on 12/18/23 at 9:15 a.m. The diagnoses included, but were not limited to, Alzheimer's disease, dementia with other behavioral disturbance, severe with anxiety, colostomy status, need for assistance with personal care, attention and concentration deficit, and mild cognitive impairment of uncertain or unknown etiology. The care plan, dated 11/15/22, indicated the resident required care and assistance for his colostomy with a potential for complications. The interventions included, but were not limited to, change the ostomy as ordered, provide care as ordered, report abdominal distention or discomfort, erythema, edema, tenderness, or drainage to stoma. The Social Services note, dated 1/25/23 at 8:50 a.m., indicated the resident had increased confusion. He was stating he was leaving. He was able to be redirected and had a wander guard in place. He was then found at the doors again with his jacket on and his pictures in his hands. The IDT (Interdisciplinary Team) met with the resident's family and discussed moving him to the Memory Care Unit. The Social Services note, dated 1/25/23 at 9:55 p.m., indicated the resident's family agreed to place him on the secured unit. The Social Services note, dated 1/31/23 at 9:06 p.m., indicated the resident was adjusting well to the Memory Care Unit. He participated in activities, enjoyed listening to live music, and had no exit seeking behaviors. He did flirt with women, but it was not inappropriate. The care plan, dated 1/31/23, indicated the resident had a diagnosis of dementia which negatively impacted his cognition and judgement, causing him to require a locked, structured unit. The interventions included, but were not limited to, educating family of the disease process, encouraging the resident to eat in the dining room, participate in activities, and provide cues and reminders, as necessary. The care plan, dated 1/31/23, indicated the resident frequently liked to compliment women and tell them how beautiful they were. The interventions included, but were not limited to, encouraging outings with the resident's family on Thursday nights for a change in scenery, ensure he was not making the other person uncomfortable, remove him from that person if he was, and keep the resident active in facility life. The care plan had no revision or additional interventions after it's initiation on 1/31/23. The Social Services note, dated 2/9/23 at 3:57 p.m., indicated a care plan meeting was held with the resident's family. The family member stated Resident B liked to flirt with the ladies and asked the facility to please document that he did that because he meant no harm. The nurse's note, dated 2/11/23 at 9:39 p.m., indicated the resident came out of his room without any underwear on and went into another female resident's room. He was asked not to go into anyone's room, and to put on his underwear. He apologized and went back to his room and got back into bed. The care plan, dated 2/23/23, indicated the resident urinated in other resident's rooms in their trash cans and their beds. The interventions included, but were not limited to, remind the resident to go to the restroom frequently and when walking down the hall redirect him to his room. The care plan, dated 2/23/23, indicated the resident masturbated without closing the door or pulling the curtain and would disrobe in public. The interventions included, but were not limited to, attempt to stop him before he leaves with no clothes on and remind him, he needed to wear clothing, encourage family outings for change in scenery, psychiatric services, and pull curtain and shut for the resident as needed. The nurse's note, dated 2/26/23 at 3:04 p.m., indicated the resident was continuously going in female rooms. When staff attempted to redirect him, he began to curse at staff. The resident threatened staff when redirected stating he was going to knock her head off and calling her names. The resident was standing behind staff continuing to call names and curse at her. He refused to move when asked. He eventually walked into the dining area and sat at a table. The resident cursed at two other female residents when sitting at table with them. He had no further behaviors. The nurse's note dated 2/27/23 indicated the Psychiatric NP (Nurse Practitioner) gave new orders for Paxil 20 mg daily for increased agitation and anxiety. The Social Services note, dated 2/27/23 at 8:56 p.m., indicated the MCC (Memory Care Coordinator) spoke with the resident's family concerning the weekend events. The resident had a history of getting confused when finding his room. A picture would be placed on his door to help him find his room to help him not wander into other resident rooms. The resident was very active and attended all activities that day. He was in a pleasant mood with no behaviors. The nurse's note, dated 2/28/23 at 4:50 a.m., indicated the resident was asked several times to stay out of female resident rooms. He was not easy to redirect. He went back in the same rooms again and would get angry and start cursing when asked to come out. The nurse's note, dated 3/21/23 at 10:39 a.m., indicated the resident tried to change his colostomy bag and placed toilet paper on his stoma. The nurse cleaned and changed the colostomy and would continue to monitor. The Social Services note, dated 4/20/23 at 4:58 p.m., indicated the resident was seen by psychiatric services with no new orders. He continued to remain very active in facility life and attended and participated in most activities. He continued to be flirtatious with female staff but had not done anything inappropriate. The Social Services note, dated 4/27/23 at 5:11 p.m., indicated the resident was seen by psychiatric services and started on mirtazapine and Depakote. The Social Services note, dated 5/12/23 at 3:44 p.m., indicated the resident continued to wander around the neighborhood and went into other residents' rooms but was now just focusing in on female residents' rooms. When the nurse attempted to redirect him, he balled his fist up and stated he was not going to move out of the room. Other staff assisted and the resident exited the room. The resident had a flirtatious demeanor since admitting to the neighborhood and usually was easy to redirect but lately he had some underlying anger issues and his focus, even when participating in activities, was on women. The Psychiatric NP was notified and gave orders to start the resident on a Climara patch. Staff had been monitoring closely and redirecting. The nurse's note, dated 5/30/23 at 10:57 a.m., indicated the resident continued to be flirtatious with female staff. He urinated in the dining room that morning and stated, they told him to. The nurse's note, dated 6/6/23 at 10:54 a.m., indicated the resident was redirected several times to his restroom. He was attempting to use the restroom in the hallway and in other resident rooms. The nurse's note, dated 6/9/23 at 1:33 p.m., indicated the resident took his colostomy off and threw it in another resident's room. He was taken to his room and cleaned up and a new colostomy wafer and bag were applied. The resident's care plan was not updated with any interventions or goals related to the resident's behavior of removing his colostomy bag. The nurse's note, dated 6/14/23 at 3:48 p.m., indicated new orders were given to increase the resident's Paxil to 30 mg daily. The nurse's note, dated 6/19/23 at 11:15 a.m., indicated the resident was attempting to push other residents in their wheelchairs and trying to feed residents He became agitated and verbally aggressive when staff attempted to redirect him. He kept stating he wanted something to eat when his plate was in front of him untouched. Staff attempted to show it to him, and he became argumentative. The nurse's note, dated 6/28/23 at 2:05 a.m., indicated the resident's colostomy bad was changed and he was educated on the rationale of keeping his colostomy bag in place. The nurse's note, dated 7/7/23 at 10:27 a.m., indicated the resident removed his colostomy and threw it in the trash. The bag was changed. The Quarterly MDS (Minimum Data Set) assessment, dated 7/12/23, indicated the resident was severely cognitively impaired and had no behaviors. The nurse's note, dated 7/24/23 at 9:00 a.m., indicated the resident was redirected from pushing another resident in her wheelchair and became verbally aggressive stating I will knock you're a** out to the nurse. He was again redirected and put his fists up and stood there stating he was going to hit the nurse. He walked off cussing and went to the dining area to sit at a table with another resident. Staff would continue to monitor. The nurse's note, dated 7/24/23 at 11:00 a.m., indicated the resident was redirected not to push resident's wheelchairs. The resident because verbally aggressive with the nurse and walked over to the nurse's station where another nurse was charting stating he was going to hit the nurse in the mouth. The nurse attempted to redirect the resident, the resident then put up his fists and jumped forward to hit the nurse's hand with his fist. The nurse blocked. The resident then started whispering f**k you several times, stating you're ugly several times while walking down the hall and returning to his room. The nurse's note, dated 7/24/23 at 12:45 p.m., indicated the resident was in the dining room trying to push a female in her wheelchair. The nurse tried to redirect the resident and asked him to go for a walk with her. He stated, Yes I will go for a walk with you outside so I can beat you're a** because you are so ugly! The nurse walked away, as the resident was away from other residents. Therapy took the resident to the gym to help defuse. Social Services and psychiatric services were notified. The Social Services note, dated 7/24/23 at 1:12 p.m., indicated the resident had been agitated most of the day and during report from weekend staff they stated he had been like that all weekend. He liked to push female residents in their wheelchairs even if they did not want pushed. When staff intervened, he would ball up his fists and threaten them. He had struck two nurses on that day. This SSD would speak to him after the incident and due to his cognitive deficits, he did not remember the incident. The SSD also was intervening when he stated, I'm going to have you arrested but before that I am going to kick your a**. The Psychiatric NP was informed and gave new orders to increase his Depakote to 250 mg twice daily with meals. The Social Services note, dated 7/24/23 at 3:24 p.m., indicated the resident on three different occasions was yelling names and threatening to hit female staff when they were redirecting him out of other resident rooms. The resident's family was contacted and they were on the way to speak with him. He was currently with the MCC in one on one. Every time the MCC tried to speak to him he would turn it into an argument. The nurse's note, dated 7/29/23 at 12:58 p.m., indicated the resident tried to take another resident's sweater off her walker earlier in the shift. The resident asked him to leave it alone because it was hers. Resident B got agitated and told the female resident he would take it if he liked. The nurse intervened and was able to redirect the resident. The nurse's note, dated 8/3/23, indicated the psychiatric NP was in and ordered to change the resident's Depakote to 125 mg three times daily. The nurse's note, dated 8/8/23 at 12:55 a.m., indicated the resident was exit seeking, combative, placed his colostomy bag in the refrigerator, spit phlegm in inappropriate areas, forcefully shook the medication cart drawer handles in attempt to gain entry, and was very disruptive and disturbing to other residents. He required constant redirection all shift and did not sleep. He drew back his fists as if he was going to strike staff while exhibiting very angry facial expressions. The refrigerator was emptied, a new colostomy bag was given, the resident was given a snack and encouraged to watch an episode of his favorite show, the X-files, and he was encouraged not to hit staff. Communication was placed in the physician's rounding book. Staff were rounding per the facility protocol. The Social Services note, dated 8/8/23 at 2:05 p.m., indicated when an activities staff member mentioned she was getting hot the resident stated, Take off all your clothes and I will watch. The resident was redirected back into the facility. The care plan, dated 8/8/23, indicated the resident had sexually inappropriate behaviors which required the use of Depakote. The only intervention was when the resident became aggressive, to give him space and allow him to calm down then re-approach him. The care plan did not provide any resident specific interventions for de-escalation of behaviors or safety of the resident and others. The care plan lacked documentation of any revision or new interventions past its initiation on 8/8/23. The nurse's note, dated 8/8/23 at 4:17 p.m., indicated the resident was seen by the NP and received new orders for a CBC (Complete Blood Count), BMP (Basic Metabolic Panel), and a urinalysis with c&s (Culture and Sensitivity). The Social Services Note, dated 8/21/23 at 10:46 a.m., indicated the resident had some increased agitation and cursing noted over the weekend. At times he could be hard to redirect but usually if another staff member came to assist; he would go with that other staff member without incident. He was placed on the list to have Psychiatric services see him. The Social Services note, dated 8/24/23 at 4:08 p.m., indicated the psychiatric NP increased the resident's Depakote for mood stabilization. The Social Services note, dated 8/30/23 at 5:00 p.m., indicated the resident was in the dining room waiting for dinner. He was pushing female residents in their wheelchairs even if they weren't ready to be pushed to a table. The MCC thanked the resident for his help but asked him to please leave the other resident alone. He turned around and stared at the MCC with a furrowed brow and piercing eye expression. She got the resident a cup of coffee and he went and sat with some other ladies. She then noticed arguing coming from that table and the female resident began to yell at the resident and told him to quit talking to her. The resident laughed, pointed his finger, and said things to the female resident who was getting visually upset along with two other ladies sitting there. She offered him to sit at another table with a male resident and to freshen his coffee. He proceeded to tell the MCC what she needed to do and was making fun of other staff members. He was redirected but only lasted a short time before he was up and trying to push other residents again. The nurse's note, dated 9/12/23 at 2:40 a.m., indicated the resident had increased sexual behaviors. The CNA (Certified Nurse Aide) found the resident with barrier cream on his hands, putting it in his anus. The physician was notified through the communication binder. The Social Services note, dated 9/12/23 at 10:53 a.m., indicated the Psychiatric NP was notified and gave orders to send the resident to an inpatient behavioral unit. The resident was accepted to the outside unit, however, was unable to go due to subsequently testing positive for COVID-19. The resident was on 15-minute checks during his isolation period and had no further sexual behaviors during the time. His isolation ended on 9/24/23, and he was seen by Psychiatric NP on 9/25/23 with no new orders given. The nurse's note, dated 10/5/23 at 12:46 a.m., indicated the resident was following the CNAs to other rooms. He was attempting to wake his roommate up. He told the CNA multiple times he wanted to kiss her. He told the nurse, I'm going to take you into my bed tonight, you need a little attention. He had also made references to the CNA going to bed with him. Several snacks were provided, and he was sitting at the nurses station for supervision. The nurse's note, dated 10/10/23 at 10:06 p.m., indicated the resident smacked a CNA on the butt. The CNA explained to the resident that it was inappropriate, but the resident just laughed. Multiple nursing notes, between 11/1/23 and 12/18/23, indicated the resident continued to remove his colostomy bag at night. The nurse's note, dated 11/13/23, indicated the resident had increased insomnia, anxiety, was going in and out of other residents' rooms waking them up, refused to follow simple commands or instruction, was swinging his fists to fight staff, and urinating on the floor. The resident was placed on the physician's rounding log. The nurse's note, dated 11/13/23 at 4:01 p.m., indicated the NP gave new orders for a CBC, BMP, and a urinalysis with C&S. The urinalysis was unable to be obtained due to resident refusal and incontinence and the order was discontinued. The nurse's note, dated 11/25/23 at 5:15 a.m., indicated the resident was found in another female resident's room sitting on the floor. He was naked from the waist down with his legs and genitals facing the female resident who was watching him sitting on the floor. The supervisor and family were notified, and the resident was assisted back to his room. The Social Services note, dated 11/27/23 at 1:30 p.m., indicated the resident toileted himself and had frequent issues with putting his pants on properly and needed assistance from staff. Signs were made bigger that had his name and picture on them and placed next to his name plate to assist him in finding his room. The nurse's note, dated 12/11/23 at 12:41 a.m., indicated the resident was walking in and out of resident rooms, scaring some of the females. When redirected the resident would become aggressive with staff. He was urinating on his floor and was unable to be redirected. He was sitting at the nurse's station and staff would continue to monitor. The physician's note, dated 12/11/23 at 1:45 a.m., indicated the resident had aggressive behavior and was trying to hit staff and wandering into other resident rooms. He had an unspecified injury of the left wrist, hand, and fingers. Orders were given for an x-ray with 3 views of the left wrist and a 1-time dose of Haldol 3 mg intramuscular. The x-ray was negative for fracture. The nurse's note, dated 12/11/23 at 2:37 a.m., indicated the resident became more aggressive with staff and twisted right wrist and hit staff in the arm. The physician was notified, and a new order was given. The Social Services note, dated 12/12/23 at 11:33 a.m., indicated the resident was displaying anxious behaviors. He was asking if people wanted coffee and passed out empty bowls thinking they were coffee cups. When staff would try to redirect, he would stare at them and then continue. He was laying in other resident's beds. He became agitated when staff tried to assist him to the dining room. Psychiatric services would follow up with him on the next visit. The nurse's note, dated 12/17/23 at 10:29 p.m., indicated the resident's left hand had improved, but the knot and discoloration continued. The swelling had decreased. The resident had attempted to go in other resident rooms, was throwing trash in other resident rooms, and became aggravated with CNA redirection. He was hitting the CNA but calmed down when the nurse intervened. She walked him to his room, he stayed for a while but started to go into other rooms again. He was sitting at the nurse's station at the time talking about breasts and stated one of the CNA's had a bunch of d***s inside of her. Staff would continue to monitor. The nurse's note, dated 12/18/23 at 5:18 a.m., indicated the resident was found urinating on another resident's bed. He was redirected back to his room, reminded of where his bathroom was, and made aware that urinating on beds was inappropriate. During an observation on 12/18/23 at 9:30 a.m., Resident B was observed to enter a female resident's room and lie down on the first bed in the room. He was fully clothed with shoes on. During an observation on 12/18/23 at 9:32 a.m., CNA 5 indicated the resident in the female's bed was Resident B. She entered the room and indicated to the resident,, Hey you're in another resident's bed. Let me show you where your bed is. She then assisted the resident to his bed which was down the hall. There were signs and pictures on the door indicating it was his room with his pictures. Upon interview the CNA indicated Resident B sometimes went into the female resident beds. During an observation on 12/18/23 at 11:12 a.m., Resident B was in another room which belonged to two female residents. He was lying in the first bed and the curtain was drawn between him and the second bed. He smiled and waved as he laid in the bed. There were no staff observed to be on the hall. There was a nurse and an aide at the end of the hall behind the nurse's station. During a continuous observation, from 11:12 a.m. to 11:45 a.m., no staff members walked down the hall or checked on Resident B's location. Unit Manager 6 was down the hall providing care for another female resident. During an observation on 12/18/23 at 11:45 a.m., LPN (Licensed Practical Nurse) 7 walked down the hall and observed the resident in bed. She left to obtain assistance. During an observation on 12/18/23 at 11:47 a.m., LPN 7 returned with LPN 8 and indicated she was getting my male patient out of this female bed. Upon entering the room, Resident B was lying abed. He had on no pants. His colostomy bag was removed, with the wafer in place. His abdomen, the stoma, and his brief were covered in brown stool. LPN 7 and LPN 8 assisted the resident to clean up and replace his colostomy wafer and bag. The second bed in the room was occupied by a female resident who was resting with her eyes closed. During an interview on 12/18/23 at 11:50 a.m., LPN 7 indicated it was a mystery where his colostomy bag could be. He removed them all the time. They would have to go and find it when they got done cleaning him up. The bag could be in any room. During an interview on 12/18/23 at 12:01 p.m., LPN 7 indicated she rounded and saw the resident in the female resident's room. She then got help to change him. They rounded on everyone every 2 hours. It was hard to redirect Resident B. He could get verbally and physically aggressive with staff. He went in and out of rooms, but he'd done that a lot. She was not aware of any recent sexual inappropriateness. They tried to redirect him away from women. She knew when he had specific behaviors before, she thought they'd done 15-minute checks on him, but he was not still on them. They did round on him more frequently, but she was not sure if there was a note in there or any orders for increased monitoring. Everybody tried to always keep track of him because of the stuff he did. He urinated in trash cans and took his colostomy bag off. When she had last rounded on the hall probably after breakfast, around 10:15 a.m., he was in his room, and he had clothes on at that time. She had been informed he'd been in another female resident's room prior. They would have to go find his colostomy bag. He threw them in the toilet, in the rooms, he'd put it in his room, he had left them in other rooms and that's where they would end up finding them at. During an observation on 12/18/23 at 12:12 p.m., Resident B was back in the same room from the prior observation, lying in the female resident's bed. LPN 7 redirected him back to his room once more. There was liquid on the floor to the right side of his bed, with yellow staining the edge of his sheet. There was brown matter on his roommate's bed, a stool covered towel in the bathroom, and his roommates drawers were open, appearing rifled through. The nurse could not locate the resident's colostomy bag after searching multiple rooms. During an interview on 12/18/23 at 12:46 p.m., the MCC indicated Resident B had a big cognitive decline over the last few months. He used to be very active in activities and would participate, but recently he was more to himself. He was anxious and agitated with redirection. Usually, he was really good if you came at it with a joking way. He liked to take care of people, so he was always wanting to do things for other people. She'd had him help wipe down and different things like that. She would give him towels, washcloths, he did participate in that. Then would get kind of bored. So, she would take him for walks. Occasionally they went off the unit. That helped him. He would help pass out shirt protectors. She was not typically there on weekend, but they had one activities staff there on day shift. When they weren't there the nursing staff were responsible for intervening with him. They probably had not developed specific care plans with interventions for him. He did not respond well to instructive redirection. He could not be educated and education for him would be inappropriate. He didn't like to hear from women. She did not know about the incident of him urinating on another resident's bed. She knew he did urinate in other areas. She was not aware of a toileting schedule for him. It couldn't hurt. The IDT had conversations, but she had not written a list of his likes and dislikes. They had not implemented more frequent monitoring or supervision interventions. It sounded like he did need to be checked on more frequently than every 2 hours. She didn't know he was still having issues with taking his colostomy off. She thought messing with it was part of his dementia. He'd had it 30 plus years. It wasn't anything new to him. She didn't realize taking it off consistently was a problem. She thought the one instance with the freezer was a behavior like a temper tantrum. She felt she should have a weekly communication with the nursing staff. That had done that in the past and then it just got crazy, but she thought it was something that needed to be started again. During an interview on 12/18/23 at 1:11 p.m., Unit Manager 6 indicated the resident had behaviors that were sexual in nature. He had made comments to female staff about getting naked in his bed. He would walk past and pat the female residents. He had been wandering into other resident rooms for quite a while. He would take off his colostomy bag and throw it in the trash or the toilet. Typically, she didn't go looking for it. It happened more on night shift than day shift. They would ask him to come to the common areas, to not touch other residents, they would redirect him to his room, and call his family. He did not, at the present moment, have increased monitoring. The standard was every 2 hours, but with him people checked on him whenever. With him it appeared as if the sweeter tone for the most part worked better than a firmer tone, but sometimes the firm worked. He didn't understand or he doesn't care when it came to being educated. She didn't know if it was the disease process or him just being defiant. Education was not appropriate and did not help with him. The most current Philosophy of Service and Care policy included, but was not limited to, . Our Cherished Memories program is focused on enriching the lives of residents, loved ones, our associates, and friends of persons with dementia through our activity focused approach to care. Our program allows you the opportunity to listen, love and accept the altered psychological and emotional status of our residents . Values . offers a safe, comfortable place that . maximizes choice, service and care based on the personalized needs of our residents . Meaning and purpose is the framework of our dementia program, empowering the resident's responses and participation with value . Associates will focus on resident's strengths in order to achieve the highest opportunity for success . Throughout the day all associates will be a part of our daily life enrichment programs . We strive to know our residents' likes and dislikes, and teach our associates to allow our residents to make their own choices throughout the day . The most current Behavior Management policy included, but was not limited to, . Some of our residents have medical disabilities that can lead to disruptive behaviors and these behaviors have the potential to create a negative effect on the resident, other residents, visitors and staff. It is [Corporation Name] policy that each community will have a behavior program that: identifies, monitors, manages and disseminates (whenever possible) all behavioral events by utilizing the least invasive approach based on the individual resident affected . [Corporation Name] believes in a person-centered approach and tailors all considerations for the individual affected, including physical and psychosocial aspects of well being when it comes to managing maladies that manifest behavioral disturbances . This citation relates to Complaint IN00422843. 3-1.37(a)

Based on record review and interview, the facility failed to ensure interventions were implemented for falls and to ensure safe transfer procedures were implemented for a resident that required maximum assistance which resulted in multifocal acute intracranial hemorrhage, right convexity subdural hematoma, small acute subarachnoid hemorrhage in the right sylvian fissure and interhemispheric fissure and small volume acute intraventricular hemorrhage in the right lateral ventricle for 1 of 6 residents reviewed for accidents. (Resident 57) Findings include: 1.a The record for Resident 57 was reviewed on 8/24/23 at 9:30 a.m. The resident's diagnoses included, but were not limited to, traumatic subdural hemorrhage without loss of consciousness, the need for assistance with personal care, reduced mobility, unsteadiness on feet, and contracture of the left hand. The Annual MDS (Minimum Data Set) assessment, dated 5/9/23, indicated the resident was severely cognitively impaired. She required extensive assistance with 2 staff members physical assistance with transfers, personal hygiene, and toileting. The resident had impairment to the upper and lower extremities. The care plan, dated 11/10/19 and last revised on 8/7/23, indicated the resident was at risk for falling and fall related injuries related to impaired cognition, decreased mobility, generalized muscle weakness and some decreased bilateral knee ROM (Range of Motion). The interventions included, but were not limited to, the resident would be in a supervised area while up in her wheelchair, with a start date of 7/10/23; assistance of 2 staff members while providing incontinent care, with a start date of 6/19/23; and a bolster mattress on the resident's bed, with a start date of 6/21/21. The nurse's note, dated 6/17/23 at 4:16 a.m., by LPN 7 (Licensed Practical Nurse) indicated around 3:48 a.m., a staff member came and got her and stated that a resident just rolled out of the bed and hit her head. The CNA (Certified Nursing Aide) indicated she tried to catch her but did not get to the resident in time. The resident was on the side of her bed on her right side and the resident was incontinent of urine. She was able to move all 4 extremities without any groaning or grimacing. The resident had a baseball sized mass on the right size of her head. At 3:51 a.m., the physician was called, and he stated just to do neurological checks. When the residents POA (Power of Attorney) was called at 3:52 a.m., he stated to send her to the hospital to be checked out. The nurse's note, dated 6/17/23 at 2:26 p.m., indicated the resident was admitted to the hospital ICU (Intensive Care Unit) with a diagnosis of subdural hematoma. The Incident Report, dated 6/18/23, indicated the resident rolled out of bed and hit her head. The CNA tried to catch the resident but did not get to the resident in time. The resident was sent to the hospital for evaluation. A written document by CNA 8, dated 6/18/23, indicated the CNA stated she was providing incontinent care for the resident when the incident happened. The hospital discharge summary, dated 6/20/23, indicated the resident was on chronic anticoagulation with Eliquis for atrial fibrillation. The CT (Computerized Tomography) scan indicated on admission the resident had a multifocal acute and cranial hemorrhage, right convexity subdural hematoma measuring 1.1 cm (centimeters) as well as small other intracranial hemorrhages. The nurse's note, dated 6/24/23 at 4:21 p.m., indicated the resident's right eye had a bruised hematoma. She was able to open her right eye a little bit with some redness observed to the sclera. When speaking to the resident she was not able to speak back. She would open her eyes to verbal stimuli. During an interview on 8/28/23 at 9:20 a.m., LPN 5 indicated the CNA was assisting the resident with incontinence care. The CNA pulled the resident towards her, and the resident's legs came out of the bed, and she slid out. 1.b. The nurse's note, dated 7/7/23 at 6:08 a.m., indicated the resident fell during care that morning. Staff was transferring the resident to a chair when she leaned forward and went down. The resident often pushed the opposite way during care making it harder and harder to control her body weight. The resident could benefit from a mechanical full body lift where she would have 2 staff available for all transfers. The resident was sent to the hospital for evaluation and treatment. The nurse's note, dated 7/8/23 at 9:40 p.m., indicated the resident had a large bump to her right forehead with steri strips in place. A small amount of bloody drainage was observed. During an interview on 8/28/23 at 10:30 a.m., RN 6 indicated she was the nurse on duty when the resident fell out of her chair. One CNA came to get her indicating the resident had fallen out of her chair. The CNA indicated the resident was transferred to the chair and she leaned forward and went down. The Fall Prevention Policy, dated 5/2016, provided on 8/29/23 at 8:24 a.m. included, but were not limited to, .The components of this fall program include: 1. Fall risk assessment; 2. Fall event assessment; 3. Strategies of prevention; 4. Strategies of intervention; 5. Interdisciplinary guidance; 6. Care planning; and 7. Staff education. As such, the Community must take reasonable steps to ensure it implements, best practices and evidence-based approaches to prevent falls and protect residents who are at risk for falling. Due to the risk associated with falls for older adults living in long-term care facilities, compliance with this policy is essential . 3.1-45(a)(1)

Based on record review and interview, the facility failed to ensure the physician was notified when a resident's blood sugar readings fell outside the physician ordered parameters for 1 of 3 residents reviewed for notification of change. (Resident 104) Findings include: The record for Resident 104 was reviewed on 8/25/23 at 11:29 a.m. The diagnoses included, but were not limited to, type 2 diabetes mellitus with hyperglycemia and hypoglycemia, type 1 diabetes without complications, nutritional anemia, and dependence on renal dialysis. A care plan, dated 6/4/23, indicated the resident had the potential for hypoglycemia or hyperglycemia and diabetic complications related to diabetes mellitus. The goal was for the resident to be free of unrecognized hypoperglycemia or hyperglycemia. The approaches included, but were not limited to, administer accu checks (blood sugar checks) and any insulin coverage per physician's order; and to report any signs of hypoglycemia or hyperglycemia. The Quarterly Minimum Data Set (MDS) assessment, dated 6/27/23, indicated the resident was cognitively intact; had frequent appetite issues; and received insulin daily. The resident was admitted to the facility from the hospital on 4/5/23 with the following order: finger stick blood sugar AC (before meals) and HS (at bedtime). Notify the physician if the blood sugar was less than 60 mg/dL (milligrams per deciliter) or greater than 400 mg/dL. On 4/7/23, a new physician's order was received, in addition to the 4/5/23 order, for Insulin lispro insulin pen 100 unit per mL (milliliter); amt (amount): Per Sliding Scale: - If Blood Sugar was less than 60 mg/dL, call physician. If Blood Sugar was greater than 499 mg/dL, call physician. Give subcutaneous four times a day. Indicate (Y=yes or N=no) if physician required notification. Four Times A Day and PRN (as needed) symptoms. The April 2023 Medication Administration Record (MAR), indicated the resident had the following blood sugar reading. - dated 4/30, upon rising the resident's blood sugar reading was high. The June 2023 MAR, indicated the resident had the following blood sugar readings: - dated 6/7, before lunch the resident's blood sugar reading was 422 mg/dL - dated 6/13, before bedtime the resident's blood sugar reading was 413 mg/dL The August 2023 MAR, indicated the resident had the following blood sugar readings: - dated 8/4, before lunch the resident's blood sugar reading was 416 mg/dL - dated 8/9, upon rising the resident's blood sugar reading was 479 mg/dL - dated 8/9, afternoon the resident's blood sugar reading was 450 mg/dL - dated 8/9, before bedtime the resident's blood sugar reading was 479 mg/dL - dated 8/12, before lunch the resident's blood sugar reading was 425 mg/dL Documentation was lacking in the clinical record of the physician having been notified of the blood sugar readings above 400 mg/dL. During an interview with the Director of Nursing (DON) on 8/29/23 at 8:10 a.m., she indicated the facility did not have a diabetic blood sugar monitoring policy. During an interview with LPN (Licensed Practical Nurse) 1 on 8/29/23 at 8:50 a.m., she indicated that she would follow both physician and hospital physician orders. She would give the resident the required amount of sliding scale insulin and then would notify the physician of the high blood sugar reading. During an interview with the Infection Preventionist on 8/29/23 at 9:10 a.m., she indicated the nurses should follow both physician orders until they could get the orders clarified as to which high blood sugar reading the physician wanted to be notified about. During an interview with the ADON (Assistant Director of Nursing) on 8/29/23 at 12:50 p.m., she indicated the days the physician was not notified of the high blood sugars was because the staff were following the sliding scale orders and forgot to discontinue the first order. The resident had one set of orders and then after only a couple of days, nursing realized his blood sugars were not regulated, so new sliding scale orders were obtained. The new orders indicated the physician was to be notified if the resident's blood sugar was above 499 mg/dL. The most current Change in a Resident's Condition or Status policy included, but was not limited to, Our facility shall promptly notify the resident, his or her Attending Physician and representative of changes in the resident's medical/mental condition and/or status .Policy Interpretation: 1. The Nurse Supervisor/Charge Nurse will notify the resident's Attending Physician or the On-Call Physician when there has been: .e. A need to alter the resident's medical treatment significantly; .h. Instructions to notify the physician of changes in the resident's condition .6. The Nurse Supervisor/Charge Nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status . 3.1-5(a)(2) 3.1-5(a)(3)

Based on observation, record review, and interview, the facility failed to follow appropriate infection control guidelines related to perineal care for 3 of 6 residents with a history of urinary track infections reviewed for bowel and bladder. (Residents 76, 42, and 35) Findings include: 1. During an observation of perineal care for Resident 76 on 8/29/23 at 9:39 a.m., CNA (Certified Nurse Aide) 9 performed hand hygiene and applied gloves from her pocket. A wet soapy washcloth was obtained and with 4 swipes of the same area of the washcloth the labial area was cleaned. She obtained a wet washcloth and with 3 swipes of the same area of the washcloth she rinsed the creases. She obtained a wet washcloth and with 2 swipes of the same area of the washcloth she rinsed the labial area. The resident was rolled onto her left side and a wet soapy washcloth was obtained. With 11 swipes of the same area of the washcloth she cleaned the buttocks and anal area with a back-and-forth motion. Stool was observed on the washcloth. She obtained a wet soapy washcloth with 5 swipes of the same area of the washcloth she cleaned the buttocks and anal area using a back-and-forth motion. A wet soapy washcloth was obtained and with 4 swipes of the same area of the washcloth she cleaned the anal area using a back-and-forth motion. She obtained a wet washcloth and with 8 swipes of the same area of the washcloth she rinsed the buttocks and anal area using a back-and-forth motion. A clean brief was placed and fastened. The record for Resident 76 was reviewed on 8/24/23 at 1:53 p.m. The resident's diagnoses included, but were not limited to, a personal history of UTI (urinary tract infections), sepsis, muscle weakness, and unsteadiness on her feet. The care plan, dated 11/4/22 and last revised on 8/9/23, indicated the resident was unable to independently perform late loss ADLs (Activities of Daily Living) related to a recent history of sepsis and a UTI with a decline in selfcare, and required assistance and encouragement for toileting. The interventions, dated 11/4/22, indicated staff were to provide incontinence care with toileting as needed. The UA (urinalysis) report, dated 11/23/22, indicated the resident's urine had three plus large leukocytes and one plus blood. The urine was positive for macrolide resistance markers. The nurse's note, dated 2/10/23 at 10:52 a.m., indicated the resident complained of flank pain, foul odor of urine, and confusion. The physician was notified, and a new order was received for a UA with culture and sensitivity as indicated. The UA report, dated 2/13/23, indicated the urine was enterococcus faecalis positive and morganella morganii positive. The urine was positive for ESBL (extended spectrum beta lactamase) and macrolide resistance markers. The Quarterly MDS (Minimum Data Set) assessment, dated 2/15/23, indicated the resident was moderately cognitively impaired. She required extensive assistance of one staff for toileting. The physician's order, dated 2/17/23, indicated the resident was to receive Macrobid 100 mg (milligrams) twice daily until 8/24/23. The physician's order, dated 2/25/23, indicated the resident was to receive nitrofurantoin microcrystal capsule 50 mg at bedtime. The medication was discontinued on 5/24/23. 2. During an observation of perineal care for Resident 42 on 8/28/23 at 9:58 a.m., CNA 10 performed hand hygiene and applied gloves. She filled the two basins with water and let the resident test it. She brought the basin back into the room after getting the temperature to the resident's liking. The CNA obtained a wet washcloth and applied soap. Using 3 swipes with the same area of the cloth the resident's creases were cleaned in a front to back motion. She obtained another wet washcloth and applied soap. Using 2 swipes with the same area of the cloth she cleaned the labia in a front to back motion. She folded the washcloth and with 2 swipes of the same area of the cloth she cleaned the labia again. She obtained a wet washcloth and with 2 swipes of the same area of the washcloth she rinsed the labia and creases. She folded the washcloth and with 2 swipes of the same area of the washcloth she rinsed the labia and creases. She patted the resident dry. The resident was rolled onto her left side and the CNA obtained a wet washcloth. With 5 swipes of the same area of the washcloth the resident's buttocks and anal area were cleaned. The resident had a slight bowel movement. She rinsed the resident and patted the anal area dry. The clean brief was placed under the resident. During an interview on 8/28/23 at 10:23 a.m., CNA 10 indicated during perineal care she would perform hand hygiene, explain the procedure to the resident, test the water in the basin, and lay the resident back. Wiping from front to back, she would clean the labial area, rinse, and dry them. The same process would be conducted on the resident's anal area. She would clean the resident from front to back and using only one wipe of the washcloth, and then change to another washcloth. The record for Resident 42 was reviewed on 8/25/23 at 8:27 a.m. The resident's diagnoses included, but were not limited to, hemiplegia and hemiparesis following a cerebral infarction affecting the left side, urinary tract infection, weakness, and anemia. The care plan, dated 11/29/22 and last revised on 7/8/23, indicated the resident had specific needs related to care. The interventions, dated 11/29/22, indicated the resident was incontinent of bladder and bowel. The Quarterly MDS assessment, dated 1/24/23, indicated the resident was severely cognitively impaired. The resident required extensive assistance of 2 staff for toileting. The UA results, dated 6/7/23, indicated the resident's urine had three plus large leukocytes, positive nitrates, two plus protein, and three plus blood in the urine. The nurse practitioner's note, dated 6/19/23 at 2:29 p.m., indicated the resident was being seen that day in follow-up for dysuria and urinary urgency. The resident began to experience the symptoms on 6/18/23. Staff were unable to get a urine sample for 3 attempts due to sediment. An order was received for Macrobid 100 mg twice daily for 5 days. The Events indicated, on 8/19/23 at 4:48 p.m., the resident was having a burning feeling during urination. The nurse's note, dated 8/20/23 at 4:25 p.m., indicated a sterile in and out procedure was performed. The urine was placed in sterile UA tubes. The specimen was collected around 4:00 p.m. The UA results, dated 8/20/23, indicated the resident's urine had three plus large leukocytes, one plus protein, and trace blood in the urine. 3. During an observation of perineal care for Resident 35 on 8/29/23 at 10:10 a.m., CNA 9 performed hand hygiene and applied gloves. She swiped the labial area 4 times with the same area of the washcloth to rinse. The brief was soaked through and onto the chuck under the resident. The resident was rolled onto her left side and with 10 swipes of the same area of the washcloth the buttocks and anal area were cleaned with a back-and-forth motion. She folded the washcloth and with 2 swipes of the same area of the washcloth she cleaned the buttocks and anal area again from the vagina to the coccyx. She obtained a clean washcloth and with 6 swipes of the same area of the washcloth she rinsed the buttocks and anal area. She folded the washcloth and with 3 swipes of the same area of the washcloth she rinsed the buttocks and anal area. The record for Resident 35 was reviewed on 8/29/23 at 11:07 a.m. The diagnoses included, but were not limited to, urinary tract infection, elevated white blood cell count, muscle weakness, and overactive bladder. The Quarterly MDS assessment, dated 2/13/23, indicated the resident was cognitively intact. The resident required extensive assistance of one staff for toileting. The care plan, dated 8/25/23 and last revised on 8/28/23, indicated the resident had signs and symptoms of a urinary tract infection. The interventions, dated 8/28/23, indicated staff were to administer antibiotics as ordered, assist with incontinence care, encourage fluid per plan of care, report adverse side effects of antibiotic, and report continued or worsening symptoms of a UTI. The nurse's note, dated 8/24/23 at 10:22 a.m., indicated new orders were received from the physician for a UA with culture and sensitivity, a chest x-ray, and 1 gram of Rocephin intramuscularly now. The nurse's note, dated 8/25/23 at 8:21 a.m., indicated a doctor's order to continue intramuscular Rocephin 1 gram daily until the UA results were available. The UA results, dated 8/24/23, indicated the resident's urine had one plus small leukocytes in the urine. The nurse's note, dated 8/29/23 at 7:27 a.m., indicated a new order was received to discontinue the rocephin and to start Ciprofloxacin 250 mg twice daily for 7 days for a diagnosis of a UTI through 9/4/23. The current Incontinence Care Skills Validations included, but was not limited to, . 9. For Females:-Using a warm moistened cloth apply 4 in 1 and; Separate labia. Wash urethral area first. Wash between and outside labia in downward strokes, alternating from side to side and moving outward to thighs. Use different part of washcloth for each stroke . 3.1-41(a)(2)

Based on record review and interview, the facility failed to ensure appropriate pain management interventions were implemented for 1 of 2 residents reviewed for pain. (Resident 102) Findings include: The record for Resident 102 was reviewed on 8/24/23 at 10:00 a.m. The diagnoses included, but were not limited to, unspecified pain (present on admission on 5/26/23), low back pain (added on 7/14/23), and intercostal pain (added on 7/18/23). The physician's order, dated 5/29/23, indicated staff were to administer the resident's hydrocodone-acetaminophen 5/325 mg (milligram) every 4 hours as needed for pain. The physician's note, dated 5/26/23 at 10:31 p.m., indicated the physician was contacted for a controlled substance refill, a bridge supply was ordered until the primary team evaluated the resident. The physician indicated they discussed non-pharmacological pain management options, however, did not indicate what they were. The Admission MDS (Minimum Data Set) Assessment, dated 6/2/23, indicated the resident was cognitively intact and in the last five days prior to the assessment, the resident had received as needed pain medication but had not received non-medicated interventions for pain. A pain assessment was conducted, and the resident indicated she had pain frequently. The Quarterly MDS Assessment, dated 6/3/23, indicated the resident was cognitively intact and in the last five days prior to the assessment, the resident had received as needed pain medication but had not received non-medicated interventions for pain. A pain assessment was conducted, and the resident indicated she had pain frequently. The Controlled Drug Record sheet indicated in June the resident received 7 doses of hydrocodone-acetaminophen without any documentation of the administration on the MAR (Medication Administration Record), a pain assessment, or nonpharmacological interventions on the following dates: June 6, 11, 13, 16, 20, 23, and 25, 2023. The physician's note, dated 7/18/23 at 1:48 p.m., indicated the resident was seen due to a recent change in her medication regimen. The resident had a fall since her blood pressure medication had been increased and had left sided rib pain. She took hydrocodone for chronic pain control and could use ice packs. The physician's order, dated 7/19/23, indicated staff were to apply ice packs to the resident's left rib as needed once a morning. The physician's note, dated 7/19/23 at 1:50 p.m., indicated the resident had no fractures on the x-ray and the resident was to have ice packs applied several times daily for 20 minutes, as well as Bio-freeze twice daily for three days and to reassess if no improvement. The Controlled Drug Record sheet indicated in July the resident received 7 doses of hydrocodone-acetaminophen without any documentation of the administration on the MAR (Medication Administration Record), a pain assessment, or nonpharmacological interventions on the following dates: July 3, 5, 6, 13, 14, and twice on July 15, 2023. The Controlled Drug Record sheet indicated in August the resident received 2 doses of hydrocodone-acetaminophen without any documentation of the administration on the MAR (Medication Administration Record), a pain assessment, or nonpharmacological interventions on the following dates: August 2 and 20, 2023. The record lacked documentation of a care plan for pain, including nonpharmacological interventions and an assessment of pain. The MAR lacked documentation of any administrations of ice packs to the resident's ribs in July or August. During an interview on 8/23/23 at 2:08 p.m., Resident 102 indicated she had recently asked the nurse for a pain pill and the nurse would not give it to her. She believed it was on 8/22/23, the day prior. She couldn't recall who it was, but her head was hurting and she had to lay down because it got so bad. It didn't get any better after laying down. During an interview on 8/28/23 at 1:46 p.m., LPN (Licensed Practical Nurse) 1 reviewed the Controlled Drug Record sheet and indicated she had only administered pain medication to the resident one time on 8/1/23. When they administered pain medication, they would document then what the pain level was. She only did pain assessments if the system asked her to. If it popped up to be done, then she would. During an interview on 8/29/23 at 12:40 p.m., MDS Coordinator 3 indicated they developed the long-term care plans for residents. They looked at diagnoses, medications, and got an overall picture. Most of the time everyone got a care plan for pain even if they didn't trigger, because everyone was at risk for pain. The resident should have had a care plan for pain implemented. During an interview on 8/29/23 at 12:54 p.m., MDS Coordinator 4 indicated it was a fluke that Resident 102 did not have a care plan. When her Quarterly MDS assessment triggered, she should have had a care plan for pain initiated. During an interview on 8/29/23 at 12:56 p.m., LPN 2 indicated when administering as needed pain medication to a resident, she would ask their pain rating and ask about their pain, including where it was and what level of pain it was. She would sign it out on both the Controlled Drug Record sheet and the MAR. Documentation on the MAR included what the pain level was, where it was, a description of pain, and if it was effective. She would not sign the medication out on the Controlled Drug Record sheet without signing it also on the MAR. Some of the MAR's did not include nonpharmacological interventions, they were supposed to document those. She did not know why they did not include nonpharmacological interventions. During an interview on 8/29/23 at 1:59 p.m., Resident 102 indicated she had pain at different times. She had chest pain from where she'd had open heart surgery in the past and it still hurt at times. She had been hit by a car when she was younger and had two broken vertebrae. She fell on ce and broke her hip and had to have surgery on that. Her knees ached all winter and summer from a prior surgery she'd experienced. Staff did not come in and ask her if she was having any pain. She was lucky if she got her pain medicine. The most current Pain Policy included, but was not limited to, . Pain is whatever the person says it is, existing whenever he/she says it does . Pain cannot be managed with analgesics alone, the underlying cause of the pain must be addressed whenever possible. Alternative treatments should be sought such as: lower doses, alternative medications to prevent the risk of adverse consequences . Nursing considerations . Acute pain is assessed by the licensed nurse routinely and reviewed by the clinical team to determine if a pain assessment needs to be performed . It is recommended that residents using PRN [as needed] analgesics routinely be assessed by the physician or practitioner and the clinical team perform a root cause analysis to discover the etiology of the pain . 3.1-37(a)

Based on record review and interview, the facility failed to ensure the physician was notified when a dialysis resident's weight was above the physician-ordered set parameters for 1 of 7 dialysis residents currently residing in the facility. (Resident 104) Findings include: The record for Resident 104 was reviewed on 8/25/23 at 11:29 a.m. The diagnoses included, but were not limited to, metabolic syndrome, diabetes mellitus with hyperglycemia and hypoglycemia without coma, nutritional anemia, and end stage renal disease with dependence on renal dialysis. A care plan, dated 6/4/23 with a last review date of 8/28/23, indicated the resident was at nutritional risk related to the carbohydrate controlled diet, fluid restricted diet and an altered BMI (body mass index).The goal was for the resident to tolerate the carbohydrate controlled/fluid restricted diet. The approaches included, but were not limited to, monitor/record weight routinely and notify the physician and Registered Dietitian of significant weight changes. A care plan, dated 6/4/23 with a last review date of 8/28/23, indicated the resident received hemodialysis due to end stage renal disease and was at risk for complications. The goal was for the resident to have effective fluid management and be hemodynamically stable, without complications. The approaches included, but were not limited to, monitor vital signs as indicated; provide diet as ordered and encourage compliance; and report fluid excess (wt. gain). The Quarterly Minimum Date Set (MDS) assessment, dated 6/27/23, indicated the resident was cognitively intact; had frequent appetite issues; and received dialysis three times a week. On 4/21/23, a physician's order indicated the resident was to be weighed three times weekly on (Monday, Wednesday, and Friday); and staff were to notify the physician if the resident had a weight gain of 3 pounds daily or 5 pounds in a week. The April 2023 Medication Administration Record (MAR) indicated the resident had the following weights which required physician notification: - On 4/10, the resident's weight was 298.4 pounds. On 4/12, the resident's weight was 302.4 pounds. the Resident had a weight gain of 4 pounds. - On 4/26, the resident's weight was 287.8 pounds. On 4/28, the resident's weight was 297.4 pounds. The resident had a gain of 9.6 pounds. The May 2023 MAR indicated the resident had the following weight which required physician notification: - On 5/3, the resident's weight was 289.6 pounds. On 5/5, the resident's weight was 302.8 pounds. The resident had a weight gain of 13.2 pounds. The June 2023 MAR indicated the resident had the following weight which required physician notification: - On 6/26, the resident's weight was 296 pounds. On 6/28, the resident's weight was 308.4 pounds. The resident had a weight gain of 8.4 pounds. The July 2023 MAR indicated the resident had the following weights which required physician notification: - On 7/3, the resident's weight was 295 pounds. On 7/5, the resident's weight was 305.8 pounds. The resident had a weight gain of 10.8 pounds. - On 7/19, the resident's weight was 280.7 pounds. On 7/21, the resident's weight was 288 pounds. The resident had a weight gain of 7.3 pounds. - On 7/24, the weight was 264.4 pounds. On 7/26, the weight was 290.4 pounds which was a gain of 16 pounds. The August 2023 MAR indicated the resident had the following weights which required physician notification: - On 8/4, the resident's weight was 277.2 pounds. On 8/7, the resident's weight was 282.9 pounds. The resident had a weight gain of 5.7 pounds. - On 8/16, the resident's weight was 276.1 pounds. On 8/18, the resident's weight was 279.8 pounds. The resident had a weight gain of 3.7 pounds. Documentation was lacking in the clinical record of the physician having been notified of the resident's weight gains per his order. A nurse's note, dated 6/9/23 at 3:53 a.m., indicated the resident was requesting fluids to drink. He was advised of being on a 1500 ml (milliliter) fluid restriction. The resident stated he would call his family to share with them regarding fluid restrictions. A nurse's note, dated 6/26/23 at 10:29 a.m., indicated the resident left dialysis earlier than his scheduled time. The nurse contacted the resident's POA (Power of Attorney) to let her know the resident was continuously cutting his treatments short. The Dialysis nurse informed the nurse that the resident was retaining fluid and was educated that he could end up back in the hospital. The resident indicated he was aware. The Nurse Practitioner was also notified. During an interview with the Director of Nursing (DON) on 8/28/23 at 11:14 a.m., she indicated that usually with dialysis residents, the dialysis nurse would let the nephrologist know if the weight fluctuated as they were the ones monitoring pre and post weights. She also indicated the dialysis nurse would let the nurses know through the SBAR (Situation, Background, Assessment, Recommendation) dialysis note. The most current Change in a Resident's Condition or Status included, but was not limited to, Our facility shall promptly notify the resident, his or her Attending Physician and representative of changes in the resident's medical/mental condition and/or status .Policy Interpretation: 1. The Nurse Supervisor/Charge Nurse will notify the resident's Attending Physician or the On-Call Physician when there has been: .e. A need to alter the resident's medical treatment significantly; .h. Instructions to notify the physician of changes in the resident's condition .6. The Nurse Supervisor/Charge Nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status . 3.1-37(a)

Based on record review and interview, the facility failed to ensure a resident with a history of respiratory failure and hypercapnia, who had recently had a surgical procedure, received appropriate care and monitoring when she experienced a sudden change in condition and had complaints of not being able to breathe. The resident was found with blue discoloration around her mouth and no visible signs of life. (Resident E) The Immediate Jeopardy began on [DATE], when Resident E experienced a change in condition while in the dining room. She became weak and tired and requested to go to bed. The resident was slipping down in her chair. The resident was placed in her room and left in her wheelchair. She was not placed in bed or on her BIPAP (bilevel positive airway pressure, type of ventilator, a device that helps with breathing) machine. She yelled out for help and that she could not breathe for 20 minutes or more before becoming quiet. No staff were observed to enter her room until much later when she was found in her room with blue discoloration around her mouth and no visible signs of life. The ED (Executive Director) and DON (Director of Nursing) were notified of the Immediate Jeopardy at 3:03 p.m. on [DATE]. The Immediate Jeopardy was removed on [DATE], but noncompliance remained at the lower scope and severity level of isolated, no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: During an interview on [DATE] at 9:25 a.m., Resident B indicated on [DATE] they had an incident where one of the other resident's was sitting at the dinner table in the activity room. He identified the resident as Resident E. He indicated her nasal cannula kept coming off. While she was eating, she started falling out. She had her tray on the table and kept tipping it. He tried to find an aide, but he couldn't, so he found two nurses. They sat her up in her chair and took her to her room. A little bit later he kept hearing her holler, I can't breathe! I can't breathe! Somebody help me! I'm dying! He didn't believe anyone went in there. CNA (Certified Nurse Aide) 5 was running up and down the hall, he knew she had to have heard the resident. When someone was hollering like that, they should stop and go in and check on them. He could not remember how long she was hollering, but the next thing he knew, she got quiet. Later he heard them in there hollering the resident's name, telling her to wake up. Resident E had another episode the weekend before where she was physically weak and not herself for a few days. When she had the episodes, they'd put her mask on her, and she would wake up fine. She always complained to him that staff never put her mask on her. They left her sitting in that chair for 2 and a half hours knowing she couldn't breathe, on a nasal cannula. It bothered him that she sat there so long. He was told she didn't have a mask on by both CNA 5 and LPN 6. Several residents had complained about staff not helping Resident E. The Clinical Record for Resident B was reviewed on [DATE] at 12:46 p.m. The most recent Annual MDS (Minimum Data Set) Assessment, dated [DATE], indicated the resident was cognitively intact. During an interview on [DATE] at 11:22 a.m., Resident E's family member indicated LPN 7 told her the resident should have had her BIPAP on or she would die. The resident had been in the activity room eating dinner, and she started having one of her episodes. When she was not responding right it was because she wasn't getting enough oxygen. Staff knew to take her and put her in bed and put her BIPAP machine on her. A couple of hours later she would be back to being coherent. Her friends were in the activity room when the nurses got her. Her friends said she was having trouble, and they assumed staff had put her on her BIPAP machine, but they just left her in her wheelchair sitting in her room. Staff tried to tell her the resident was fine, coherent, and talking, but she never sat in her room in her wheelchair. An hour or so passed and suddenly, the other residents heard her screaming and crying I'm dying! I'm dying! Somebody help me! She was told that a nurse from the other end, thirty minutes later, went in and found her passed away in her chair. She always went to bed and was in bed by 7:30 p.m. She should have been on her machine at that time. During an interview on [DATE] at 11:43 a.m., Resident C indicated on [DATE] they had two new staff members of a nurse and an aide. One aid called in and everybody was busy. They had to wait for things. Resident E had died . She was on oxygen, and she needed to stay on it. The night before they had her on her BIPAP when she was really getting short of breath. On [DATE] she heard her hollering, Help! I'm dying! Somebody come! No one checked on her for a long time, then they went in there. She thought the aide went in there first, and then she came running out and got the nurse and then they were both in there. They shut the door a little bit so she couldn't see anything. When Resident E was yelling out, she was in her room, and she could see Resident E's room through the open door. She was in her wheelchair, and she just had a nasal cannula on. She was screaming out, on and off, the whole 20 minutes. The lights were going off, they pushed their own lights thinking maybe if they saw their lights, they could get her help. It was evening time, after supper and she didn't see any staff go into the room to help her during that time. Resident E was screaming as loud as she could. The record for Resident C was reviewed on [DATE] at 12:52 p.m. The most recent Quarterly MDS assessment, dated [DATE], indicated the resident was cognitively intact. During an interview on [DATE] at 11:49 a.m., Resident D indicated she heard Resident E yelling for help for quite some time, and she didn't see any staff help her during the time. The record for Resident D was reviewed on [DATE] at 12:56 p.m. The most recent Quarterly MDS, dated [DATE], indicated the resident was cognitively intact. During an interview on [DATE] at 11:35 a.m., LPN 7 indicated the night Resident E passed, she was not her nurse when she passed, but she did care for her earlier in the day. She did see the resident at dinner time. She was sliding down in her chair and then Resident B came to get them. She was tired, but she was ok. Her and another nurse sat her up in her chair and brought her to her room. She connected her to the concentrator. She had oxygen on. They did not lay her down. She said she would look for someone to put her back to bed. They were changing shifts. She looked, but there was nobody around (no aides) and she was in the middle of report. The resident had told her she was tired between 6:00 p.m. and 6:10 p.m. She let her nurse know she wanted to go to bed, because the resident said she wanted to go back to bed. She did not know what time she passed; she went to see her after she passed around 9:00 p.m. She had not been put to bed. She did not hear the resident hollering, she worked on a different hall, there was no way she would have heard anything. If she had a BIPAP she would assume she needed to wear it at night During an interview on [DATE] at 11:46 a.m., CNA 5 indicated on [DATE] as she was taking trays to the dining room, Resident E had been yelling and her call light was on. She went in and answered her call light, and the resident indicated she was ready to go to bed. She said to give her a bit and someone would help her. They went ahead and got showers done and started getting other people to bed, and by the time she went to her room the resident had passed. The girl who was supposed to be her aide was on another hall. She did not know how long the resident was yelling, she didn't think it was long, but she could be wrong because she was in a room with other residents. She believed it was around 7:30 p.m. to 8:00 p.m. when she told the resident she would put her to bed. She didn't get back in there to put her to bed until 8:45 p.m. to 9:00 p.m. She did not hear her yelling out anymore. When she heard her yelling, she was yelling help. She just said she was ready to go to bed. She seemed tired but other than that she seemed normal. She was not on her BIPAP. During an interview on [DATE] at 11:59 a.m., LPN 10 indicated she started her medication pass at 7:00 p.m. The resident said she wanted to go to bed soon. She told the resident the CNA was almost to her room. The resident was sitting in her wheelchair. She told her she was tired when she went in there to give her medications, which was probably between 7:30 p.m. and 8:00 p.m. She was told about a procedure to do with her dialysis, that she had something new put in or fixed the Friday before. She was told in report that LPN 7 went in to see her because someone stated she wasn't acting the same earlier in the day. As far as surgery went, she knew they needed to be monitored. She was not given any specific instructions on post-op monitoring. She did not apply the resident's BIPAP that night. Generally, they put them on when they laid down and she was not in bed. During an interview on [DATE] at 10:55 a.m., NP 9 indicated she did recall the resident. She had end stage renal disease (ESRD), COPD (chronic obstructive pulmonary disease) with hypercapnia, respiratory failure, and she had been in and out of the hospital for respiratory issues. She had the BIPAP, which was recently new for her. Her understanding was sometimes she did refuse to wear it, but she had voiced to her as well that some of the nursing staff did not know how to use it appropriately, so she didn't always get to wear it. She was always hypercapnic to some degree, but there were one or two instances where she wound up in the hospital, and at least one instance since she had the BIPAP ordered. There was one episode recently, about 2 weeks prior when she was unresponsive in dialysis. She received a text close to 10:00 p.m. on [DATE] from the DON (Director of Nursing) saying the resident had passed and she didn't want her caught off guard. Post-op monitoring would be up to the hospital to let them know, but if it was general surgery and depending on how soon they sent her back, if someone came back under general anesthesia and they were still sedated somewhat and confused she would say to monitor them more closely, every hour or 2 hours vital signs to make sure their blood pressure was staying up and hold sedating medications. She should have been wearing her BIPAP. Her understanding was to have her wear it when she was napping and when she was sleeping. She had mentioned on stand-down the resident had complaints of staff not assisting to apply her BIPAP. She advised the nurses, supervisors, DON, ADON (Assistant Director of Nursing), and Social Worker of this concern. The clinical record for Resident E was reviewed on [DATE] at 10:00 a.m. The diagnoses included, but were not limited to, arteriovenous fistula, chronic kidney disease (CKD) stage 4, hypertensive heart and chronic kidney disease, end stage renal disease, altered mental status, acute and chronic respiratory failure with hypercapnia and hypoxia, hypotension, hypo-osmolality and hyponatremia, dependence on renal dialysis, hyperkalemia, wheezing, insomnia, hypokalemia, difficulty walking, COPD, CHF (congestive heart failure), HTN (hypertension), and dependence on supplemental oxygen. The care plan, dated [DATE] and last revised [DATE], indicated the resident had a potential for respiratory distress related to COPD/chronic respiratory failure. She had shortness of air while lying flat as evidenced by increased respirations. The goal was for the resident to not exhibit unrecognized signs of respiratory distress such as restlessness, wheezing, dyspnea, difficulty with expectoration, diaphoresis, crackles, bubbling, tachycardia, cyanosis, decreased breath sounds thru her next review. The interventions included, but were not limited to; administer medications and oxygen per physician's order; elevate the head of the bed to alleviate shortness of breath while lying flat; and report signs of respiratory distress. The care plan did not include any interventions specific to the resident's BIPAP usage. The Hospital note, dated [DATE], indicated the resident was admitted with the inability to maintain wakefulness and an elevated CO2 (carbon dioxide) level. BIPAP was initiated with significant improvement and mentation. Pulmonary was consulted. She had severe OSA (obstructive sleep apnea) with pulmonary hypertension. The physician's order, dated [DATE], indicated the resident was to have her BIPAP with 2 lpm (liters per minute) bled in as needed every shift and at and before bedtime to be administered between 7:00 p.m. to 11:00 p.m. with special instructions for nursing to assist and document acceptance or refusal. The nurse's note, dated [DATE] at 10:37 a.m., indicated the nurse went to check the resident's vitals prior to and found the resident in bed with no nasal cannula or BIPAP in place. This nurse applied a nasal cannula and obtained vitals. The resident's vitals included a heart rate of ,d+[DATE] mm/Hg (millimeters of mercury), a heart rate of 79 bpm (beats per minute), and an O2 (oxygen saturation) of 95% on 3 lpm. The resident was very confused, and weak. She was unable to stand. The nurse had to crush her morning medications to administer them. The nurse then had the resident lay back down and BIPAP was applied. After 2 hours of wearing BIPAP, the nurse entered to recheck the resident's vitals. The resident's vitals included a BP of ,d+[DATE], a heart rate of 84 bpm, a temperature of 97.9, and an O2 of 94% on 3 lpm. The nurse listened to the resident's lung sounds which were diminished. The RLE (right lower extremity) was observed with 2 to 3 plus edema. The resident indicated she was short of air. The nurse asked the resident some questions. She was unable to answer where she was, what month it was, what year it was, and she was unable to name her children. The nurse then put a call in to the on-call physician who ordered stat CBC (complete blood count), CMP (complete metabolic panel),UA (urinalysis), venous doppler on BLE (bilateral lower extremities), and a CXR (chest x-ray) and gave orders to check the resident's vitals every four hours and to call back if the resident worsened. The Hospital note, dated [DATE], indicated the resident was admitted to the hospital on [DATE] complaining of altered mental status. The resident presented due to unresponsiveness and low blood pressure. The resident's family member was present and indicated the resident had experienced worsening mental status since the day prior. She was admitted for an acute exacerbation of COPD. The resident's assessment and plan indicated she had acute metabolic encephalopathy, acute hypoxic hypercapnic respiratory failure, and a UTI (urinary tract infection). The resident was a high risk for further or rapid decline and her family was aware. The NP's note, dated [DATE], indicated the resident's provider was alerted by dialysis RNs that Resident E was not as alert as usual before dialysis and had continued to decompensate. Her BP had been stable, but during their assessment, the resident's BP was low at ,d+[DATE] mm/Hg, and it was currently at ,d+[DATE] mm/Hg. The NP was unable to awaken the resident with deep, painful stimuli. The NP gave an order to send the resident to the hospital and EMS was called. The EMS call was canceled by the DON who indicated she was able to awaken the patient and she did not want to go to the hospital. The Nurse's note, dated [DATE] at 5:31 a.m., indicated the resident was lethargic most of the shift. The nurse was able to wake the resident after much difficulty to take her medications around 11:30 p.m. Her vital signs were normal, and she was wearing her BIPAP. The resident experienced a fall because she was confused and was trying to get out of bed. The physician ordered for a CBC, CMP, and a UA to be obtained. The resident's family was notified. The hospital discharge summary, dated [DATE], indicated the resident had a surgical procedure to superficialize her dialysis fistula. The Monitored Anesthesia Care sheet, provided on discharge, indicated to have a responsible adult stay with the resident for the time she was told, and to have someone help take care of her until she was awake and alert. If the resident had sleep apnea, surgery and certain medications could increase her risk for breathing problems. She was to follow instructions from her provider about wearing her sleep device. The instructions included to wear the device any time she was sleeping, including during daytime naps, and while taking prescription pain medications, sleeping medicine or medication that could make her sleepy. She was to get help immediately if she had trouble breathing or a new onset of confusion at home. It was important to have someone help care for her until she was awake and alert. The nurse's note, dated [DATE] at 4:16 a.m., indicated the resident returned from the hospital from her surgery appointment and was alert and oriented. The clinical record lacked documentation of any respiratory, cognitive, or other nursing assessment at the time Resident B alerted LPN 7 to Resident E's condition in the activity room, until an hour and twenty-four minutes later. The vitals report indicated the resident's oxygen saturation, on [DATE] at 7:24 p.m., was 98% and her respirations were 18 breaths per minute. Her blood pressure at 7:26 p.m. was ,d+[DATE]. There were no documented assessments of the resident's lung sounds or her cognitive status at the time. The clinical record lacked documentation of any further respiratory, cognitive, or other nursing assessment, or any follow-up vitals assessments, on [DATE] from 7:26 p.m., until the time the resident was discovered with no visible signs of life in her room. The Medication Administration Record, indicated LPN 10 had signed off on the resident's order to apply the resident's BIPAP between 7:00 p.m. and 11:00 p.m. on [DATE]. The physician's note, dated [DATE] at 9:49 p.m., indicated the resident had been doing poorly over last several days, according to the nurse's report. The patient died unexpectedly while sitting in her chair and was found already expired when the nurse came back to put the patient to bed. The nurse's note, dated [DATE] at 12:12 a.m., indicated on [DATE] at 9:00 p.m. the resident was found sitting in her wheelchair in her room. She had slight blue discoloration around her mouth. She was non-responsive and all signs of life had ceased as verified by two nurses. The family and physician were notified. The immediate jeopardy, that began on [DATE] was removed on [DATE], when the facility conducted the following: All licensed Nurses and CNA's that worked at the facility were educated regarding respiratory devices, change of condition, post-operative monitoring, and the importance of assisting residents to bed in a timely manner and assisting with the application of respiratory devices if needed; All licensed nurses completed the skills validation for assessing the thorax and lungs and oxygen administration; The facility ensured all licensed nurses and CNAs that were not present to receive the initial education and would be provided education prior to working their next scheduled shift; All residents were reviewed for respiratory devices, change of condition, and post-operative to ensure respiratory devices were in place and they exhibited no signs or symptoms of distress; and All residents in the facility with respiratory devices had a care plan review. The most current Change in a Resident's Condition or Status policy, last revised ,d+[DATE], provided on [DATE] at 2:00 p.m. by the DON, included but was not limited to, . Our facility shall promptly notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status . The Nurse Supervisor/Charge Nurse will notify the resident's Attending Physician or On-Call Physician when there has been . d. A significant change in the resident's physical/emotional/mental condition; e. A need to alter the resident's medical treatment significantly; f. A need to transfer the resident to a hospital/treatment center . h. Instructions to notify the physician of changes in the resident's condition . 2. A 'Significant change' of condition is a decline or improvement in the resident's status that: a. Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions . This Federal Tag relates to Complaint IN00412136. 3XXX,d+[DATE](a)

Based on record review and interview, the facility failed to ensure prompt physician notification of a resident's change in condition for 1 of 3 residents reviewed for change in condition. (Resident E) Findings include: The clinical record for Resident E was reviewed on 7/7/23 at 10:00 a.m. The diagnoses included, but were not limited to, arteriovenous fistula, chronic kidney disease (CKD) stage 4, hypertensive heart and chronic kidney disease, end stage renal disease, altered mental status, acute and chronic respiratory failure with hypercapnia and hypoxia, hypotension, hypo-osmolality and hyponatremia, dependence on renal dialysis, hyperkalemia, wheezing, insomnia, hypokalemia, difficulty walking, COPD (chronic obstructive pulmonary disease), CHF (congestive heart failure), HTN (hypertension), and dependence on supplemental oxygen. The care plan, dated 1/9/23 and last revised 6/29/23, indicated the resident had a potential for respiratory distress related to COPD/chronic respiratory failure. She had shortness of air while lying flat as evidenced by increased respirations. The goal was for the resident to not exhibit unrecognized signs of respiratory distress such as restlessness, wheezing, dyspnea, difficulty with expectoration, diaphoresis, crackles, bubbling, tachycardia, cyanosis, decreased breath sounds thru her next review. The interventions included, but were not limited to; administer medications and oxygen per physician's order; elevate the head of the bed to alleviate shortness of breath while lying flat; and report signs of respiratory distress. The vitals report indicated, on 6/11/23 at 7:56 a.m., the resident's blood pressure measured as 88/59 mmHg (millimeters of mercury) and was flagged in red as out of range. The acceptable range was indicated to be 100 to 180 mmHg over 60 to 90 mmHg. The clinical record lacked documentation of any notification to the physician until 10:30 a.m. The physician's note, dated 6/11/23 at 10:30 a.m., indicated the physician was contacted for a new onset of mental status. The nurse's note, dated 6/11/23 at 10:37 a.m., indicated the nurse went to check the resident's vitals prior to and found the resident in bed with no nasal cannula or BIPAP in place. This nurse applied a nasal cannula and obtained vitals. The resident's vitals included a blood pressure of 88/58 mm/Hg, a heart rate of 79, an O2 (oxygen) saturation rate of 95% on 3 lpm (liters per minute.) The resident was very confused, and weak. She was unable to stand. The nurse had to crush her morning medications to administer them. The nurse then had the resident lay back down and her BIPAP was applied. After 2 hours of wearing the BIPAP, the nurse entered to recheck the resident's vitals. Her vitals included a blood pressure of 110/57 mm/Hg, a heart rate of 84, a temperature of 97.9, and O2 saturation rate of 94% on 3 lpm. The nurse listened to the resident's lung sounds which were diminished. The RLE (right lower extremity) was observed with 2 to 3 plus edema. The resident indicated she was short of air. The nurse asked the resident some questions. She was unable to answer where she was, what month it was, what year it was, and she was unable to name her children. The nurse then put a call in to the on-call physician who ordered stat CBC (complete blood count), CMP (complete metabolic panel), UA (urinalysis), venous doppler on BLE (bilateral lower extremities), and a CXR (chest x-ray) and gave orders to check the resident's vitals every four hours and to call back if the resident worsened. The nurse's note, dated 6/11/23 at 2:10 p.m., indicated the nurse contacted the on-call physician due to the resident not waking to eat or drink. The nurse was attempting to get the resident to drink and was unsuccessful. The nurse spoke to the physician who ordered to administer 1 liter of IV (intravenous) fluids at a rate of 125 mL/hr (milliliters per hour). The nurse's note, dated 6/11/23 at 3:46 p.m., indicated the nurse administered the resident's IV antibiotic at 2:20 p.m. and went in to run her IV fluids at 3:30 p.m. When the nurse entered, the resident was unresponsive. The nurse contacted her supervisor who came to the resident's room and ordered the nurse to call 911. The emergency transport 911 was called and they arrived at 3:50 p.m. The Hospital note, dated 6/11/23, indicated the resident was admitted to the hospital on 6/11/23 complaining of altered mental status. The resident presented due to unresponsiveness and low blood pressure. The resident's family member was present and indicated the resident had experienced worsening mental status since the day prior. She was admitted for an acute exacerbation of COPD. The resident's assessment and plan indicated she had acute metabolic encephalopathy, acute hypoxic hypercapnic respiratory failure, and a UTI (urinary tract infection). The resident was a high risk for further or rapid decline and her family was aware. During an interview on 7/7/23 at 10:55 a.m., NP 9 indicated she did recall the resident. She had end stage renal disease, COPD with hypercapnia, respiratory failure, she had been in and out of the hospital for her respiratory issues, and she had the BIPAP, which was fairly new for her. She was always hypercapnic to some degree. There were one or two instances where she wound up in the hospital, and at least one instance since she had the BIPAP. On 6/11/23 there should have been a call to the doctor when the resident had a change in condition. She found out about the change of condition after the fact. She reviewed the note from 6/11/23 at 10:37 a.m., and indicated someone should have been notified immediately, when she was weak and unable to stand, and her blood pressure was that low. They shouldn't have even administered her medications. Knowing her history she would have sent her out to the hospital. During an interview on 7/10/23 at 10:00 a.m., the DON (Director of Nursing) indicated she expected staff to notify the physician of any acute change in condition. There were not certain parameters for blood pressures. If the blood pressure was abnormal from the resident's normal they would notify the physician. She would expect notification if the resident's blood pressure was low and they were symptomatic. If the resident had symptoms and a change in condition she would expect the physician to be notified as soon as staff were able to. It would depend on what was going on with the resident, they would need to do a full assessment and notify the physician. The most current Change in a Resident's Condition or Status policy, last revised 10/2010, provided on 7/7/23 at 2:00 p.m. by the DON, included but was not limited to, . Our facility shall promptly notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status . The Nurse Supervisor/Charge Nurse will notify the resident's Attending Physician or On-Call Physician when there has been . d. A significant change in the resident's physical/emotional/mental condition; e. A need to alter the resident's medical treatment significantly; f. A need to transfer the resident to a hospital/treatment center . h. Instructions to notify the physician of changes in the resident's condition . 2. A 'Significant change' of condition is a decline or improvement in the resident's status that: a. Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions . This Federal Tag relates to Complaint IN00412136. 3.1-5(a)(2) 3.1-5(a)(3)

Based on record review and interview, the facility failed to ensure professional standards of care related to implementation of physician orders and provision of medically necessary emergent care for 1 of 3 residents reviewed for professional standards of care. (Resident E) Findings include: The clinical record for Resident E was reviewed on 7/7/23 at 10:00 a.m. The diagnoses included, but were not limited to, arteriovenous fistula, chronic kidney disease (CKD) stage 4, hypertensive heart and chronic kidney disease, end stage renal disease (ESRD), altered mental status, acute and chronic respiratory failure with hypercapnia and hypoxia, hypotension, hypo-osmolality and hyponatremia, dependence on renal dialysis, hyperkalemia, wheezing, insomnia, hypokalemia, difficulty walking, COPD (chronic obstructive pulmonary disease), CHF (congestive heart failure), HTN (hypertension), and dependence on supplemental oxygen. The care plan, dated 1/9/23 and last revised 6/29/23, indicated the resident had a potential for respiratory distress related to COPD/chronic respiratory failure. She had shortness of air while lying flat as evidenced by increased respirations. The goal was for the resident to not exhibit unrecognized signs of respiratory distress such as restlessness, wheezing, dyspnea, difficulty with expectoration, diaphoresis, crackles, bubbling, tachycardia, cyanosis, decreased breath sounds thru her next review. The interventions included but were not limited to; administer medications and oxygen per physician's order; elevate the head of the bed to alleviate shortness of breath while lying flat; and report signs of respiratory distress. The nurse's note, dated 6/16/23 at 12:05 p.m., indicated the resident was in dialysis and was not responding to verbal or tactile stimuli for the NP. However, when the DON (Director of Nursing) went in to see the resident her eyes were open, and the resident was mumbling. The DON asked the resident if she wanted to go to hospital and the resident indicated no, and shook her head no. The NP (Nurse Practitioner) was made aware that the resident did not want to go to hospital. A call was placed to the resident's family member and there was no answer. The nurse from dialysis kept stating Resident E's speech was slurred and she needed to go to the hospital. The DON explained to her that the resident had stated that she did not want to go to the hospital. The NP's note, dated 6/16/23, indicated the resident's provider was alerted by dialysis RNs to the resident's status when checking on another resident. The provider was told the patient was not as alert as usual before dialysis and had continued to decompensate. Her BP (blood pressure) had been stable, but during their assessment, the resident's BP was low at 77/55 mm/Hg (millimeters of mercury), and it was currently at 124/94 mm/Hg. The NP was unable to awaken the resident with deep, painful stimuli. The NP gave an order to send the resident to the hospital and EMS (Emergency Medical Services) was called. The EMS call was canceled by the DON who indicated she was able to awaken the patient and she did not want to go to the hospital. Dialysis RNs insisted she needed to go to hospital due to slurred speech and AMS (altered mental status). The NP was concerned that the patient was unable to make decisions at the time due to AMS and likely hypercapnia. The NP was called back to the facility after leaving for the day to sign a POST (physician orders for scope of treatment) form (a form which outlines treatments that a person would like to receive or not receive related to end of life) for the resident to have comfort measure only. The NP discussed what was documented on the form with the resident and what decisions were checked that she elected. The resident indicated she never made those decisions and she wanted to go to the hospital because she wanted to live. The NP did not sign the POST form and informed the unit manager she would not sign the form. The NP indicated the resident likely needed an evaluation for capacity to make medical decisions. During an interview on 7/6/23 at 11:22 a.m., Resident E's family member indicated Resident E was a DNR (Do Not Resuscitate), but she was not opposed to going to the hospital. She went to the hospital many times. Resident E had an episode in dialysis where staff couldn't get her to come around. She was at work and didn't have access to a phone. She didn't know why an ambulance was not called then. Anytime she went to the hospital, they put the BIPAP on her and she would come out of it. They knew it from experience. When she had her episodes, she was not in the capacity to make decisions. She would not be in a state to say she didn't want to go to the hospital. On 7/7/23 at 10:32 a.m., the facility was not able to get a hold of her because she was at work and they had left messages, all they said was they needed her to call them. They did not have any conversations about hospice, she wasn't said to be dying. Nobody had ever mentioned hospice to her, and she had never consented to bringing on hospice services. No one ever talked to her about putting her family member on hospice. During an interview on 7/7/23 at 10:45 a.m., Dialysis RN 8 indicated she was working on 6/16/23 and recalled the incident with Resident E. While she was on dialysis and doing vital signs, she tried to wake her, and she was not waking up. She was pinching and tapping the resident's shoulder, but she wasn't waking up. They called the NP who was just around the corner. The NP did recommend for the resident to go to the hospital. She did believe the resident needed to go to the ER and the NP gave orders for it. She did start to wake up before sending her back to her room, but her speech was slurred, and she was not her normal self. She was saying yes and no, but she was not sure how much she was comprehending and if she was in her right state of mind. She said no to the hospital, but she could not be certain that she was in her full mental capacity. The resident had a history where she could go hypercapnic, and it was a possibility that could alter her mental state. The resident was not waking up and it was not safe for them to do the dialysis in that condition. During an interview on 7/7/23 at 10:55 a.m., NP 9 indicated she did recall the resident. She had end stage renal disease, COPD with hypercapnia, respiratory failure, and she had been in and out of the hospital for respiratory issues. She had the BIPAP, which was recently new for her. There was one episode recently, about 2 weeks prior where she was unresponsive in dialysis. The NP went to round on a different patient and the main Dialysis RN 8 voiced concern that Resident E was less responsive than what she was usually, so she went to see her. She would not open her eyes; she was kind of in and out of it. She did a deep sternal rub on her and she was just barely moving her head. She listened to her lungs, and she was very concerned with her condition. She had the nurse check her sugar, but it wasn't low. When she came back into the room the resident was even less responsive. She did another deep sternal rub, and she wasn't even flickering her eyelids. She made the decision to send her to the hospital. Her nurse went out and called EMS. When she came back, the DON was at the nurses' station and was on the phone. When she walked up to her, she was hanging up the phone and said she canceled EMS. The NP asked her why, and she said because she went in, and the resident was alert and awake and didn't want to go to the hospital. The NP asked if she was awake, the DON said yes, and the NP relayed to the DON that the resident was completely unresponsive when she saw her. She told the DON the resident was likely hypercapnic and confused. And the DON said she's a DNR and she doesn't want to go to the hospital. The resident wasn't on hospice or receiving comfort measures only. She was concerned with that decision to cancel the emergency transport. Dialysis RN 8 had told her she was slurring her speech even when she said she didn't want to go to the hospital, and she felt she wasn't able to make that decision. It was her medical opinion she should have gone to the hospital and she never canceled her order to send the resident to the hospital. During an interview on 7/7/23 at 1:09 p.m., the CEO of Clinical indicated their company provided the NP services for the residents in the building. The NP ordered the resident to be sent out to the hospital and the DON canceled the EMS transport to the hospital. The NP did not reassess the resident at that time. The NP later in the day assessed the resident and she was then considered stable. We have to come from a place of pure medical judgement and that can change. The resident had a right to refuse the order to go to the hospital and a hypercapnic patient can wake up and be back to baseline. If she refused, they rested on the facility. During an interview on 7/10/23 at 10:00 a.m., the DON indicated she expected nurses to follow a physician's orders, as nurses were taught to do that. If a nurse did not agree with a physician's order, then they would go and speak to the provider, and make them aware of what was going on and see if they were in agreement or not. If they were in agreement with the nurse, they would cancel the order. If the NP or the physician did not agree with the nurse they would follow the recommendation or the orders. When the NP ordered to send Resident E to the hospital, she went and talked to the NP. She went to her and let her know the resident did not want to go. The resident was her own person and she did not have a power-of-attorney put in place. She said she did not want to go to the hospital. When she went in to see the resident, she said her name and the resident responded. Previously, the dialysis nurse said she wasn't waking up. She told the resident she fell asleep and they wanted to send her to the hospital and asked her if she wanted to go. The resident said no, and shook her head. She did not do any other assessment to the residents cognitive status. She did not do any education to the risks or benefits of going to the hospital. She did not have the physician come in and reassess the resident, but she notified the physician that she did not want to go. The resident did later indicate she did want to go. Later on, she did say she changed her mind. The physician did not ever give her an order to cancel EMS. She asked the NP verbally if she was ok keeping the resident in the facility and the NP said yes, but she didn't document it and she should have. The Indiana State Board of Nursing Compilation of the Indiana code and Indiana Administrative Code 2013 Edition, included but was not limited to, . IC 25-23-1-1-.1 Additional definitions Sex 1.1 . (b) As used in this chapter, registered nursing means performance of services which include but are not limited to: (1) assessing health conditions; (2) deriving a nursing diagnosis; (3) executing a nursing regimen through the selection, performance, and management of nursing actions based on nursing diagnoses; (4) advocating the provision of health care services through collaboration with or referral to other health professionals; (5) executing regimens delegated by a physician with an unlimited license to practice medicine or osteopathic medicine, a licensed dentist, a licensed chiropractor, a licensed optometrist, or a licensed podiatrist . (7) delegating tasks which assist in implementing the nursing, medical, or dental regimen; or (8) performing acts which are approved by the board or by the board in collaboration with the medical licensing board of Indiana. (c) As used in this chapter, 'assessing health conditions' means the collection of data through means such as interviews, observation, and inspection for the purpose of: (1) deriving a nursing diagnosis; (2) identifying the need for additional data collection by nursing personnel; and (3) identifying the need for additional data collection by other health professionals . IC 25-23 Sec. 2. The registered nurse shall do the following: (1) Function within the legal boundaries of nursing practice based on the knowledge of statutes and rules governing nursing . (3) Communicate, collaborate, and function with other members of the health team to provide safe and effective care . (8) Delegate and supervise only those nursing measures which the nurse knows, or should know, that another person is prepared, qualified, or licensed to perform . Unprofessional conduct Authority . Nursing behaviors (acts, knowledge, and practices) failing to meet the minimal standards of acceptable and prevailing nursing practice, which could jeopardize the health, safety, and welfare of the public, shall constitute unprofessional conduct. These behaviors shall include, but are not limited to, the following: (1) Using unsafe judgment, technical skills, or inappropriate interpersonal behaviors in providing nursing care. (2) Performing any nursing technique or procedure for which the nurse is unprepared by education or experience . This Federal Tag relates to Complaint IN00412136. 3.1-35(g)(1)

Based on record review and interview, the facility failed to ensure a hot liquid assessment was completed for a resident with a decline in function for 1 of 3 residents reviewed for accidents. (Resident G) Finding includes: Review of the Reportable to State incident report, dated 5/23/23, indicated Resident G spilled his coffee in his lap during dinner. The next day, the resident was discovered to have a reddened area with quarter size blister. The record for Resident G was reviewed on 6/8/23 at 11:00 a.m. The diagnoses included, but were not limited to, restlessness and agitation, unspecified pain, need for assistance with personal care, Alzheimer's disease with late onset and generalized anxiety disorder. The Quarterly Minimum Data Set (MDS) assessment, dated 2/9/23, indicated the resident had severe cognitive impairment and required supervision of one staff member's assistance for eating. The Quarterly MDS assessment, dated 5/10/23, indicated the resident had a severe cognitive impairment and required extensive assistance of one staff member for assistance with eating. A care plan, initiated on 3/8/22 with a last reviewed date of 6/8/23, indicated the resident was unable to independently perform late loss ADLs (Activities of Daily Living) R/T (related to) dementia with behaviors, general weakness, and required assistance/encouragement for eating. The goal was for the resident to not experience a decline in level of participation of late loss ADLs. The approaches included, but were not limited to; dated 3/8/22, monitor for any eating/swallowing/meal issues; provide assistance and encouragement as needed and report any issues; and dated 6/8/23, cup with sipper end to assist with independence with drinking. A new care plan was added on 5/25/23 for burn wounds to Right and Left thighs. The goal was for it to heal with no complications and the approach was for treatment, monitoring and healing. A nurse's note, dated 5/24/23 at 2:21 p.m., indicated the resident was assessed by the nurse while in bed and observed superficial open areas to inner right and left thighs and outer left thigh. The Wound Physician was in the building and was asked to assess the resident. The Rash/Lesions Assessment, dated 5/24/23, indicated the resident had an injury to the inner and outer left and right thighs. The blisterlike, generalized widespread, rash/lesions. A nurse's note, dated 5/30/23 at 3:37 p.m., indicated the resident's skin was assessed by this nurse due to possible infection reported post burn wounds. The Wound Care physician was notified and sent pictures and she indicated it was not infected. The resident's record lacked a Hot Liquids assessment to address the decline in eating prior to the accident on 5/23/23 or afterwards. The Nursing Referral for Therapy to Screen, dated 5/31/23, indicated OT (occupational therapy) evaluated the resident due to a fall only and was not referred for a change in feeding skills/adaptive equipment needs after his coffee spill on 5/23/23. During an interview with LPN (Licensed Practical Nurse) 1 on 6/8/23 at 10:25 a.m., she indicated that the resident was only alert to his name. During an interview with Activities Aide on 6/8/23 at 10:33 a.m., she indicated the resident used to use a regular coffee cup with a handle, but since he spilled his coffee on himself, now he used a sippy cup with a lid and handles. During an interview with CNA (Certified Nurse Aide) on 6/8/23 at 10:40 a.m., she indicated the resident had been more tired and required more help in the last couple of weeks and was not really capable of helping himself. During an interview on 6/8/23 at 1:50 p.m., the Executive Director indicated the resident still liked to feed himself when he could and was using a regular coffee cup at that time. He had no injury initially but the next day, he had blistered areas on his thighs. During an interview with the DON on 6/8/23 at 2:00 p.m., she indicated the staff did not notice there was an area on his legs until the next day and since he usually wore dark clothing, it wasn't initially noticed his pants might have been wet. Sometimes he could feed himself and other times he needed help if he would allow it. Staff wanted him to try to maintain what abilities he still had. The aides on the night shift that put him to bed should have noticed if his pants were wet or not. During an interview with CNA 3 on 6/8/23 at 2:25 p.m., she indicated the resident was feeding himself that night as he had good and bad days where he could feed himself independently and other days he needed more help. He was steady with his hands to hold things like a cup until recently. She also indicated she first noticed his burns the next day when she went to lay him down and had pulled his pants down. She did not actually see him spill the coffee on himself that evening and only saw a cup on the floor next to him. During an interview with the OT Therapy Supervisor on 6/8/23 at 2:45 p.m., she indicated the nursing supervisor came to her after the resident spilled his coffee and she gave her some different cups to try. Staff were to let her know if there was anything else that needed to be done. She did not do a formal assessment on him to determine if he was safe with hot liquids by himself and that it depended on the situation if she would do that type of assessment as one was not normally done. He was on her list to evaluate since PT (physical therapy) was getting ready to discharge him due to making no progress. During an interview with the DON on 6/9/23 at 8:10 a.m., she indicated staff had tried to group the residents who needed to be fed together at one table with a nurse or aide there to monitor them. If they saw someone who was having trouble holding their cup, then the resident would get a cup with a lid and handles. She indicated they did not do Hot Liquid assessments on any residents and would have to ask therapy if they did one. During an interview with the Dietary Manager/Cook on 6/9/23 at 8:35 a.m., she indicated the kitchen sent the coffee in a big carafe to the dementia unit and the aides would pour it out to the residents with their meals. The coffee machine maintained a temperature of 160 degrees Fahrenheit. The kitchen was notified the day before (6/8/23) that the resident needed a special cup. The staff kept it back on the unit for him to make sure he had it as it had not come back on his tray yesterday or today. During an interview with the Corporate Nurse on 6/9/23 at 12:30 p.m., she indicated the facility did not have a specific Hot Liquids assessment policy. The MDS was completed quarterly and would reflect any changes the resident had. 3.1-45(a)(1)

Based on record review and interview, the facility failed obtain a physician's order and ensure safe usage of warm compresses which resulted in second-degree [CONDITION(S)] to a resident's back for 1 of 3 residents reviewed for accidents. (Resident C) Finding includes: The review of the 10/3/22 Incident Report to the State indicated Resident C requested a warm compress to be placed on her back for muscle aches. LPN (Licensed Practical Nurse) 2 placed the warm cloth on the resident's back. The resident reported no discomfort, but the area was slightly red later with small blisters. The clinical record for Resident C was reviewed on 10/17/22 at 9:30 a.m. The diagnoses included, but were not limited to, [CONDITION(S)], burn of second degree of lower back, spinal stenosis and polyneuropathy. The Quarterly Minimum Data Set (MDS) assessment, dated 8/17/22, indicated the resident was cognitively intact; required extensive assist of 2 staff for all Activities of Daily Living, including bed mobility, and had impairment in functional range of motion of both lower extremities. The nursing note, dated 10/2/22 at 2:22 a.m., indicated at 10:15 p.m. the resident had complained of back and neck pain. The PRN (as needed) pain medication was given with some relief. LPN 2 then applied warm compresses to the resident's neck and back for about 20 minutes for comfort. When the nurse went in to remove the compresses, the resident had asked to leave it in place for a little longer as she felt some relief. The nurse returned ten minutes later the nurse removed the compresses. At 1:00 a.m., LPN 2 went back into the resident's room and observed redness and blisters on the resident's back. The resident denied pain in the area, but was able to feel the nurse's hand on her back. The physician was notified and new orders were received to keep open to the air, use a lanolin, [MEDICATION(S)] ointment or some petroleum jelly; and a wound care consult. The nursing note, dated 10/2/22 at 3:00 p.m., indicated after the assessment of the resident's back, 2 rows of blisters were observed. The right one measured 22 centimeters (cm) long by 4 cm wide by 0.1 cm deep. The one on the left measured 18 cm long by 7 cm wide by 0.1 cm deep. One open area was 5 cm long by 7 cm wide, in the left row. The resident denied pain, but indicated the area was sore. The wound doctor was notified and new orders were received to cleanse the area with normal saline, apply calcium alginate and cover with ABD (abdominal) pads, and secure with paper tape. On 10/3/22, the resident developed a fever and a change in orientation, which resulted in the resident being transferred to the hospital until 10/7/22 with a diagnosis of [CONDITION(S)] due to urinary tract infection. On 10/7/22 at 8:42 p.m., the resident was transferred back to the facility. Her skin was assessed as warm, dry and intact, but continued with blister wounds to the middle of the back. The resident did complain of soreness to the area related to the transfer back in her bed. On 10/8/22, the wound physician completed a wound care assessment and evaluation of the resident's wounds. The evaluation indicated the following areas: Site 1 - Burn Wound of the Left Lateral Back Full Thickness which measured 1 cm long by 1 cm wide by 0.1 cm deep; moderate serous exudate and abnormal granulation was present within the wound margins. Site 2 - Burn Wound of the Left Medial Back Full Thickness, which measured 20 cm long by 4 cm wide by 0.1 cm deep; moderate serous exudate; thick adherent devitalized necrotic tissue and slough were present as well as granulation tissue. Site 3 - Burn Wound of the Right Back Full Thickness which measured 17 cm long by 3 cm wide by 0.1 cm deep; moderate serous exudate present and abnormal granulation were present within the wound margins. All areas required chemical cauterization with topical anesthetic of the abnormal tissue in order to facilitate healing. Treatment orders to all areas included Alginate Calcium dressing with ABD pad and tape. The Skin Condition Progress Note, dated 10/13/2022 at 11:00 p.m., indicated the burn continued to heal. The nursing note, dated 10/17/22 at 10:14 a.m., indicated there was still redness to the site and blisters had popped with pain. The care plan, dated 10/2/22, indicated a problem of a burn wound of the left medial and right back The interventions included, treatment per wound physician; nursing to monitor until healed; notify the provider of any changes. The written statement from LPN 2, dated 10/3/22, indicated at 10:15 p.m., she applied the warm compresses to the resident's neck and back for comfort measures for 20 minutes initially. She then went back to remove the compresses and the resident indicated she would like to keep them in place for a little longer because she was starting to feel better. The LPN returned 10 minutes later to remove the compresses. The resident's skin was assessed to have redness due to the compresses, but her skin was intact and dry. At 1:00 a.m. while providing care, the blisters were on the resident's back. During an interview with Resident C on 10/17/22 at 11:40 a.m., she indicated when she complained of neck pain and soreness, LPN 2 gave her a warm wash cloth for her neck. When she told the nurse it felt good and wished she had something for her back, she guessed the nurse went and got some towels, wet them, maybe placed them in the microwave and brought them to her. She indicated it felt good and was not too hot to her skin. She then forgot about them and so did the nurse and later blisters were noticed on her back. During an interview with the Director of Nursing (DON) on 10/17/22 at 12:05 p.m., she indicated the resident wanted something for soreness, so the nurse warmed up some wet wash cloths in the microwave, placed them in a bag and gave them to the resident. She was unsure how long the resident had them on her back. She indicated she spoke with the nurse after it happened and told her she really needed a physician's order for the compresses and about leaving the compresses in place when the resident refused to remove them the first time. LPN 2 was given a written warning for the incident with education on how to properly apply a warm compress even if the resident refused and to re-check the skin and offer to re-apply it. An all nursing in-service was given the next day 10/3/22 on How to make a warm compress. This tag was related to past non-compliance as the facility took immediate steps for treatment; all nursing staff were re-educated on how to apply warm compresses on 10/3/22, and the LPN received disciplinary action on 10/3/22. This Federal tag was related to Complaint IN 638. 3.1-45(a)(1)

Based on observation, record review, and interview the facility failed to ensure interventions were implemented for falls and to ensure safe transfer procedures were implemented for a resident that required maximum assistance which resulted in bilateral knee fractures (Resident B) for 3 of 5 residents reviewed for accident hazards. (Residents B, H, and F) Findings include: 1. The clinical record for Resident B was reviewed on 7/26/22 at 9:30 a.m. The diagnoses included, but were not limited to, [CONDITION(S)], diabetes mellitus, fracture of shaft of left fibula, nondisplaced supracondylar fracture without intracondylar extension of lower end of right femur, [CONDITION(S)], renal osteodystrophy, specified disorders of bone density and structure, pain, heart failure, muscle weakness, renal [CONDITION(S)], and [CONDITION(S)]. The current care plan, dated 1/10/22 and last revised on 7/26/22, indicated the resident was unable to independently perform ADL's (activities of daily living) related to [CONDITION(S)] ([CONDITION(S)]) on [CONDITION(S)], [CONDITION(S)], incontinence, anxiety, pain, weakness, impaired vision and required assistance and encouragement for bed mobility, transfers, toileting and eating. The interventions included, but were not limited to, with a start date of 1/10/22 staff were to provide assistance with transfers (use assistive device) Hoyer lift with two staffs' assistance and follow PT/OT (Physical Therapy and Occupational therapy) recommendations. There was no stop date from the original start date of 1/10/22 related to the resident's use of a Hoyer lift for transfers by staff. The nurse's note, dated 3/2/22 at 11:38 a.m., indicated the resident required the assistance of two staff members with ADL's and transfers via Hoyer lift. The Quarterly MDS assessment, dated 4/26/22, indicated the resident required total dependence of two staff members for transfers. The activity of the resident to be able to move from seated to standing position did not occur. The resident walking with an assistive devise did not occur. Transfer between surfaces including to or from bed, chair, wheelchair total dependence full staff. The resident had lower extremity impairment on both sides. The Quarterly MDS assessment, dated 6/14/22, indicated the resident required total dependence of two staff members for transfers. The activity of the resident to be able to move from seated to standing position did not occur. The resident walking with an assistive devise did not occur. Transfer between surfaces including to or from bed, chair, wheelchair total dependence full staff. The resident had lower extremity impairment on both sides. The resident was cognitively intact. The nurse's notes, dated 6/14/22 at 3:00 p.m., indicated Resident B was up in his wheelchair. The nurse and CNA (Certified Nursing Aide) were attempting to transfer the resident back to bed. The nurse lost her footing and fell with the resident falling on top of the nurse. The resident complained of pain to his knees after staff assisted the resident to bed. Pain medication was administered and effective with the resident's pain. An order for X-rays of the resident's bilateral knees was ordered. The nurse would continue to monitor. The Event Report, dated 6/14/22 at 3:00 p.m., indicated the resident had a witnessed fall. The resident was being transferred by the nursing staff from the wheelchair to the bed by 2 staff members. One staff member tripped over an obstacle and lost her footing. The staff member fell and the resident fell on top of the staff member. A period of time after the fall the resident complained of pain and the resident's knees were swollen. The report indicated no assistive devices were used at the time of the fall. The nurse's note, dated 6/15/22 at 3:24 p.m., indicated the resident attended [CONDITION(S)], and then he was transferred to the hospital per physician's order for increased swelling and pain in his left knee. The CT (computed tomography) scan, dated 6/15/22, indicated the resident had a nondisplaced fracture of the left fibular head. Additional fractures were not seen, but could be a difficulty due to osteopenia. There were no displaced fracture. The right extremity had a minimally displaced, minimally impacted fracture along the posterior and lateral distal familiar metaphysis. This correlated for underlying etiologies given the patient's age. Renal osteodystrophy were most likely. The physician's order, dated 6/24/22, indicated staff were to apply the ACE wrap to LLE (left lower extremity) until further notice (Please wrap from foot up to over knee) twice a day, the resident could be up as tolerated, knee immobilizer to the right leg until further notice (Check skin daily underneath immobilizer) twice a day. During an interview on 7/27/22 at 1:03 p.m., Resident B indicated his fall was an accident. He was on oxygen at the time and when the nurses picked him up, the nurse got tangled in his 02 tubing and his knees hit directly on the floor. He was grateful he did not hit his head. He was afraid the nurse was hurt also. He ended up with knee fractures, but they were healing up. He did use a Hoyer lift when he was assisted into his wheelchair for [CONDITION(S)]. During an interview on 7/28/22 at 1:00 p.m., RN 8 indicated a nurse and a CNA were transferring the resident to his wheelchair and the nurse tripped over a cord. The nurse fell and the resident fell with her. He received fractures to his knees. He had an immobilizer on one leg and an ace wrap on the other leg. She indicated gait belts should be used for the residents and employee safety. She felt like more education was needed to be provided to make employees aware of the clutter on the floors like oxygen tubing. After the accident the resident only got up with the Hoyer lift. He could not bear weight on his legs. During an interview on 7/28/22 at 2:08 p.m., the Physical Therapy Supervisor indicated therapy was working with the resident on using a slide board for transfers from the bed to the wheelchair before the accident. When the resident was admitted to the facility, he was completely immobile. He was able to use the slide board. When physical therapy worked with a resident, they always used a gait belt. They do not pass out gait belts to every resident because they always ended up lost. Several residents came from the hospital with gait belts and those were used. When transferring a resident it was safer for the resident when the gait belts were used. During an interview on 7/29/22 at 9:41 a.m., the DON indicated a nurse and a CNA were transferring the resident from the wheelchair to the bed. The nurse tripped over a cord and fell . The resident fell on top of the nurse hitting his knees on the floor. He sustained bilateral knee fractures. He required the assistance of two staff lift with a gait belt and could use a slide board for transfers. Some days he would use the Hoyer lift if he felt weak. After the accident the resident was a complete Hoyer lift for transfers. The resident was unable to stand and used a wheelchair for mobility. The staff did not use the slide board or Hoyer lift on the day the accident occurred. or he fell off the slide board when the nurse lost her footing. During an interview on 7/29/22 at 1:10 p.m., CNA 9 indicated she was one of the CNA's that helped the nurse transfer the resident. He required the assistance of two staff for transfers. He sat on the side of the bed, and they lifted the resident from underneath his arms with their arms. When they got the resident up his knees buckled and he fell . They did not use a gait bed or Hoyer lift to assist with transferring the resident. 2. The clinical record for Resident H was reviewed on 7/27/22 at 10:00 a.m. The diagnoses included, but were not limited to, spinal stenosis of cervical region, dementia with behavioral disturbance, [CONDITION(S)], dysarthria and anarthria, unsteadiness on feet, low vision of left eye, attention and concentration deficit following cerebral infarction, other seizures, and muscle weakness The care plan, dated 7/24/19 and last revised 7/8/22, indicated the resident was at risk for falling and fall related injuries related to Cervical 6 and 7 moderate canal stenosis with a history of falls, impaired mobility, impaired cognition with poor safety awareness, and use of anti-depressant medication. The interventions included, but were not limited to, anti-slip strips to be added to bedside to minimize the risk of slips when arising from bed (dated 7/20/22), bolster mattress to bed ( dated 7/8/22), anti-rollbacks to wheelchair (dated 7/1/22), replace crocs with tennis shoes (dated 6/3/22), nursing staff to provide hourly checks to ensure safety (dated 6/1/22), psychiatric NP (Nurse Practitioner) to review medications to see if they were contributing to falls (dated 6/1/22), resident to be a third shift get up, staff to assist with toileting and ADLs (dated 5/25/22), footboard to be fixed and secured to bed (dated 5/25/22), staff to offer stand-by assist while ambulating, as resident will allow (dated 4/23/22), NP to review medications (dated 4/23/22), ensure proper footwear is in place while resident is up during the day (dated 4/12/22), ensure resident is wearing non slip socks while abed (dated 2/27/22), place sign on resident's walker to remind her to use her walker (dated 7/12/21), educate staff to remind resident to use walker while up ambulating (dated 6/2/21), non-skid socks in place at all times when out of bed (dated 6/2/21), cue and remind the resident to utilize the call light to seek assistance as needed (dated 7/24/20). During an observation, on 7/27/22 at 10:17 a.m., Resident H was resting in bed. There were no non-skid strips observed in her room, and there was no sign observed in the room to remind the resident to use her walker. During an observation on 7/28/22 at 8:33 a.m., The resident was lying in bed, she had one shoe on her right foot and only a sock on the left foot. Her other shoe was not in sight. There were no non-skid strips in the room and no sign could be located on her walker or in the room to remind the resident to use her walker. During an observation, on 7/29/22 at 9:32 a.m., The resident was lying in bed with no non-skid strips on the floor or any signs observed in the room. The nurse's note, dated 2/26/22 at 6:25 p.m., indicated at 4:10 p.m. the resident was ambulating without her walker. Staff observed her to reach down to pick up something and then fall to the floor on her left side. The IDT (Interdisciplinary Team) follow-up, dated 2/27/22 at 4:38 p.m., indicated a new intervention was added for staff to remind the resident to use her walker was put into place. The nurse's note, dated 4/11/22 at 9:46 p.m., indicated a QMA (Qualified Medication Aide) found the resident lying on the floor next to her bed. She was not using her walker and was walking over to her dresser and fell . The IDT follow up, dated 4/12/22 at 8:44 a.m., indicated the resident did not have proper footwear on and the intervention would be for staff to ensure the resident had on non-slip socks while abed and to ensure resident had good fitting shoes in place while up during the day. The nurse's note, dated 4/23/22 at 3:31 a.m., indicated the resident was found lying prone in the hall way outside her room door. The IDT follow-up dated 4/23/22 at 9:48 p.m., indicated it was unclear what the resident was doing up as it was the middle of the night. Therapy would evaluate the resident due to the increase in the number of falls recently and the NP would be made aware and asked to review the resident's medications. The nurse's note, dated 4/30/22 at 2:20 p.m., indicated the resident was observed ambulating in the unit, towards the dining room, without her walker as an assistive device. The on duty nurse began to walk towards the resident to provide assistance, at that time the resident began to back up to dining room chair and attempted to sit back in a chair. The resident missed the seat of the dining room chair, which caused her to stumble to the left and the resident was observed to very slowly fall to the dining room floor and land onto her left side. The IDT follow-up dated 5/1/22 at 9:17 p.m., indicated the intervention was for the resident to have an MRI (magnetic resonance imaging) of her head. The nurse's note, dated 5/22/22 at 7:00 p.m., indicated at 4:30 p.m., the nurse was walking down the H Hallway and heard a screeching like sound from the resident's room. The nurse approached the room and observed the resident sitting on the top of the footboard of the bed. As the nurse was entering the resident's room, the footboard appeared to break on one side, causing one side of the footboard to fall to the floor. This caused the resident to fall to her left side, and land on the floor next to the bed. The nurse's note, dated 5/22/22 at 7:00 p.m. indicated at 5:45 p.m., indicated the nurse heard yelling from the resident's room and entered to observe the resident sitting in the floor next to her bed in front of the bedside chair she was previously sitting in. The bedside table was observed to be laying on the floor, at resident's feet. A styrofoam cup of water was observed to be spilled onto the floor. The IDT follow-up dated 5/25/22 at 11:45 a.m., indicated the intervention was for the resident's footboard to be fixed and secured. The IDT follow-up dated 5/25/22 at 11:58 a.m., indicated the new intervention was for therapy to give the resident a wheelchair with anti-rollback device on it and therapy was to focus on improving her balance. The nurse's note, dated 5/30/22 at 5:00 p.m., indicated at 3:50 p.m. the resident attempted to transfer herself from an unlocked wheelchair. The nurse was unable to reach the resident before she lost her balance during an attempted self-transfer and slid off the seat onto the floor. The IDT follow-up dated 6/1/22 at 11:44 a.m., indicated the resident had been found on 5/29/22 in another room. She was up ambulating without her walker and went into another room and fell in front of the bathroom with her brief around her calves. The new intervention would be for the resident to be a 3rd shift get up between 5:30 a.m. and 6:00 a.m. Staff were to toilet and get the resident ready for the day and offer to lay her down on top of the covers if she wanted to sleep a little longer. The nurse's note, dated 6/2/22 at 7:33 p.m., indicated the resident had a witnessed fall in the hallway when her right leg twisted causing her to fall to the floor. The IDT follow-up, dated 6/3/22 at 8:46 a.m., indicated the psychiatric NP had just changed resident's medication order 2 days ago due to recent increase in falls. The resident was ambulating in the hallway without an assistive device. The resident did not remember to use it or her wheelchair even though there were reminder notes posted in her room and on the devices. The new intervention would be for staff to provide hourly safety checks on resident. The nurse's note, dated 6/29/22 at 5:12 p.m., indicated the resident had an unwitnessed fall. She was found in the activities room lying on the floor. The IDT follow-up, dated 7/1/22 at 11:07 a.m., indicated the resident was attending an activity in the activity room with an activities assistant. The activities assistant got up and walked across the hall into the dining room and told the resident to follow her. The resident stood up from the wheelchair to begin to attempt to walk, but fell to the floor. The resident only had on one shoe which was a croc. The new intervention would be for activities staff to assist residents in their wheelchairs when moving about the unit and the resident to wear well-fitting shoes when up. The nurse's note, dated 7/7/22 at 6:30 p.m., indicated the resident had an unwitnessed fall at 9:30 a.m. with no injury. She had landed on her bottom. The IDT follow-up, dated 7/8/22 at 10:28 a.m., indicated the resident had a fall in her room. The nurse manager reported she was ambulating in her room and looking out the window and was educated about the need to use wheelchair for safety. The resident refused to use a wheelchair initially but eventually sat in the wheelchair. Staff walked away and re-checked a few moments later, and the resident was on the floor in front of her wheelchair. The resident had cognitive impairment, but was wearing appropriate shoes and fully dressed. The intervention discussed, was to ensure with the therapy department that anti-rollback devices were placed on the wheelchair. The nurse's note, dated 7/19/22 at 8:54 p.m., indicated the staff were called to the room and the resident was observed lying on the floor by her bed. She indicated she'd hit her head, but was unable to explain what she was doing prior to the fall. The IDT follow-up, dated 7/20/22 at 11:42 a.m., indicated the resident was found on the floor lying on her right side and was unable to report how the fall occurred. She had non-skid socks on and was toileted after the assessment was completed. The interventions added, was for the resident to have a bolster mattress to assist the resident with bed parameters while resting, in addition the resident would have anti-slip strips placed on the floor of the open side of the bed to decrease risk of slips when resident arises. During an interview, on 7/29/22 at 10:47 a.m., LPN (Licensed Practical Nurse) 11 indicated the resident had several interventions, including anti slip strips to her bedside, hourly checks, non-slip socks while abed, a sign on her walker to remind usage, educate staff to remind the resident to use a walker. She did not see any non-skid strips in the resident's room. She normally did have a sign, but she did not currently see a sign to remind her to use her walker. Non-skid strips should be applied the same day it is made as an intervention. During an interview on 7/29/22 at 12:40 p.m., the DON typically non-slip strips were placed pretty quickly. They communicated it with maintenance to put them down and they should be in place in less than 24 hours. 3. The clinical record for Resident F was reviewed on 7/28/22 at 9:00 a.m. The diagnoses included, but were not limited to, [CONDITION(S)] not intractable with [CONDITION(S)], mood disorder, conversion disorder with seizures or convulsions, dementia, repeated falls, history of shoulder fracture, and a history of clavicle fracture. The care plan, dated 3/1/21 and last revised 7/26/22, indicated the resident was at risk for falling and fall related injuries related to impaired cognition, poor safety awareness, seizures, unsteady gait, and use of anti-psychotic medication. The interventions included, but were not limited to, bed in lowest position and encourage to get assistance with transfers (5/31/22), change in medication administration time of anti-[CONDITION(S)] medication (3/31/22), bolster mattress to bed (3/18/22), staff to do hourly checks for safety due to seizures being cause of falls (2/14/22), bed placed against wall (1/17/22), light added to provide visibility during toileting (12/2/21), assist with ADL's as needed to meet needs, assist with transfers as needed, cue and remind resident to utilize call light to seek assistance as needed, keep personal items and frequently used items within reach, and report any noted functional changes (3/1/21). The physician's orders included, but were not limited to the following: -[MEDICATION(S)] tablet 750 mg 1 tablet every 12 hours at 7:00 a.m. and 7:00 p.m. Special instructions: time specific to maintain level of medication in system to attempt to prevent or decrease [CONDITION(S)] activity. Medication should be administered as close to 5:00 a.m. as possible to keep the every 12 hour requirement, with a start date of 4/12/22. -Resident to be on 15 minute checks due to mental change every shift, which started on 7/8/22. The nurse's note, dated 12/2/21 at 2:48 a.m. indicated the resident's call light was on and she was observed sitting on the floor with no injuries. Staff would increase rounding to ensure safety. The IDT follow-up note, dated 12/2/21 at 9:52 a.m., indicated the resident's fall may have been due to low lighting and additional lighting would be added for better visibility. The nurse's note, dated 12/21/21 at 4:21 a.m., indicated the resident was found lying on her left side across the bed with her right leg up in the air. Her upper and lower extremities had small jerking movements, bilateral eyes blinking, mouth smacking, and the resident's bed and gown were soaked. The resident had a [CONDITION(S)] that lasted off and on about 30 minutes. The MD ordered to do a CBC (complete blood count), BMP (basic metabolic panel), [MEDICATION(S)] level, and urinalysis. The nurse's note, dated 12/21/21 at 5:28 p.m., indicated the resident was heard yelling out for help but it was muffled in sound. She was in the prone position between the bed and the wall, unable to get up or move. She had a small 1 cm (centimeter) cut with very little blood noted. The second injury was to the right cheek bone. Both areas were reddened in color and swollen. The resident was inconsolable at the time and was sent to the hospital. The nurse's note, dated 12/24/21 at 1:00 p.m., indicated the resident had a 3 night stay at the hospital and had a [CONDITION(S)] (urinary tract infection) which she was receiving an antibiotic for. She had a close displaced fracture of the acromial end of her right clavicle. The nurse's note, dated 1/15/22 at 6:35 p.m., indicated at 7:30 a.m. the nurse entered the resident's room to observe her lying face down on the floor, next to her bed. She was not answering questions appropriately. The right side of her face observed to be twitching and quivering. The physician was notified with orders to send the resident to the hospital. The IDT follow-up, dated 1/17/22 at 8:04 p.m., indicated the resident had a recent new diagnosis of seizures and in the past had falls due to seizures. Her bed would be placed against the wall, and staff were to ensure bed was in lowest position to floor. The nurse's note, dated 2/13/22 at 6:18 a.m., indicated the resident was found on floor face down in the prone position. The patient had a change of her normal level of consciousness. She was unable to communicate and was sent to the hospital. The nurse's note, dated 2/13/22 at 1:51 p.m., indicated the resident returned to the facility and checks resumed per facility protocol. The nurse's note, dated 2/13/22 at 6:26 p.m., indicated at 4:10 p.m., the nurse was called to the room by the on duty CNA. The resident was found lying on the floor, on her right side, outside of the bathroom. She had slurred speech and garbled speech, and was not able to verbalize answers to questions at the time of fall. Her right eye and right side of mouth were observed to be involuntarily twitching. She was not able to follow commands and was moaning and yelling out. She was sent to the hospital. The IDT follow-up notes dated 2/14/22 at 3:18 p.m. and 3:24 p.m., indicated the new intervention would be to do hourly checks on the resident for her safety. The nurse's note, dated 2/14/22 at 10:40 p.m., indicated the resident fell and hit her head with loss of consciousness very briefly. She was sent out to the hospital. The nurse's note, dated 3/31/22 at 5:57 a.m., indicated at 5:53 a.m., the CNA heard a noise and entered the resident's room. She found the resident sitting upright with her back up against the bed. She had a very small non bleeding abrasion right forearm and right side. The CNA stayed with the resident until the next shift arrived due to history of seizures. The MD was notified with orders to monitor abrasion and for [CONDITION(S)] activity. The IDT follow-up, dated 3/31/22 at 4:10 p.m., indicated the resident fell and was sent out the hospital. Staff did not witness any [CONDITION(S)] activity and the fall was unwitnessed. She arrived back without any new orders. The resident was given [MEDICATION(S)] at the hospital as she had not yet received her morning dose. As needed [MEDICATION(S)] was ordered for seizures. The IDT follow-up, dated 3/31/22 at 4:20 p.m., indicated the resident had a fall around 5:30 a.m. The new intervention would be for the administration times of her [MEDICATION(S)] to be given earlier. The nurse's note, dated 4/12/22 at 4:25 p.m., indicated the order was clarified for times of administration of the resident's [MEDICATION(S)] to be given specifically at 5:00 a.m. and 5:00 p.m. The clinical record lacked documentation of the administration times being updated to 5:00 a.m. and 5:00 p.m. as ordered. The nurse's note, dated 5/29/22 at 2:37 a.m., indicated the nurse heard a loud thud and found the resident on the floor crying out with a skin tear on her elbow. The resident was sent out to the hospital for evaluation. The nurse's note, dated 5/29/22 at 9:08 a.m., indicated the resident returned to the facility at 7:35 a.m. with no new orders. The nurse's note, dated 7/4/22 at 9:00 a.m., indicated the resident had an unwitnessed fall and was unable to follow commands and non-verbal, appeared to have hit her head. She was sent to the hospital for evaluation. The nurse's note, dated 7/4/22 at 5:25 p.m., indicated the resident was transported back to the facility by her family member. All workup was negative. The IDT follow-up, dated 7/5/22 at 12:43 p.m., indicated the resident was known to have falls related to [CONDITION(S)] activity. She had been seen by multiple neurologists. She had increased confusion 1 to 2 days prior to seizures and was observed to not be herself. Nursing would monitor for these changes and place appropriate interventions at that time. The nurse's note, dated 7/8/22 at 3:15 p.m., indicated the resident was awake throughout the night, had increased anxiety and agitation, along with audible and visible hallucinations. The NP was notified with new orders provided included [MEDICATION(S)] 2 mg/ml (milligrams per milliliter), 1 mL IM (intramuscularly) related to increased anxiety and agitation. Every 15 minute checks were initiated per DON instruction. During a continuous observation on 7/28/22 from 8:40 a.m. to 9:31 a.m., the following observations of Resident F were made: - At 8:40 a.m., the resident was in her room, with the room door was closed. Staff could not observe the resident from the hallway as they were walking by. - At 8:54 a.m. CNA 12 entered the resident's room, picked up her tray, and exited the room, closing the door behind her. - The resident was not checked on again by staff until 9:31 a.m. when 2 CNAs entered the resident's room. During a continuous observation on 7/28/22 from 10:14 a.m., to 10:38 a.m., no staff were observed to physically check on the resident. Her curtain was pulled, and she was not able to be observed from the hallway. During a continuous observation, on 7/28/22 at 1:05 p.m., the resident was in her room, in bed, with the curtain pulled and was not visible from the hall. At 1:28 p.m. 2 CNAs entered the resident's room and exited one minute later pulling the door nearly closed with a 1 inch gap. Both CNAs re-entered the room at 1:30 p.m., and exited at 1:34 p.m. carrying trash, and closed the door behind them. No staff observed or checked on the resident until 1:51 p.m. when the resident came out into the hallway. During an interview, on 7/28/22 at 1:27 p.m., CNA 12 indicated she was caring for the resident. She checked each resident every 2 hours and was not aware of any residents who required more frequent monitoring. She was not aware of the resident having any history of seizures. During an interview, on 7/28/22 at 1:18 p.m., CNA 13 indicated most of the residents were to be checked on every 2 hours. She was not aware of any residents who required more frequent checks for safety. During a continuous observation, on 7/29/22 at 9:30 a.m., the resident was lying in bed with her curtain pulled and was not visible from the hallway. No staff were observed to check on the resident until 9:50 a.m. when a housekeeper entered the room to clean. Staff did not check on the resident again, until 10:29 a.m. when CNA 12 entered the room. During an interview, on 7/29/22 at 10:36 a.m., CNA 14 indicated she did not have any residents who had frequent checks. During an interview, on 7/29/22 at 10:40 a.m., LPN 11 indicated the resident had 15 minute checks in place for [CONDITION(S)] activity. She did not maintain a log of the checks. During an interview, on 7/29/22 at 12:36 p.m., the DON indicated they did not have sheets for the 15 minute checks. She expected that the nurse or a staff member checked on the resident every 15 minutes. She would expect them to be going and physically checking on the resident and visualizing them. She thought the resident's [MEDICATION(S)] was changed to be given earlier. The Fall Prevention Policy and Procedure, dated 5/2016, provided on 1/29/22 at 10:37 a.m. by the CS (Clinical Support), included, but was not limited to, . Step Three: Strategies of Intervention . Strategies for interventions to prevent falls will be individual for each patient . Care Planning . Care plans are a vital part of the nursing process and serve as individualized pathway used by all caregivers . Fall risk care plans will be kept current by the IDT and other associates within each community. Individualized interventions on the fall care plan will be duplicated onto care sheets to ensure care plan strategies are integrated into the health system . This tag relates to Complaint IN 068 3.1-45(a)(1)

Based on observation, record review, and interview, the facility failed to ensure adequate supervision and the implementing of care planned interventions for residents with dementia related to wandering and aggressive behaviors which resulted in agitation, abrasions, and a fracture for 2 of 3 residents reviewed for dementia care. (Resident C and B) Findings include: 1. During an observation on 1/2/20 at 8:40 a.m., Resident C was observed in the common area on Hall D sitting on the couch. The resident had a large skin tear on her right hand and bruising to the right side of her face. During an observation on 1/3/20 at 11:50 a.m., the resident was laying on the sofa in the common area. The QMA (Qualified Medication Aide) indicated, We are waiting on lunch. The resident got up and walked toward another resident. The resident's gait was unsteady and she stumbled around when walking. The QMA was sitting at a table with other residents and did not get up to redirect the resident. During an observation on 1/3/20 at 2:15 p.m., the resident was making movements like she was cleaning the doorway. She was patting a floor fan and trying to get the fan to move. The resident was mumbling some words, that could not be understood. The resident's clinical record was reviewed on 1/3/20 at 12:29 p.m. The resident's [DIAGNOSES REDACTED]. The Quarterly MDS (Minimum Data Set) assessment, dated 12/9/19, indicated the resident's cognition was severely impaired. The current care plan, initiated on 8/16/19, indicated the resident experienced wandering (moves with no rational purpose, seemingly oblivious to needs or safety) behaviors. The interventions include, but were not limited to, redirect resident with folders (paperwork - resident worked at a school for many years), resident to have own snacks and candy, maintain calm environment and approach to the resident, obtain a psych consult/psychosocial therapy, post identifying pictures at nurse's stations and at reception desk, remove resident from other resident's rooms and unsafe situations. The current care plan, initiated on 11/29/19, indicated the resident has dementia with behavioral disturbance that required the use of anti-psychotic medications related to restlessness/agitation, relentless pacing/wandering and difficulty redirected. The interventions include, but were not limited to, if resident refused interventions provide counseling on alternative and/or alternative approaches to address behavioral and psychiatric evaluation as indicated. A progress note, dated 9/5/19, indicated the resident had an open area to the top of her left hand. The wound measured 1 cm (centimeter) by 1 cm and was from and unknown origin, Resident unable to tell me. A progress note, dated 9/7/19 at 12:25 p.m., indicated a CNA was attempting to come through D Hall entrance door and resident was standing on the opposite side of the door. Upon entering the side of the door frame hit against center of resident forehead .21.5 cm bruise purple/red in color noted to center of resident forehead. A progress note, dated 11/1/19, indicated the resident was on the floor in the dining area. The nurse indicated she had seen her a few minutes prior watching television. The resident was unable to voice how event occurred . A progress note, dated 11/9/19 at 3:15 p.m , indicated the resident was attempting to get Resident H to follow her for a lesson and became frustrated when Resident H did not wish to go with her. Resident C grabbed onto her (Resident H's) walker and was trying to make her follow her . Resident H reacted by making physical contact with Resident C and struck the resident on the right cheek. A fall note, dated 11/17/19 at 11:03 p.m., indicated the resident had a fall at 5:50 a.m. The resident had wandered into another resident's room and opened his drawer and took out his candy. Per other resident he was trying to get them back, when she lost her balance and fell . The resident had a skin tear to her forearm and a bruise to her head. A progress note, dated 11/20/19 at 7:54 p.m., indicated a CNA notified nursing staff that the resident was found on the floor. The resident was laying next to her bed in the supine position and was incontinent of urine at time of fall. The resident had a 1 cm abrasion to her left hand. A progress note, dated 11/30/19, indicated a CNA alerted the nurse that the resident had fallen in the dining room. The resident was noted to be sitting on her buttocks with her back up against another resident wheelchair. .CNA stated that resident fall was unwitnessed . A progress note, dated 12/3/19, indicated Upon entering resident room to give morning medications, per this nurse found resident lying on the floor in her bedroom . The resident had a skin tear to her right elbow that were approximately 3 by 2.5 cm in size and scattered small abrasions to her left forearm. A progress note, dated 12/12/19, indicated the resident was noted to be ambulating around the unit with a limp and not bearing weight to her right lower extremity. .resident appears to be in pain while resting or applying any pressure on right hip . A progress note, dated 12/13/19 at 1:48 a.m., indicated staff were called to the resident's room by laundry staff. The resident was crawling on her floor and got up by herself and was standing by the door. The resident had swelling, redness, and a small abrasion under her right eye. A progress note, dated 12/17/19 at 3:50 p.m., indicated the resident had a fall and was unable to bear weight on right lower extremity, .CT (computed topography) indicated fracture to right greater trenchant. The clinical record lacked documentation to show interventions to obtain a psych (Psychological) consult or therapy after November; and/or alternative approaches to address behavioral, mental and/or emotional symptoms. There were no posted identifying pictures at nurse's stations and at reception desk or information to remove resident from other resident's rooms and unsafe situations. During an interview on 1/3/20 at 12:00 p.m., the DON (Director of Nursing) indicated the resident had not had not seen psych since November. During an interview, on 1/3/20 at 9:30 a.m., LPN (Licensed Practical Nurse) 5 indicated We will lay the residents down when they are tired to help prevent falls. We will use fall mats, beds in low position, encourage to use call light or a touch pad. If we see a resident that is agitated or aggressive we will redirect them, give meds as ordered, call the doctor, they can see psych and we will get them to a safe place. For our wanders we keep close observations on them. During an interview on 1/3/20 at 9:15 a.m., CNA 1 indicated there was .not a lot of activities going on back here .It is hard for one CNA and one nurse or QMA (Qualified Medication Aide) to watch the residents . 2. During an interview on 1/3/2020 at 11:32 a.m., Resident B was observed sitting on a love seat, in the unit dining room, with his eyes closed. The resident walked, with an unsteady gait, to his room and indicated activities were just the staff playing country western music and he wasn't interested. The clinical record was reviewed on 1/3/20 at 8:13 a.m. The resident's [DIAGNOSES REDACTED]. The current care plan, dated 8/1/19 and revised on 12/23/19, indicated the resident was at risk for falls and fall related injuries related to [DIAGNOSES REDACTED]. The interventions included, but were not limited to, Redirect res (resident) from nurse station and chair in area. (dated 12/23/19) Assist with ADL's (Activities of Daily Living) as needed to meet needs. Cue/remind resident to utilize call light to seek assist as needed. Keep personal items and frequently used items within reach. Report any noted functional changes .(dated 8/1/19). The current care plan, dated 7/31/19 and last revised on 12/5/19, indicated the resident had TBI and Dementia with behaviors. The resident required monitoring and for staff to utilize interventions. The interventions included, but were not limited to, .gradual involvement in activities out of room . Activities to assess resident and encourage to attend activities the resident enjoys . A progress note, dated 11/3/19 at 4:56 p.m., by LPN 10 indicated the resident was found on the floor in his bathroom. .Blood was found on floor and only apparent visible injury was laceration to nose 0.1 cm by 3 cm by 0.1 cm in size . A progress note, dated 11/16/19 at 2:53 p.m., indicated the resident was being argumentative with staff . The resident was .pacing in hallway on unit and using phone frequently to call (family member) . A progress note, dated 11/17/19 at 7:05 a.m., indicated the resident Resident states that he kicked a female resident knocking her to the floor because she was in his room . The behavioral event, dated 11/17/19, indicated the resident had a verbal and physical aggression towards another resident. The only intervention documented was 1 on 1 care. A progress note, dated 11/19/19 at 8:50 a.m., by LPN 17 indicated the resident was up wandering in the hallway on the unit. The resident was becoming increasingly agitated The resident was using the phone at the nurses station to call his family member every few minutes .Encourage resident to participate in activities, quiet time in room The behavior monitoring for the month of (MONTH) indicated the resident only had behaviors on 11/8/19 from 6:00 p.m. to 6:00 a.m. The log lacked documentation of monitoring behaviors on 11/11/19, 11/12/19, and 11/17/19 for day shift. A progress note, dated 12/23/19 at 3:58 p.m., by LPN 11 indicated the follow up note for the event on 12/22/19 at 9:21 a.m., of a nurse witnessing the resident walking into the nurses' area and as nurse approached he attempted to sit down in chair and it rolled away and he fell to floor. Res got self-off of floor and informed nurse he was ok but did allow nurse to assess and no injuries were noted. The resident denied pain or injury . The clinical record lacked documentation of any successful interventions attempted for the behaviors. During an interview on 1/2/20 at 1:00 p.m., the DON (Director of Nursing) indicated she had not been the DON when the resident was physically aggressive toward another resident, however she would have considered interventions such as obtaining labs to see if there was an underlying infection, possibly sending the resident out for behavioral care, moving the resident to a different unit. During an interview on 1/3/20 at 10:52 a.m., the Clinical Specialist indicated she would have considered interventions such as contacting psychiatric services or sending the resident out for behavioral services, involving the resident in an activity, or utilizing a stop sign for wandering. The Memory Care Community Principles and Practices dated 10/18/11, provided on 2:27 p.m. by the Clinical Specialist included, but was not limited to, .This manual serves as a guide for the care of our specialized population of residents with a primary [DIAGNOSES REDACTED]. Philosophy of Service and Care . These communities are safe, secure, and well-maintained environments that promote independence, activity, engagement, friendship and continued growth . Our Cherished Memories program is focused on enriching the lives of residents, loved ones, our associates and friends of persons with dementia through our activity focused approach to care . On 1/3/19 at 10:52 a.m., the Clinical Specialist provided a copy of the May, (YEAR) Fall Prevention Policy and Procedure included, but was not limited to, . Falls are globally common, important, and often times, preventable . It is the responsibility of the interdisciplinary team to document falls prevention, when a fall occurs, and interventions to avoid future falls . The fall risk assessment will be completed on each new admission, each readmission, with a change in resident condition, and quarterly with the minimum data set (MDS) schedule . This Federal tag relates to Complaint IN 222 3.1-37(a)

Based on observation, interview, and record review, the facility failed to ensure residents were provided the care and services to prevent the worsening of a stage IV (4) pressure ulcer and/or the development of multiple pressure ulcers for 2 of 6 residents reviewed for pressure ulcers.(Residents B and C). This deficient practice resulted in an Immediate Jeopardy. The Immediate Jeopardy began on 10/11/18 at 5:35 p.m. when an area to the coccyx was identified by staff and the facility failed to ensure interventions were implemented to prevent the worsening of a stage IV pressure ulcer. The Administrator, Director of Nursing, Clinical Specialist, and Director of Clinical Services were notified of the Immediate Jeopardy on 1/17/19 at 4:00 p.m. The Immediate Jeopardy was removed on 1/19/19, but noncompliance remained at the lower scope and severity of isolated, no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: 1. The clinical record for Resident B was reviewed on 1/16/19 at 4:50 p.m. The resident's [DIAGNOSES REDACTED]. A Weekly Skin Inspection Tool, dated 10/04/18, indicated the resident had risk factors including, but not limited to, need for assistance for repositioning, moisture exposure, and a history of pressure ulcers. She did not refuse care and did not sit up for more than two hour periods. The resident had no skin issues. The nurse's note, dated 10/11/18 at 05:35 p.m., for Resident B indicated open area noted to coccyx this am. Wound nurse looked at area and consulted with . (Name of Wound Doctor). New order to cleanse coccyx with NS (Normal Saline), pat dry, apply medi (medical grade) honey, and cover with [MEDICATION NAME] (a foam dressing) daily. Res (resident) and Rp (representative) . (Name of Resident Representative) made aware. No question or concern at this time. The nurse's note entered as a late entry on 10/15/18 at 01:44 p.m., which was recorded and dated for 10/11/18 at 01:44 p.m., indicated Resident continues to decline to get out of chair to relieve pressure. Nurse educated regarding benefits of pressure relief measures. From the time a prior wound healed in (MONTH) to the note that was documented four hours prior to the wound being found on 10/11/18, there was no documentation of turning or repositioning, education to the family member to turn and reposition or the consequences of refusal. The care plan, dated 11/29/2017, indicated the resident was at risk for further breakdown due to impaired mobility, reluctance to turn while in bed, she chose to sit in the wheelchair for extended periods of time, and not lay down. The interventions included, but were not limited to, notify the resident's representative of any refusals. During an observation of wound care on 01/16/19 at 02:08 p.m., the wound nurse changed the resident's dressing according to the physician's orders [REDACTED]. The resident had a wound to the coccyx, which measured 3.4 cm (centimeters) in width, 6.6 cm in length, and 1.7 cm in depth. There was undermining at the 12 o'clock position (12 o'clock towards the head and 6 o'clock towards the feet), which measured 4.2 cm deep. The wound care nurse indicated the peri wound was clear the last time she had observed it, but now seemed larger and had more slough. She would be notifying the doctor. During an observation of wound care on 01/17/19 at 09:06 a.m., the wound care doctor indicated, The tissue itself looks better, but the undermining was new. There was some slough in the undermined area. She then proceeded to debride the area with a scalpel by scraping at the slough. The resident was noted to be shaking during the [MEDICATION NAME]. The shaking resided when the procedure was finished. The Unit Manager finished the wound dressing. During a confidential interview between 01/14/19 to 01/28/19, Nurse 2 indicated Resident B's wound shouldn't look the way it does and it was due to the lack of help. The staffing was horrible and the resident's wound was the worst I had ever seen it. They had come in several times to find treatments that had been left in place for days. They had heard from another nurse that the resident had been left all night with the wound vac in place but turned off. This was the worst I had ever seen the wounds in the facility, and staff were not turning the resident. During an interview on 01/15/19 at 11:30 a.m., a family member of the resident indicated the resident had developed a pressure ulcer in (MONTH) and was not being turned or repositioned, which they felt was due to limited staffing. Several times they had come in and found the resident laying on the wound, with treatments not in place or changed, and once had heard from a staff member that the wound vac had been turned off and left on the wound all night. During an interview on 01/17/19 at 08:11 a.m., LPN (Licensed Practical Nurse) 5 indicated they had come in to work one morning and the wound vac was found in place but turned off. The supervisor had informed them the night shift nurses had refused to fix it and left it turned off all night. During an interview on 01/17/18 at 09:23 a.m., the resident's family member indicated they had never been educated or talked to about repositioning or turning the resident prior to the resident recently going out to the hospital. The facility had only started turning the resident regularly since the State inspectors were in the building. They had never requested the resident to be left up in her chair. .If they had educated me at all on turning and repositioning, I would have made certain it was done . On 1/17/19 at 10:40 a.m., the Director of Nursing provided a copy of the document titled Wound Management, dated 03/2015. It included, but was not limited to, .Documenting resident compliance/non-compliance . Discuss resident's condition with resident and family . Discuss treatment options with resident and family . Discuss expected outcomes with resident and family . Discuss consequences of resident's compliance . Address resident concerns and offer alternatives . Consider having the physician discuss risk/benefits with the resident . Document refusals . Refusals of alternatives and the resident has the right to refuse once all alternative options are offered. 2. The clinical record for Resident C was reviewed on 01/17/19 at 02:19 p.m., the [DIAGNOSES REDACTED]. The care plan, dated 12/27/2018, indicated the resident was admitted with a stage 4 pressure ulcer to the left trochanter, a stage 4 pressure ulcer to the sacrum, and an unstageable pressure ulcer to the right heel. The interventions included, but were not limited to, assist resident with turning and repositioning, notify MD if area worsens, provide incontinence care after each incontinent episode, and reopened stage 3 pressure ulcer. On 01/17/19 at 01:33 p.m., the resident's right heel was observed laying directly on the bed with gauze partially covering a wound. There was no adherent dressing in place. A low air loss mattress was in place, but the resident's heels were not floated. During an interview on 01/17/19 at 01:40 p.m., RN 3 indicated the resident's wounds were uncovered because therapy had just been in and provided electrical stimulation to the wounds. On 01/17/19 at 01:41 p.m., the wound to the resident's left trochanter was observed with no dressing in place, and was left open to air. The wound measured 6 cm in length, 4.4 cm in width, and 1 cm deep, with 1 cm of undermining from 9 o'clock to 12 o'clock and a 1 cm tunnel center of the wound bed. The wound bed was approximately 30% (percent) covered with greenish yellow slough. The nurse noted a secondary, new area just below the wound, which measured 3.5 cm in length, 1.5 cm in width, and 0.1 cm in depth. During an interview on 01/17/19 at 01:42 p.m., RN 3 indicated The tunneling was new, undermining was new as well. I spoke with the aide. She said she's gone in a couple times, but she did not need to be changed. She said she had repositioned her. On 01/17/19 at 1:45 p.m., the wound to the resident's left sacrum was observed as an open area to the left ischial (back part of the hp bone) and sacral (bottom of the spine and lies between the fifth lumbar segment and the coccyx). RN 3 measured the area to be approximately 2 cm in length, 1 cm in width, and 0.7 cm in depth. There was tunneling at the 12 o'clock position of the wound which measured 1 cm. On 01/17/19 at 1:50 p.m., the resident was rolled further onto her right side. A new area on the coccyx and a cluster of new open areas were discovered on the coccyx and bilateral buttocks. The resident was incontinent of stool and urine. During an interview on 01/17/19 at 01:51 p.m., RN 3 indicated, due to the wound being covered in slough, the area to the coccyx would be an unstageable area and it was one she had not seen before. The wound measured 0.7 cm in length by 0.5 cm wide. She was unable to determine the depth due to slough. The resident had another wound next to the main wound that would be considered unstageable due to part of the wound being covered with eschar. On 01/17/19 at 2:06 p.m., the cluster of open areas to the bilateral buttocks for Resident C were measured. The first area (7 o'clock in relation to main wound on the coccyx) was 50% covered with eschar. The second area (6 o'clock in relation to the main wound) measured 2.3 cm in length by 1.3 cm wide with a depth of 0.1 The third area (5 o'clock in relation to main wound) measured 0.9 cm in length by 0.7 cm in width. The wound care physician's notes, reviewed on 01/18/19 at 11:50 a.m., indicated the first area noted (7 o'clock in relation to the main wound on the coccyx) measured at 6 cm in length, by 3 cm in width, and was a stage two wound. During an interview on 01/17/19 at 02:07 p.m., RN 3 indicated she would notify the MD of the new areas and the resident was about to leave for an appointment with wound care. She indicated wound care would provide staging and measurements as well. During an interview on 01/17/18 at 01:30 p.m., the resident's family member indicated the facility did not turn the resident regularly. .Every once in a while they will. Maybe once or twice a day. They have gotten a little bit better. She hasn't been turned at all today. During a confidential interview on 01/17/19, CNA 4 indicated she was not aware of the new open areas on the resident. She had not changed the resident since starting her shift (this was 6 to 8 hours into her shift). She had rotated her a few times, but not as often as she should have. She had received no report that morning. She stated,It's really rough. Sometimes, honestly I try to get to everybody like I'm suppose to. Either you get pulled away or stopped . So if there's stuff going on down here, I don't even know about it. Our staffing is horrible . Often people are late. So there's only one aide for this entire unit until someone shows up. There's more people here, because you guys are here (DON's name) and . (Scheduler's name) they try to get staff, but they can't. People are calling in all the time or just not showing up. During a confidential interview between 01/14/19 to 01/28/19, CNA 6 indicated it was hard to get everything done, sometimes she was the only aide on her area and the nurse was busy. She felt the resident's needed consistency and residents tended to act up when a new CNA was on their hall. During a confidential interview between 01/14/19 to 01/28/19, CNA 8 indicated feeling rushed all of the time. Some days I can't get my work done. I have been here a month. I try to get showers done, but the charting doesn't get done. During a confidential interview between 01/14/19 to 01/28/19, CNA 7 indicated she was everywhere in the facility. It makes it hard because you have new residents and you don't know their routine. We have trouble with charting. Sometimes the jobs are just quickly done for the resident and the care is not done perfectly. During a confidential interview between 01/14/19 to 01/28/19, CNA 3 indicated It is hard to get everything done. Some days I am the only CNA .(in the area for 3 hours). One person has to be in the dining room at all times, and that usually ties up the nurse .we can't watch all of the residents .We used to have three CNA's and they took one completely away. During a confidential interview between 01/14/19 to 01/28/19, Nurse 12 indicated: .Sometimes we just have one CNA for a few hours. The Immediate Jeopardy began on 10/11/18 was removed on 1/19/19 when the facility began inservicing staff related to the monitoring, interventions of turning and repositioning of resident, and providing treatments for pressure ulcers, but the noncompliance remained at the lower scope and severity level of isolated, no actual harm with potential for more than minimal harm that is not immediate jeopardy, because all employees had not been inserviced. This Federal tag relates to Complaint IN 673 3.1-40

Based on observation, interview, and record review, the facility failed to provide immediate assessment and care to a resident in an emergency situation resulting in excessive bleeding and death for 1 of 3 residents reviewed for [MEDICAL TREATMENT]. (Resident B) This deficient practice had the potential to affect 6 of 6 residents with [MEDICAL TREATMENT] catheters that resided in the facility. This deficient practice resulted in an Immediate Jeopardy. The Immediate Jeopardy began on [DATE] at 8:50 p.m. when the facility failed to ensure staff remained with a resident in an emergency situation without a resident assessment being completed. The Executive Director and Director of Nursing were notified of the Immediate Jeopardy on [DATE] at 2:28 p.m. The Immediate Jeopardy was removed and corrected on [DATE] when the facility completed staff education on emergency protocol for residents with active bleeding from fistula site; audits were completed on residents receiving [MEDICAL TREATMENT] to ensure pre [MEDICAL TREATMENT] and post [MEDICAL TREATMENT] protocols were followed; review of other residents with the potential to be affected by the alleged deficient practice utilizing a [MEDICAL TREATMENT] check list; and newly admitted residents receiving [MEDICAL TREATMENT] were to be reviewed utilizing the [MEDICAL TREATMENT] check list. The correction date was prior to the start of the survey and was therefore Past Noncompliance. Findings include: The clinical record for Resident B was reviewed on [DATE] at 2:00 p.m. [DIAGNOSES REDACTED]. The care plan indicated the resident was at risk for complications related to the need for [MEDICAL TREATMENT] and had a shunt to the left thigh. The nurse's note, dated [DATE] at 8:40 p.m., indicated the resident sat up on the side of the bed and took her medications. The nurse's note, dated [DATE] at 8:50 p.m., indicated the resident yelled for help. There was fresh blood on the bed and floor. RN 2 ran down the hall to get about ten ABD (abdominal) pads, asked another nurse to call 911, went back to the resident's room, uncovered the resident, and blood from the resident's thigh squirted about two and one half feet in the air. A pressure dressing was applied and reinforced. The nurse's note, dated [DATE] at 9:00 p.m., indicated licensed staff were called for support, a QMA (qualified medication assistant) took over pressure dressing, and the resident was losing consciousness. The nurse's note, dated [DATE] at 9:05 p.m., indicated the resident's pressure dressing was held and reinforced. The nurse's note, dated [DATE] at 9:15 p.m., indicated EMS (emergency medical services) arrived and took the resident to the hospital. The clinical record lacked documentation of a nursing assessment for Resident B when RN 2 looked into the resident's room and observed blood on the resident's sheet and floor. During an interview, on [DATE] at 3:52 p.m., RN 4 indicated when a resident has extensive bleeding from a [MEDICAL TREATMENT] catheter, you apply pressure and yell for help. You do not leave the resident and you use whatever you can find in the room to apply pressure. During an interview, on [DATE] at 4:44 p.m., QMA 3 indicated he was on break outside on the phone and heard an overhead page stat (immediately) to Resident B's room. He came in through laundry door, which was right by the resident's room, went in and the nurse, RN 2 was holding ABD pads and applying pressure on the resident's left thigh. QMA 3 took over holding pressure and told RN 2 to go do his assessment or whatever he still needed to do, paperwork, call 911, just whatever he needed. The residents left leg was hanging off the bed so, while he continued to apply pressure, QMA 3 placed the resident's left leg back on the bed. There was quite a lot of blood on the floor and blankets. The resident was breathing on her own at that time, but would not respond when spoken to. From the time QMA 3 got into the resident's room, ,[DATE] minutes went by before EMS arrived. During an interview, on [DATE] at 9:02 p.m., RN 2 indicated the resident was sitting on the side of her bed when given her medications and had no complaints at that time. Approximately 10 minutes later, he heard her yell for help, went to the door, looked in, and blood was everywhere. On the sheets, on the floor. It was a good amount of blood. I knew she was having a massive bleed. There was nothing in the room that I thought would be useable as a pressure dressing and there was nobody in sight. I ran down the hall towards the east wing nurses station, told the nurse to call 911 because a resident was bleeding out. I went into central supply and grabbed as many ABD pads as I could. As I was running back to the room I yelled that I needed all licensed staff stat. I got back to room and applied pressure. QMA 3 entered the resident's room and took over holding pressure. He was advised not to remove any of the pressure dressing, just add if needed. RN 2 indicated if a resident was bleeding excessively from a [MEDICAL TREATMENT] catheter, pressure should be applied and help summoned. He left the resident because he could not identify anything that could be used as a pressure dressing and no one would have heard him yell for help. On [DATE] at 3:32 p.m., the distance from Resident B's room to the Central Supply room and back was observed to be 360 feet. The Central Supply room was locked with a key hanging on the left side of the door. The EMS care record, dated [DATE], indicated dispatch was notified (911 call received) at 9:07 p.m. and the clinical impression upon arrival was bleeding out of shunt with signs and symptoms of cardiogenic shock. The hospital emergency evaluation report, dated [DATE], included, but was not limited to, Clinical Impression .[MEDICAL CONDITION] .bleeding from left groin fistula site .deceased The AJKD (Official Journal of the National Kidney Foundation) (October (YEAR)), Volume 70, Issue 4, Pages 570 to 575, Fatal [MEDICAL TREATMENT] Vascular Access Hemorrhage (FVAH) included, but was not limited to, .Prevention of FVAH .rapid blood loss leads to hemorrhagic shock within only 1 to 2 minutes at usual blood flow rates .direct continuous pressure for 15 to 20 minutes until emergency medical help arrives, avoiding the application of tourniquets, blood pressure cuffs, or bandages to the extremity . On [DATE] at 3:43 p.m., the Director of Nursing provided a current copy of the document titled [MEDICAL TREATMENT] Catheters, dated (MONTH) 2009. It included, but was not limited to, General Guidelines .[MEDICAL TREATMENT] catheters are surgically placed in the jugular, [MEDICATION NAME], or femoral veins .Major bleeding .apply pressure to insertion site, contact emergency services and [MEDICAL TREATMENT] center. Verify that clamps are closed on lumens. This is a MEDICAL EMERGENCY. DO NOT LEAVE RESIDENT ALONE UNTIL EMERGENCY SERVICES ARRIVES . The past noncompliance Immediate Jeopardy that began on [DATE]. The Immediate Jeopardy was removed and corrected on [DATE] when the facility completed staff education on emergency protocol for residents with active bleeding from fistula site; audits were completed on residents receiving [MEDICAL TREATMENT] to ensure pre [MEDICAL TREATMENT] and post [MEDICAL TREATMENT] protocols were followed; review of other residents with the potential to be affected by the alleged deficient practice utilizing a [MEDICAL TREATMENT] check list; and newly admitted residents receiving [MEDICAL TREATMENT] were to be reviewed utilizing the [MEDICAL TREATMENT] check list. This Federal tag relates to Complaint IN 454 3XXX,[DATE](a)

Based on interview and record review, the facility failed to ensure a resident was provided the care and treatment to a stage 2 pressure ulcer to prevent worsening to an unstageable, larger wound, for 1 of 5 residents reviewed for pressure ulcers.(Resident G) Findings include: The clinical record for Resident G was reviewed on 9/6/18 at 10:08 a.m. [DIAGNOSES REDACTED]. The quarterly MDS (Minimum Data Set) assessment, dated 7/27/18, indicated the resident required two staff physical assistance with bed mobility. The care plan, dated 5/2/18, indicated the resident was at risk for pressure ulcers with interventions of sage boots (heel protector to prevent pressure injury) while in bed; assistance with turning and repositioning every two hours; keep linens clean, dry and wrinkle free, and to apply skin prep both heels. The physician order, dated 5/8/18, indicated the treatment was for skin prep to both heels twice daily. The weekly skin assessment, dated 5/9/18, indicated the right heel had a 5 cm (centimeter) deflated blister with redness around the surrounding area. The weekly wound assessment, dated 5/11/18, indicated the resident had a stage 2 pressure ulcer (partial-thickness skin loss with exposed dermis or forms a blister) to the right heel which measured 2 cm in length and 2 cm in width with a depth of 0.1 cm. The physician order, dated 5/11/18, indicated the treatment was to discontinue the skin prep to the right heel, start cleansing with normal saline, apply [MEDICATION NAME]/Santyl ([MEDICATION NAME] wound agent), and cover the wound with a dry dressing daily The weekly wound assessment, dated 5/18/18, indicated the resident had an unstageable pressure ulcer (full thickness tissue loss in which the base of the ulcer was covered by slough (yellow,tan,gray, green or brown) or eschar (tan, brown, or black)) to the right heel which measured 1.2 cm in length and 1.5 cm in width with no depth. The weekly wound assessment, dated 5/23/18, indicated a stage 2 pressure ulcer to the right heel which measured 3.2 cm in length and 3.5 cm in width with a depth of 0.1 cm. The weekly wound assessment, dated 5/30/18, indicated a stage 2 pressure ulcer to the right heel which measured 2 cm in length and 2.4 cm in width with a depth of less than 0.1 cm. The (MONTH) (YEAR) TAR (treatment administration record) indicated the resident's treatments to his right heel were not completed on 5/16/18, 5/27/18, 5/28/18, 5/29/18, and 5/30/18. The weekly wound assessment, dated 6/22/18, indicated the resident had an unstageable pressure ulcer to the right heel which measured 4.8 cm in length and 3.2 cm in width with a depth of less than 0.1 cm. The weekly wound assessment, dated 6/27/18, indicated the resident had an unstageable pressure ulcer to the right heel which measured 4.4 cm in length and 3.8 cm in width with no depth. The physician order, dated 6/5/18, indicated to discontinue the resident's previous treatment to the right heel and to apply Iodosorb gel ( cleans by absorbing fluids, removing exudate, sloth and debris), cover with non-adherent pad, then wrap with kerlix daily The (MONTH) (YEAR) TAR indicated the resident's treatments were not completed on 6/8/18, 6/13/18, 6/17/18, and 6/28/18. The weekly wound assessment, dated 7/14/18, indicated the resident had an unstageable pressure ulcer to the right heel which measured 4.5 cm in length and 6 cm in width with no depth. The weekly wound assessment, dated 7/20/18, indicated the resident had an unstageable pressure ulcer to the right heel which measured 4.5 cm in length and 5.8 cm in width with a depth of 1 cm. The weekly wound assessment, dated 7/27/18, indicated the resident had an unstageable pressure ulcer to the right heel which measured 4 cm in length and 5.2 cm in width with a depth of 0.1 cm. The physician order, dated 7/3/18, indicated to discontinue the resident's current treatment to the right heel. Start cleansing the wound with normal saline, apply Dakin's (deriding agent) one half strength, cover with a dry dressing then wrap with kerlix daily. The (MONTH) (YEAR) TAR indicated the resident's treatments were not completed on 7/7/18, 7/8/18, 7/9/18, 7/24/18, 7/26/18, 7/27/18, and 7/30/18. The physician order, dated 7/25/18, indicated to discontinue the resident's current treatment to the right heel. Start cleansing the wound with normal saline, pat dry, apply a thin layer of [MEDICATION NAME] to wound, skin prep surrounding edges, cover with 4 by 4 gauze, and wrap with kerlix daily for 14 days. The weekly wound assessment, dated 8/3/18, indicated the resident had an unstageable pressure ulcer to the right heel which measured 4.5 cm in length and 5.8 cm in width with a depth of 1 cm. The (MONTH) (YEAR) TAR indicated the resident's treatments to the right heel were not completed on 8/2/18 and 8/3/18. The clinical record lacked documentation of the off-loading of the residents heels during the month of May. The wound measurements between 5/30/18 and 6/22/18 were not provided. During an interview, on 9/7/18 at 2:50 p.m., RN 7 indicated after a treatment was completed the nurses were to sign them off on either the MAR (medication administration record) or the TAR. On 9/7/18 at 3:13 p.m., the Clinical Support Nurse provided a copy of the document titled Administering Medications, dated (MONTH) (YEAR). It included, but was not limited to, Medications shall be administered in a .timely manner, and as prescribed .13. Topical medications used in treatments must be recorded on the resident's treatment record (TAR) . This Federal tag relates to Complaint IN 043 3.1-40

Based on interview and record review, the facility failed to ensure staff followed a resident's (Resident D) plan of care for a two person physical assistance with a transfer, which resulted in a fall with a fracture to the left femur for 1 of 3 residents reviewed for accidents. Findings include: The clinical record for Resident D was reviewed on 5/21/18 at 2:41 p.m. [DIAGNOSES REDACTED]. The annual MDS (Minimum Data Set) assessment, dated 2/13/18, indicated the resident required extensive two person physical assistance with transfers. The care plan, dated 2/15/18, indicated the resident was at risk for falls due to unsteady balance and was a two person physical assistance with transfers. The CNA (Certified Nursing Aide) assignment sheet indicated the resident was to be transferred with the assistance of two staff members. The written statement by CNA 3, dated 5/14/18, indicated when the CNA went to transfer Resident D, the resident was not stable. She tried to transfer the resident back to her chair without assistance and the resident started to fall. After the resident started to fall the CNA helped her to the floor. The progress note, dated 5/14/18 at 8:30 a.m., indicated CNA 3 lowered the resident to the floor to prevent the resident from falling. The progress noted, dated 5/14/18 at 7:53 p.m., indicated at 9:30 a.m., the resident began to complain of left knee pain and a new order was obtained for a stat x-ray of the left knee, which showed a fracture to the distal femur. The physician was notified and the resident was sent to the emergency department for evaluation. During an interview on 5/21/18 at 3:43 p.m., the Administrator indicated the resident was a two person physical assist with transfers and CNA 3 did not follow the CNA assignment sheet. The hospital radiology report, dated 5/14/18 at 7:28 p.m., indicated the resident had a [MEDICAL CONDITION] femur with displacement. The operation report, dated 5/16/18, indicated a left femur retrograde intramedullay nailing (an alternative technique for the treatment of [REDACTED]. This Federal tag relates to Complaint IN 959 3.1-45(a)

Based on interview and record review, the facility failed to ensure treatment was not delayed on two residents (Resident #E and #G) with confirmed [MEDICAL CONDITION] secondary to falls for 2 of 3 residents reviewed for accidents. Findings include: 1. The clinical record for Resident #G was reviewed on 9/1/16 at 10:15 a.m. [DIAGNOSES REDACTED]. The nurses note, dated 5/24/16 at 3:37 a.m., included, but was not limited to, the following: resident (sic) walking back to .room and was found sitting in a straight up position in hallway (sic) nurse asked what happened (sic) i (sic) sat down bc (sic) (because) i (sic) was getting weak (sic) quoted (sic) resident (sic) gripper socks were on floor (sic) dry (sic) nothing in area that may have contributed to fall (sic) resident said (he/she) did not hit (his/her) head and no noticeable (sic) (noticeable) injuries noted .assisted to a standing position and assisted to room . The nurses note, dated 5/24/16 at 11:23 a.m., included, but was not limited to, the following: Resident was in .room resting in bed. This nurse had just left room about 30 minutes before. Housekeeper was down there and alerted staff that resident was on the fllor (sic) (floor). (He/She) was found on .left side by .bed. Nurse from another hall assessed resident and no injurys (sic) (injuries) noted. Neuro (neurological) checks (assessment used for head injury) started r/t (related to) fall was unwitnessed. Resident brought up in w/c (wheelchair) to TV (television) lounge and will have MD (medical doctor) review meds (medications) . The MAR (Medication Administration Record) for May, 2016, indicated, on 5/24/16 at 12:00 p.m., Resident #G received a [MEDICATION NAME] 5/325mg (milligrams) (pain medication) orally. The nurses note, dated 5/24/16 at 1:23 p.m., included, but was not limited to, the following: Resident c/o (complained of) of (sic) pain to left groin/hip/pelvic area. Resident frequently c/o (complains of) of (sic) paibn (sic) (pain) to the area but as precaution will get stat X-ray to left hip/pelvic area . The nurses note, dated 5/24/16 at 4:47 p.m., included, but was not limited to, the following: F/U (follow up) to being found on floor x (times) 2 today. This (sic) first time occurred early am (sic) (a.m.) and (he/she) stated (he/she) sat down purposefully as (he/she) felt weak. This is likely turi (sic) (true) as (he/she) has been witnessed numerous times sitting down or crawling on floor purposefully. (He/She) is being treated for [REDACTED]. The second time (sic) unsure if (he/she) tried to get up or rolled off the bed. The bed is low and (he/she) has mat to floor for safety .Are awaiting hip x-ray result r/t (related to) discomfort in hip . The radiology report, dated 5/24/16 at 4:50 p.m., included, but was not limited to, the following: Patient .(Resident #G's name) .Results .Acute intertrochanteric [MEDICAL CONDITION] left femur .Conclusion .Acute fracture . The nurses note, dated 5/24/16 at 10:07 p.m., included, but was not limited to, the following: this (sic) nurse was notified of f/u (follow up) fall this evening. resident (sic) sitting in chair in mdr (main dining room), complaing (sic) (complaining) of pain to left hip. when (sic) it was time to have xray (sic) (x-ray) taken, took two assist to transfers (sic) (transfer) resident to wheelchair, being that (he/she) was not able to bare (sic) (bear) weight on the left leg at this time. received (sic) results from xray (sic) to left hip/ pelvis& (sic) results show acute fracture to left hip. md (sic) notified of results & requested that we send the resident to the emergency (sic) to be tx (treated). this nurse notified 2nd contact of results, r/t (related to) the 1st contact being unreachable .dtr (sic) (family member) return (sic) (returned) call, was not aware that (resident) had fallen . During an interview on 9/1/16 at 4:20 p.m., the Director of Nursing indicated, it appeared, according to the nurses note on 5/24/16 at 10:07 p.m., the fax regarding the x-ray result, was received when the note was documented. During an interview on 9/1/16 at 4:38 p.m., the Account Manager for the radiology facility, indicated the x-ray was ordered at 12:56 p.m., completed at 4:24 p.m., and results were sent to the facility's east hall at 4:52 p.m. On 9/1/16 at 5:28 p.m., the Administrator provided a copy of the document titled, Resident Status History List. It included, but was not limited to, the following: .(Resident #G's name) .D (discharge) .5/24/16 .7:40 p.m . 2. The clinical record for Resident #E was reviewed on 9/1/16 at 10:15 a.m. [DIAGNOSES REDACTED]. The nurses note, dated 6/4/16 at 10:14 a.m., included, but was not limited to, the following: Late entry for 6/4/16 @ (at) 7:am CNA (Certified Nursing Assistant) entered room after hearing resident yell out (sic) CNA called for nurse. This nurse entered room and resident was lying in front of bathroom door (sic) it was open (sic) on .back with .legs out straight. Resident disoriented (sic) unable to answer simple questions at this time. There was urine on the floor and the resident had .pants down around .ankles. Resident assisted to bathroom and then to bed with 2 assist. Resident began to c/o (complain of) bilat (bilateral) hip pain and hold onto (sic) (on to) (his/her) right leg with (his/her) hand. Resident able to move legs independently .Supervisor informed .MD (medical doctor) informed (sic) new order to x-ray righ (sic) hip (sic) x-ray left hip stat (immediate). Call placed to (name of radiology facility) (sic) x-rays ordered stat . The nurses note, dated 6/4/16 at 10:33 a.m, included, but was not limited to, the following: Late entry for 6-4-16 @ (at) 8:45am (name of radiology facility) here for x-ray . The radiology report, dated 6/4/16 at 10:03 a.m., included, but was not limited to, the following: .Patient: (name of Resident #E) .Results .There is an acute angulated fracture at the junction of the right femoral neck and the intertrochanteric region .Conclusion .Acute fracture right hip . The nurses note, dated 6/4/16 at 10:36 a.m., included, but was not limited to, the following: X-ray results here (sic) left hip intact (sic) right hip noted with acute fracture. Report viewed by Supervisor. MD notifed (sic) new order received and noted to send resident to (initials of hospital) ER (emergency room ) for eval (evaluation) and treatment . The nurses note, dated 6/4/16 at 11:17 a.m., included, but was not limited to, the following: Transportation made through (name of transportation service). Report callled (sic) (called) to (initials of hospital) ER . The nurses note, dated 6/4/16 at 1:26 p.m., included the following: (name of transportation service) transported resident via (by) stretcher and 2 attendants to (initials of hospital). During an interview on 5/24/16 at 4:20 p.m., the Director of Nursing indicated Resident #E was not in any distress or pain and it just took that long for the transportation service to get there. The Director of Nursing also indicated they generally do not call 911 unless there is an emergency because the fire department comes when 911 is called. This Federal tag relates to Complaint IN 663 3.1-37(a)

Based on record review and interview, the facility failed to ensure a resident with multiple falls had increased supervision to prevent further falls for 1 of 5 residents reviewed related to falls with fractures in a sample of 10 residents. (Resident J) Resident J fell and broke his left hip. Upon readmission to the facility, the resident fell three more times, and on the third fall injured the previously fractured hip. Findings include: The closed clinical record for Resident J was reviewed on [DATE] at 12:50 p.m. The quarterly Minimum Data Set assessment, dated [DATE], indicated in the section for assessment for cognition, the resident did not repeat three words, tell the year, month, or day, or recall three words, and had inattention and disorganized thinking. The resident needed extensive assistance of two staff for bed mobility, transfer, walking, and toilet use. The resident's Care Plan with Problem Onset date of [DATE], indicated the resident had "Potential for falls r/t (related to) impaired mobility, unsafe decision making, psychotropic med (medication) use, poor safety awareness." The plan indicated the resident had falls on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. A notation on the plan indicated, "rewritten [DATE]." The resident's Care Plan with Problem Onset date of [DATE] and "reviewed [DATE]" indicated the resident had "Potential for falls r/t (related to) impaired mobility, unsafe decision making, psychotropic med (medication) use, poor safety awareness." The plan indicated the resident had falls on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. Printed Approaches on the plan with the goal date of [DATE] indicated "Anticipate and meet needs; encourage rest as necessary; ensure non skid footwear when out of bed; W/C for main locomotion; provide and encourage resident to use call light and get assist with ambulation; if resident is restless in bed, staff to assist him to W/C or to bathroom; restorative amb (ambulation) plan (handwritten in); pressure alarm at all times; gripper socks for preventative measures; notify family and MD of falls; notify therapy and MD of changes in gait PRN (as needed); Fall Assessment quarterly and PRN; restorative FMP (Functional Maintenance Plan) toileting program per schedule; keep water within reach and offer PRN; encourage resident to sit at nurses station if out of bed; ask res. daily if he wants to get up and respond accordingly; low bed with mat at all times while abed. Nurse's Notes, dated [DATE] at 1:30 p.m., indicated, "Nrsg (nursing) staff responded to res alarm. Upon entering room res found lying on L (left) side in BR (bathroom). Res denies pn (pain) but stated he hit L side of head. Neuro (checks) WNL (within normal limits). (Symbol for no) apparent injury. Res able to complete full ROM (range of motion) (symbol for without) problem...." Nurse's Notes, dated [DATE] at 7:40 p.m., indicated, "N.O. (new order) 30 min (minute) safety (checks) r/t (related to) safety concerns." The order was handwritten onto the Care Plan as a new Approach. Nurse's Notes between [DATE] and [DATE] indicated the following: the resident's left hip became swollen, and an x-ray was ordered; the x-ray was negative for left hip fracture; the resident began to complain of pain with movement of the left hip and thigh, and a CT scan was ordered and obtained. Nurse's Notes for [DATE] at 5:30 p.m., indicated, "Hosp. (hospital) called res. has fractured L hip and admitted to (name of local hospital)." Documentation was lacking in the Nurse's Notes to indicate a follow-up investigation into the fall on [DATE]. Nurse's Notes indicated the resident was readmitted to the facility on [DATE]. The Care Plan related to potential for falls indicated the following Approaches were handwritten additions: [DATE] WBAT (weight bearing as tolerated); [DATE] Assist resident to lie down when fatigued. Nurse's Notes for [DATE] at 10:35 a.m., indicated, "Responded to alarm sounding from room. Res found on L side on fall mat. (Symbol for no) apparent injury....Staff to encourage resident to stay out of room when (arrow pointing up) in wheel chair...." The following approaches, dated [DATE], were handwritten onto the Care Plan: Encourage res to stay out of room when (arrow pointing up) in W/C" and "Enc. resident to call for assist to transfer." (The interventions of "Encourage resident to sit at nurses station if out of bed" and "Provide and encourage resident to use call light and get assist with ambulation" were already part of the Care Plan.) Nurse's Notes for [DATE] at 8:30 a.m., indicated, "F/U (follow-up) fall of [DATE]. Resident has an alarm which sounded. He had been in W/C prior to fall - was sitting @ nurses desk just prior to fall. He had just returned from therapy - was in W/C near nurse's desk. He wheeled himself to room tried to transfer self to bed. Mat was in place & prevented serious injury. We will cont (continue) 30 " (minute) (checks) & ins (instruct) resident to ask for assist if he wants to lie down." Nurse's Notes for [DATE] at 3:55 p.m. indicated, "Res was at nursing station after therapy. This nurse started down hall (symbol for with) cart. res. must have wheeled himself down hall to (Resident J's room number) to bathroom and fell . ROM (range of motion) was done on bil (bilateral) extremities all WNL. Res. states he put himself on toilet and fell ...." Nurse's Note for [DATE] at 5:30 p.m. indicated, "Res to wear non-skid socks even in shoes so if he takes his shoes off he will still be protected. Lab for[DIAGNOSES REDACTED] (Clostridium difficile, a bacteria that causes diarrhea)." Documentation in the Nurse's Notes was lacking to indicate a follow-up note to the fall on [DATE]. Handwritten onto the Care Plan Approaches on [DATE], and then lined through with the word "duplicate" written in, was: Gripper socks." Other additions to the Care Plan Approaches for [DATE] indicated: "Stool for[DIAGNOSES REDACTED]" and "D/C (discontinue) Surfak (laxative)." Nurse's Notes for [DATE] at 10:15 (a.m. or p.m. not specified) indicated, "Nurse student came to nurses station, stating that Res pressure alarm was alerting, (symbol for with) Res found on floor next to the bed on his R side. When I entered the room another nurse was present getting pt's (patient's) vital signs....Turned Pt to his back, when he stated his L leg was causing him some pain, that's when I noticed that the left leg was inverted inwards....Pt had recently been out for a recent fracture to his L hip...." Nurse's Notes indicated the resident was transported to the hospital by emergency services. Nurse's Notes for [DATE] at 9:00 a.m. indicated, "F/U yesterday's fall. Resident was up in W/C prior to fall. He had been to breakfast in DR (dining room) He had toileted (symbol for after) breakfast & was sitting in W/C in hall (symbol for with) alarm in place. He was able to propel self in W/C. He is presently @ hospital. Will evaluate fall interventions upon return." Nurse's Notes for [DATE] at 5:15 p.m., indicated the hospital notified the facility the resident expired at the hospital. During interview on [DATE] at 12:45 p.m., the Director of Nursing (DON) indicated she investigated all falls. The DON indicated her investigation was described in the Nurse's Notes, usually with the introduction of, "Follow-up to fall of" with the date. She indicated new interventions would also be listed on the Care Plan. During interview on [DATE] at 1:55 p.m., the DON indicated it was a "balancing act" with Resident J "between maintaining his independence and preventing falls." She indicated the resident liked to go in his room and watch TV. She indicated the resident would stay busy during the day going to meals and therapy and activities. She indicated the resident would never stay long in activities. She indicated the resident's daughter wanted him up out of bed, and sometimes the resident was tired and wanted to lie down. This federal tag relates to Complaints IN 279 and IN 858. 3XXX,[DATE](a)(2)

Based on interview and record review, the facility failed to ensure the resident at risk for low levels of oxygen in the blood was assessed to monitor use of oxygen for maintaining blood oxygen levels above 90% as ordered by the physician for 1 of 1 resident reviewed related to maintaining blood oxygen levels in a sample of 10 (Resident E) Resident E's respiratory condition declined, he required hospitalization for [MEDICAL CONDITIONS] and acute respiratory distress, and he expired at the hospital. Findings include: The closed clinical record for Resident E was reviewed on [DATE] at 2:50 p.m. The resident's [DIAGNOSES REDACTED]. physician's orders [REDACTED].@ 2L (liters) via N/C (nasal canula) as needed to keep O2 sats (saturation) above 90%" and "[MEDICATION NAME] HFA 90 mcg (microgram) inhal (inhalant) (fast acting [MEDICATION NAME][MEDICATION NAME]), give 1 puff every 4 hours as needed." The resident's Care Plan, with Problem Onset date of [DATE], indicated, "Potential risk for altered respiratory function r/t (related to) [MEDICAL CONDITION], immobility, and hx (history) of recent pneumonia. Approaches included, but were not limited to, "O2 2 L/M (liters per minute) via nasal canula PRN (as needed) to keep O2 sats above 90%." "Nursing Follow-Up Documentation," dated [DATE], indicated, "Brief Description: Lung sounds and SOA (shortness of air). Finished on AB (antibiotic) and [MEDICATION NAME] ,[DATE]." Documentation on the note on [DATE] at 2:00 p.m., indicated, "O2 (oxygen) 80 Res (resident) C/O (complained of) being SOA, (symbol for no) C/O pain, vent huff (respiratory treatment) given, slight WH (wheeze) throughout all lung fields. Will cont. (continue) to mont (monitor)." Another "Nursing Follow-Up Documentation," also dated [DATE], indicated, "Brief Description: Mont. lung sound & SOA." Documentation on this note, on [DATE] at 12 midnight indicated, "Crackles lower lungs, both sides, (symbol for no) SOA. Res resting abed @ this X (time), will continue to monitor." Nurse's Notes on [DATE] at 12:00 p.m. (noon) indicated, "N.O. (new order) to mont. O2 sats (saturations) Q (every) shift. Res cont to have (arrow pointing down) O2 sats below 90. Vent huff given & O2 applied. < (before) O2 was 61 > (after) O2 then went (arrow pointing up) to 92. Will cont. to mont. Fam (family) and MD (doctor) notified." The "Nursing Follow-Up Documentation," dated [DATE], indicating, "Brief Description: Mont. lung sound & SOA," including documentation on [DATE] at 2:00 p.m. indicated, "Cont (symbol for with) slight WH throughout. Res having SOA this a.m. (morning) O2 was at 61, give vent huff & applied O2, went (arrow pointing up) 91 (sic). Will cont to mont." Documentation on [DATE] at 9:00 p.m., indicated, "(symbol for no) S/S (signs and symptoms) of resp (respiratory) distress or SOA." Documentation on [DATE] at 1:00 a.m., indicated, "Res sitting upright on side of bed (symbol for with) some wheezing noted (arrow for upper) (arrow for lower) lobes. Cont (symbol for with) (illegible word) lip breathing. (Symbol for no) S/S resp distress noted. Resp even & non-labored @ present X. Res O2 not in place. Re-applied per nurse & educated resident on importance of O2 via N/C (nasal canula). V/S (vital signs) ,[DATE] - 96 (heart rate) - 24 (respirations) 96.4 (temperature). O2 64% (symbol for after) O2 applied (symbol for increased) 90 - 92%. (Symbol for no) C/O pain/discomfort voiced @ present X. Skin W/D (warm/dry). Will cont to monitor." The Medication Record for [DATE] indicated the resident oxygen saturation level on the 10:00 p.m. to 6:00 a.m. shift was measured at 90%. Documentation did not indicate the specific time the saturation was measured. Documentation failed to indicate the resident was monitored to ensure he continued to use the oxygen from 1:00 a.m. until 8:00 a.m. The next Nurse's Note was [DATE] at 8:00 a.m., and indicated, "Res C/O SOA, keeps taking O2 off. O2 57%, put N/C on. ,[DATE] (blood pressure) P (pulse) 100, T (temperature) 97.4 R (respirations) 36 very shallow. Monitoring O2 and resident keeping O2 NC on. Contacted (name of x-ray service) ordered CXR (chest x-ray) d/t (due to) (arrow point up) congestion, lung sounds crackles and rales." Nurse's Notes on [DATE] at 8:20 a.m., indicated the resident declined, an oxygen rebreather mask was used, and the oxygen setting increased to 5 and then 6 liters per minute, and the oxygen saturation increased to 84%. The physician ordered the resident be sent to emergency room , and the resident was admitted to the hospital with [REDACTED]. Notes indicated the hospital notified the facility the resident expired on [DATE]. During interview on [DATE] at 3:00 p.m., the Director of Nursing indicated the resident tended to take his oxygen by nasal canula off and on. She also indicated she would check on further information on the assessment of the resident between 1:00 a.m. and 8:00 a.m., and no further information was provided at the time of exit from the facility on [DATE] at 5:05 p.m. This federal tag is related to Complaint IN 858. 3XXX,[DATE](a)(6)