Every finding on record at Lutheran Life Villages

Based on interview and record review, the facility failed to ensure safety and prevention of abuse for 1 of 3 residents reviewed (Resident A). Findings include:Resident A's record was reviewed on 10/20/25 at 12:59 PM. Diagnoses included cognitive communication deficit and generalized anxiety disorder.Resident A's quarterly Minimum Data Set, (MDS) dated [DATE], indicated the resident's Brief Interview for Mental Status (BIMS) score was 7 (moderate cognitive loss).A summary of incident report, dated 10/9/25, indicated Resident A's spouse had made contact with the Resident A's face. The report indicated Adult Protective Services had been contacted. The report indicated Resident A's daughter was concerned about the spouse's decline and attempts to correct the spouse.A progress note, dated 8/23/25 at 11:59 PM, indicated Resident A's spouse had been present when the resident's skin tear had reopened.A progress note, dated 8/27/25 at 11:59 PM, indicated Resident A had reopened a skin tear on their arm. The skin tear had been reopened when Resident A's spouse had pulled the resident's arm to reposition.A progress note, dated 9/9/25 at 4:52 PM, indicated Resident A's spouse had given the resident an aspirin. Resident A's spouse stared at the staff member and did not respond when they were told they could not give Resident A medicine. Resident A's daughter was notified.A progress note, dated 9/20/25 at 7:45 PM, indicated Resident A had been verbally aggressive with their spouse. Resident A had told their spouse to get the hell out and do not return. Resident A's spouse stayed in the resident's room for 45 minutes after the resident had told them to get out.A progress note, dated 9/21/25 at 12:37 AM, indicated Resident A had been verbally aggressive to their spouse. Resident A's spouse had indicated they were not sure of what was going on.A progress note, dated 9/27/25 at 6:12 PM, indicated Resident A had been screaming at their spouse in the dining room. Resident A's spouse had been feeding the resident unsafe food items at Resident A's command.A progress note, dated 9/28/25 at 6:29 PM, indicated Resident A's spouse had given the resident a pain pill. Resident A's spouse would not identify the pill. The supervisor had been notified.A progress note, dated 10/1/25 at 9:53 PM, indicated Resident A had been yelling throughout the shift. Resident A had screamed to get out of their room even though no one else was present. Resident A's spouse left their visit early. Resident A's spouse indicated they could not take all of that.A progress note, dated 10/5/25 at 1:15 PM, indicated Resident A's spouse had come to visit. Resident A yelled at their spouse a few times.A progress note, dated 10/15/25 at 12:57 PM, indicated Resident A's spouse had repositioned the resident to a reclining position while the staff was feeding the resident. Resident A's spouse became argumentative with the staff when the staff placed the resident in an upright position to eat. The note indicated the resident became more anxious and aggressive when their spouse was present at meals. The note indicated Resident A and their spouse triggered each other during meals.A progress note, dated 10/19/25 at 2:44 PM, indicated Resident A began yelling when their spouse came to visit. Resident A had been bossing their spouse and making commands to their spouse.Resident A's care plan, dated 9/22/25, indicated the resident had potential to become verbally aggressive. Interventions included analyzation and documentation of circumstances, triggers and actions known to de-escalate aggressive behavior, assessment of Resident A's coping skills, intervention before agitation escalates and support system and a psychiatric consultation. Resident A's care plan did not indicate the resident should be monitored when their spouse was present. The care plan did not indicate staff members were directed to intervene and safeguard the resident if needed.The care plan did not indicate the resident's spouse had given them medication.The care plan did not indicate the resident's spouse had fed the resident.The care plan did not indicate the resident's spouse had repositioned the resident.The care plan did not indicate the resident's spouse had made contact with the resident's face.A unit assignment sheet for direct care staff, (resident profile) dated 8/28/25, provided various categories of care areas for each resident. Some residents had listed behaviors such as anxiety at times and combativeness with care. The resident profile indicated Resident A did not have behaviors. Some residents had listed safety concerns such as fall risk or appropriate footwear. The resident profile indicated Resident A did not have safety issues as the safety category for Resident A was blank.In an interview, on 10/20/25 at 2:07 PM, Licensed Practical Nurse (LPN) 2 indicated they had been verbally instructed to monitor Resident A when their spouse was present. LPN 2 indicated Resident A's spouse resided at the facility's independent living unit and visited Resident A frequently. LPN 2 indicated Resident A's spouse would get frustrated when the resident got aggressive with them. LPN 2 indicated Resident A's family interactions among the daughter and the spouse were tense. LPN 2 indicated safety precautions should be included in the residents' care plan. LPN 2 indicated safety precautions should be included on the resident profile assignment sheets.In an interview, on 10/20/25 at 3:05 PM, the Administrator indicated the staff had been given verbal instructions to monitor Resident A's interactions with their spouse. The Administrator indicated they had been aware of Resident A's spouse giving the resident medication. The Administrator indicated social services did not have any information due to the Administrator having handled all aspects of the situation and spoke with Resident A's daughter numerous times. The Administrator indicated they were aware Resident A's care plan and resident profile assignment sheets had not been updated to reflect the recent interactions between Resident A and their spouse. The Administrator indicated they provided verbal education as the staff do not look at their assignment sheets. The Administrator indicated they would provide staff education records. An in-service attendance log, dated 10/9/25, and provided by email from the Administrator on 10/21/25 at 7:32 AM was reviewed. The log indicated verbal education had been provided to staff to monitor Resident A for adverse events when their spouse visits. The staff members were directed to intervene and safeguard the resident if needed.A current facility policy, dated 4/1/99 and revised on 12/15/22, indicated the facility would identify, correct and intervene in situations where resident abuse is more likely to occur.This citation is related to Intake 26395753.1-27(a)(b)

Based on observation, interview and record review, the facility failed to date medications when opened, failed to ensure treatments were placed in treatment cart, failed to ensure medication carts were free from loose pills/debris, and failed to record temperature logs for the Emergency Drug Kit/narcotic refrigerator in medication room, in 4 of 4 medication carts and 1 of 1 medication storage rooms reviewed. Findings include:During an observation on 08/26/2025 at 9:52 AM on the 100 hall medication carts with the Director of Nursing (DON) was observed. At 9:55 AM Resident 34 had an opened medication of Albuterol sulfate 30 mcg inhaler dated 1-24-25, and then another opened Albuterol sulfate 30 mcg inhaler with an opened date of 4/4/25. On the label it indicated to give 2 puff every day until 5/3/25. At 9:58 AM Resident 104 had an opened medication bottle of Antacid tablet 750 mg with no open date. At 10:01 AM Resident 43 had an opened bottle of Morphine sulfate 5 ML with a small syringe, inside a clear plastic cup. The syringe was facing downward in the cup at the bottom, it was dirty with a sticky reddish brown substance. This bottle did not have an opened date. At 10:03 AM Resident 71 had an opened bottle of guaifenesin DM 100-10 mg, with no open date. At 10:04 AM Resident 54 had an opened bottle of calcium-gest 500 mg with no open date. At 10:05 AM Resident 85 had an opened bottle of guaifenesin-DM 100-10 mg, with no open date. At 10:07 AM observation with the DON of both 100 medication carts. At the bottom of drawers they were loose medication pills, debris, brown-reddish sticky substance, some were hard to scrape off. DON indicated they should be cleaning the carts. During an observation at 8/26/25 at 10:09 AM with the DON on the 400 medication cart was observed, inside the drawers there was debris, a brown sticky substance at the bottom of the drawers and some unidentifiable loose medication tablets. At 10:10 AM on the 400 medication cart, Resident 17 had 2 small clear plastic cups filled with medication pills. The 1st cup had 3 different medication pills, and the 2nd cup had 5 medication pills inside yogurt. Licensed Practical Nurse (LPN)5, indicated Resident 17, had went to the beauty shop and she placed the medication cups in the medication cart, but she should have gotten rid of them and then re-pulled them again when the resident came back from the beauty shop. During an Observation at 10:15 AM with the DON on the 200 medication carts was observed. Inside the 1st cart, brown sticky substance that flaked off and debris was located at the bottom of the drawers, LPN 6 indicated 3rd shift are the ones that are responsible for cleaning the medication carts. At 10:18 AM during observation of the 2nd medication cart on the 200 hall, in the top drawer there was a tube of bacitracin ointment(treatment) opened 8/6/25 for Resident 92. The DON indicated the treatment should not in the medication cart but instead the treatment cart. At 10:19 AM Resident 36 had an opened bottle of Calcium-Gest 500 mg with no opened date. At 10:21 AM with the DON, in the main medication room, the temperature log dated August 2025 for the Emergency drug kit/Narcotics fridge was located on the front door. The DON indicated, 3rd shift was in charge of recording the temperatures on the log. The dates missing were the 5th ,6th ,7th,8th ,11th, 14th, 15th, 18th, 20th, 21st, 22nd, 23rd, 24th,and 25th. During an observation on 8/28/25 at 12:34 PM, on the 400 hall, the medication room located in the nurses stations, was observed to be unlocked, inside the room, was a unlocked small white refrigerator. There was no staff member observed in area. In an interview 8/28/25 at 12:35 PM, the Administrator indicated, the door to the unlocked refrigerator and unlocked door to the medication room, should have been closed. A current facility policy, titled, Cleaning equipment, rooms, and common areas, dated 11/17/17, was provided by the Administrator on 8/27/25 at 9:19 AM. The policy indicated . Facility will strive to maintain a clean environment, as well as, equipment. Routine, scheduled cleaning will assure proper cleaning of nursing units, common areas and equipment . Items to be cleaned, environment cleaning (including bloodborne pathogen clean up) to touch surfaces, stethoscopes, tabletops, countertops, blood pressure cuffs, wheelchairs, shower chairs, carts, IV poles, and similar medical equipment. By nursing, immediately, when soiled at minimum, weekly if the item(s) is assigned to one resident, otherwise, between resident use 3.1-25(j)(m) and (n)

Based on observation, interview and record review, the facility failed to ensure freedom from intimate touching for 2 of 19 residents reviewed (Resident 53 and Resident 99).Findings include: Resident 53's record was reviewed on 08/26/2025 1:15 PM. Diagnoses included dementia, anxiety, and sexual dysfunction. A current annual Minimum Data Set (MDS) assessment dated [DATE] indicated Resident 53 had a Basic Interview for Mental Status (BIMS) score of 8 indicating cognitive impairment.A progress note dated 8/21/25 at 6:24 PM indicated staff reported inappropriate sexual behavior by Resident 53 with a male resident. The note indicated staff had intervened. No additional progress notes or assessments after 8/21/25 at 6:24 PM were documented from nursing or social services pertaining to sexual behavior.No further progress notes or assessments were available for review at the time of facility exit. A current care plan titled .impaired cognitive function . indicated Resident 53 had a problem of impaired thought processes, with a goal date of 11/4/25. Interventions included communicating with the resident, family, and and caregivers in regards to Resident 53's capabilities and needs. The care plan indicated Resident 53 should be cued, reoriented and supervised as needed.A current care plan titled .has a problem of being sexually inappropriate in common areas ., indicated Resident 53 had a problem of sexually inappropriate behavior with a goal date of 11/4/25. Interventions included intervening as necessary and updating family and the Nurse Practitioner.Resident 99's record was reviewed on 08/26/2025 12:52 PM. Diagnoses included dementia with behavioral disturbance and sexual dysfunction. A current annual Minimum Data Set (MDS) assessment dated [DATE] indicated Resident 99 had a Basic Interview for Mental Status (BIMS) score of 4, indicating cognitive impairment. A progress note dated 8/21/25 5:50 PM indicated Resident 99 exhibited inappropriate sexual behavior in the dining room before the supper meal. The note indicated Resident 99 touched Resident 53 between her legs on the outside of her clothes. The note indicated staff intervened and the Resident 99 was assisted away from the situation. A current care plan titled .sexually inappropriate comments .indicated Resident 99 had a problem of sexual behavior, with a goal date of 8/8/25. Interventions included intervening as necessary to protect the rights and safety of others and updating the Nurse Practitioner, family and Psychiatric Nurse Practitioner. The care plan indicated medications should be administered as ordered and observed for effectiveness. In an interview on 08/28/2025 9:38 AM the Administrator indicated Resident 53 and Resident 99 had a history of sexual contact around the beginning of 2025. She indicated she was not aware of any recent contact. A Medication Administration Record (MAR) for July, 2025 for Resident 99 indicated Depo-Provera (hormonal agent for sexual behaviors) 150mg was not administered on 7/16/25. An administration note dated 7/16/25 11:07 AM indicated Depo-Provera would be administered on 7/17/25 after pharmacy delivery. The MAR was blank in the space for initials indicating the administration of Depo-Provera on 7/17/25. During an interview on 08/28/2025 10:09 AM Licensed Practical Nurse (LPN) 6 indicated upon a resident touching a cognitively impaired resident in a sexual way, staff should immediately separate the residents ensure safety. After assessing for physical or psychological harm, staff should call the Administrator and Director of Nursing, family, and Nurse Practitioner. She indicated Resident 99 received Depo-Provera injections for sexual behaviors. She indicated after the nurse administered the medication, they would enter the administration information in the computer and their initials would appear. She indicated a blank space in the administration spot would indicate the medication might not have been given. In an observation on 08/28/2025 10:11 AM, a vial of Depo-Provera 150 mg/ml (1 ml vial) was present in the medication cart with a label indicating it had been filled on 7/16/25 for Resident 99. The cap on the vial was sealed and unopened. In an interview on 08/28/25 10:12 AM, LPN 6 indicated the pharmacy only sent one dose of Depo-Provera for Resident 99 each month. She indicated since the vial was unopened in the cart, it could not have been given as ordered. In an interview on 08/28/25 10:18 AM LPN 10 indicated non-consensual sexual touching on top of or under clothing was a form of sexual abuse. She indicated consent to sexual content could not be determined in a cognitively impaired resident. Upon occurrence of sexual touching involving a cognitively impaired resident, the residents should be separated and assessed for any physical or psychosocial harm. The occurrence should be reported immediately to the Administrator, Social Services, Director of Nursing, Nurse Practitioner, and family. In an interview on 08/28/2025 1:36 PM the Administrator indicated the contact between residents should have been reported immediately to the Administrator so an investigation could begin. She indicated the residents should have been separated, then assessed. The occurrence and assessment findings should have been reported to the Administrator, Nurse Practitioner and family. In an interview on 08/28/2025 2:22 PM the Executive Director indicated a missed Depo-Provera injection could be a contributing factor in sexual behavior.A current policy titled Abuse Policy, dated 12/15/22, provided by the Administrator on 8/26/25 at 10:06 AM indicated sexual abuse included any kind of intimate touching especially including the peri-area. The policy indicated sexual contact was non-consensual if the resident appeared to want the contact, but lacked the cognitive ability to consent. 3.1-27(a)(1)

Based on interview and record review, the facility failed to ensure an occurrence of non-consensual intimate touching was reported for 1 of 19 residents reviewed (Resident 99). Resident 99's record was reviewed on 08/26/2025 12:52 PM. Diagnoses included dementia with behavioral disturbance and sexual dysfunction. A current annual Minimum Data Set (MDS) assessment, dated 7/26/25, indicated Resident 99 had a Basic Interview for Mental Status (BIMS) score of 4, indicating cognitive impairment. A progress note, dated 8/21/25 5:50 PM, indicated Resident 99 exhibited inappropriate sexual behavior in the dining room before the supper meal. The note indicated Resident 99 touched Resident 53 between her legs on the outside of her clothes. The note indicated staff intervened and the Resident 99 was assisted away from the situation. No notes including documentation of notification of family or Nurse Practitioner were available for review. In an interview, on 08/28/2025 9:38 AM, the Administrator indicated Resident 53 and Resident 99 had a history of sexual contact around the beginning of 2025. She indicated she was not aware of any recent contact. During an interview, on 08/28/2025 10:09 AM, Licensed Practical Nurse (LPN) 6 indicated upon a resident touching a cognitively impaired resident in a sexual way, staff should immediately separate the residents ensure safety. After assessing for physical or psychological harm, staff should call the Administrator and Director of Nursing, family, and Nurse Practitioner. In an interview, on 08/28/25 10:18 AM, LPN 10 indicated non-consensual sexual touching on top of or under clothing was a form of sexual abuse. She indicated consent to sexual content could not be determined in a cognitively impaired resident. Upon occurrence of sexual touching involving a cognitively impaired resident, the residents should be separated and assessed for any physical or psychosocial harm. The occurrence should be reported immediately to the Administrator, Social Services, Director of Nursing, Nurse Practitioner, and family. In an interview, on 08/28/2025 1:36 PM, the Administrator indicated the contact between residents should have been reported immediately to the Administrator so an investigation could begin. She indicated the residents should have been separated, then assessed. The occurrence and assessment findings should have been reported to the Administrator, Nurse Practitioner and family. She indicated the occurrence should be reported to the department of health according to abuse reporting protocols.A current policy titled Abuse Policy, dated 12/15/22, provided by the Administrator on 8/26/25 at 10:06 AM indicated sexual abuse included any kind of intimate touching especially including the peri-area. The policy indicated sexual contact was non-consensual if the resident appeared to want the contact, but lacked the cognitive ability to consent. The policy indicated staff should immediately report any suspected abuse to the Administrator. The Administrator should begin and investigation and report the allegation to the Department of Health within 2 hours of the occurrence. Investigation findings should be reported to the Department of Health upon completion of the investigation.3.1-28(e)

Based on observation, interview and record review, the facility failed to ensure wound care was provided to promote healing and prevent infection for 1 of 3 residents reviewed (40).Findings include:During an observation, on 08/27/2025 10:16 AM, Registered Nurse (RN) 7 removed wound care supplies from a cart outside Resident 40's room. She carried a package of alginate wound preparation, an abdominal (ABD) pad, a package of kerlix (roll gauze used to wrap limbs), a pair of scissors, a bottle of wound cleanser and a barrier sheets into Resident 40's room. She held the items against her body as she placed a barrier sheet on the overbed table in Resident 40's room and then placed the supplies on top of the barrier prior to applying a gown and gloves. She placed another barrier sheet underneath Resident 40's right foot and removed her sock. She used the scissors to cut and remove kerlix wrapped around Resident 40's right heel. She placed the scissors back on the barrier on the overbed table. The scissors had not been cleaned since being used to cut off the old dressing. She sprayed wound cleanser on Resident 40's heel and placed the wound cleanser bottle on the floor with no barrier between the bottle and the floor. She applied a piece of alginate to the wound, applied the ABD pad and wrapped the wound with kerlix using the scissors form the over bed table to cut the kerlix after an adequate amount had been applied. The scissors had not been cleaned since being used to cut off the old dressing. No skin prep was applied to the area surrounding the wound. She placed the packages of kerlix and alginate on the floor with no barrier between the packages and the floor. No hand hygiene occurred after cleansing the wound and before applying the wound treatment. RN 7 picked up the uncleaned scissors and wound cleanser, then placed them back in the cart without cleansing either item. During an interview, on 08/27/2025 10:38 AM, RN 7 indicated she should have placed wound care supplies on a barrier instead of the floor and should have cleansed the scissors after using them to cut an old dressing. Resident 40's record was reviewed on 08/27/2025 11:17 AM. Diagnoses included Alzheimer's disease, pressure ulcer of the right heel, and type 2 diabetes. A current quarterly Minimum Data Set assessment (MDS), dated [DATE], indicated a Basic Interview for mental status was not done because Resident 40 was rarely able to make herself understood. The MDS indicated Resident 40 had a stage 3 pressure area. A current physician's order, dated 7/23/25, indicated Resident 40's right heel should be cleansed with wound cleanser and patted dry. Skin prep should be applied around the wound edges. The wound bed should be filled with silver alginate and covered with an ABD pad to assist with autolytic debridement. The dressing should be secured with Kerlix and changed twice weekly and as needed for soilage or dislodgement. During an interview, on 08/27/2025 11:18 AM, RN 7 indicated during a wound care procedure, hands should be washed after touching the resident before removing the old dressing, after removing the dressing, before wound care, and after the procedure. RN 7 indicated she had washed her hands 3 times during the course of the procedure. RN 7 indicated wound care items should be carried into the resident room carried away from the staff member's body using care to not touch their uniform. She indicated she should have not carried wound care items in to the room touching her uniform. A current policy titled Validation Checklist Wound Care, dated 2022, provided by the Administrator indicated hand hygiene should be performed after setting up supplies before opening packages and containers, after removing a soiled dressing before cleansing the wound, after cleansing the wound, after cleansing the wound and before applying a wound treatment, and after completing the procedure. The procedure guide indicated 4 handwashing opportunities during the wound care procedure. The policy indicated supplies should be maintained as sterile or clean as indicated avoiding contamination. The policy indicated physician's orders should be reviewed prior to the procedure and followed. 3.1-40(2)

Based on interview and record review, the facility the failed to ensure communication with the dialysis provider for 1 of 1 residents reviewed. (Resident 57)Findings Include:Resident 57's record was reviewed on 8/26/2025 at 1:25 PM. Diagnosis included end stage renal disease, dependence on renal dialysis, hypertensive chronic kidney disease with stage 5 chronic kidney disease or end stage renal disease, metabolic encephalopathy and anemia in chronic kidney disease. A review of physician orders, on 8/28/2025 at 9:10AM, indicated Resident 57 needed to leave the facility for dialysis at 4 AM on Monday, Wednesday and Friday and the facility is to complete pre- and post-dialysis assessments. On 8/28/2025 at 10:59 AM, in an interview, Registered Nurse 8 (RN), indicated she had not seen a dialysis book, however she was new. RN 8 indicated she asked Licensed Practical Nurse 9 (LPN) and they indicated there was no dialysis book.On 08/28/2025 at 1:45 PM, the Administrator provided a dialysis communication book for Resident 57. The dialysis book included a Nurse Responsibilities for Dialysis Resident form, physician orders, dialysis pre and post assessments for 7/25/2025, 7/28/2025, 7/30/2025, 8/1/2025, 8/4/2025, 8/6/2025, 8/8/2025, 8/11/2025, 8/15/2025, 8/18/2025, 8/22/2025, 8/25/2025, 8/27/2025 and End Stage Renal Disease (ESRD) communication forms for 8/6/2025 and 7/23/25. On 08/28/2025 at 2:15 PM, in an interview, the Administrator, indicated Resident 57 received dialysis on Monday, Wednesday and Friday. The Administrator indicated the ESRD communication form was the only way the facility had communicated with dialysis. The Administrator indicated the dialysis book should be taken to each dialysis appointment with Resident 57. The Administrator indicated the facility only had the ESRD communication forms for 7/23/2025 and 8/6/2025 and the facility should have completed the form for each dialysis appointment for Resident 57. The Administrator indicated post and pre dialysis assessments should have been completed every Monday, Wednesday and Friday. The Administrator indicated she did not have pre- and post-dialysis assessments for 8/13/2025 and 8/20/2025. The Administrator indicated Resident 57 had not missed a dialysis appointment since admission. A current policy dated 1/8/2018 provided by Administrator indicated, LLV shall ensure all appropriate medical and administrative information accompanies the resident at the time of transfer or referral to the dialysis center . The assigned nurse shall monitor the needs of the dialysis resident and review any notes/orders accompanying the resident from the dialysis center upon arrival at LLV 3.1-37(a)

Based on interview and record review the facility failed to ensure completion of physician ordered laboratory tests for 1 of 5 residents reviewed. (Resident 30)Findings Include:Resident 30's record was reviewed on 8/27/2025 at 9:52AM. Diagnoses included: Vitamin D Deficiency, fatty (change of) liver, other seizures and major depressive disorder single episode unspecified. Resident 30's record was reviewed on 8/28/2025 at 1:38PM. Orders included: Depakote Oral Tablet Delayed Release 250MG (Divalproex Sodium), Ammonia & Depakote Level every day shift every 2 month (s), Annual Vitamin D &TSH every day shift every 365 days(s) for April and Hepatic & Lipid panel every day shift every 6 month(s). On 08/28/2025 at 10:28 AM, in an interview, the Administrator, indicated the facility had identified an issue with the Medication Administration Record (MAR) not notifying staff labs needed to be drawn. On 8/28/2025 at 1:36PM, in an interview, the Administrator, indicated she was providing the labs she was able to locate. The Administrator indicated she was not able to find any additional lab results for Ammonia, Depakote Level, Vitamin D and Hepatic Function. A review of labs results, dated 12/2/2024 at 09:40 AM, included lab results for Valproic Acid. The labs did not include results for Vitamin D, Hepatic Function or Ammonia. A review of labs results, dated 05/19/2025 at 10:30 AM did not include lab results for Vitamin D, Ammonia, Hepatic Function or Depakote Level. A review of labs results dated 08/07/2025 at 09:30 AM did not include lab results for Vitamin D, Ammonia, Hepatic Function or Depakote Level. On 08/29/2025 at 1:42 PM, in an interview, the Director of Nursing (DON),indicated the facility did not have any labs for Vitamin D, Hepatic Function or Ammonia prior to 8/28/2025 for Resident 30. The DON indicated the facility did not complete labs for Vitamin D, Hepatic Function or Ammonia for Resident 30 prior to 8/28/2025. The DON indicated the facility did not have any additional Depakote labs for Resident 30. A current policy dated 12/21/2016 was provided by the DON on 8/29/2025 indicated The nurse is required to electronically acknowledge orders. The nurse should review the order for clarity and completeness, making an entry into the nurse notes, adding an additional Care Plan problem or augmenting any existing problem, an entry into a communication device or shift report and notify any ancillary department required to execute the order. When applicable, the nurse should notify pharmacy and dining services. Acknowledging/noting order takes place in the EMR. 3.1-49(f)(1)

Based on interview and record review, the facility failed to ensure the root cause of falls was assessed, care plan interventions were developed and implemented to prevent further falls from occurring for 1 of 3 residents reviewed for accidents (Resident B). Findings include: A report, dated 6/5/25, indicated Resident B had 2 falls, within a couple days, resulting in a fractured leg. Resident B's family member alleged the facility hadn't provided adequate supervision and care to prevent the falls and injury. On 6/23/25 at 11:41 A.M., Resident B's record was reviewed. Diagnoses included Alzheimer's dementia and post-hip fixation after a fall causing fracture. The resident was admitted to the facility for rehabilitation with a goal of discharging back to her daughter's home where she had lived. A nursing admission screen form, dated 5/8/25 at 10:26 a.m., indicated Resident B was alert and oriented to self and time; had short-term memory issues; used briefs for bladder and bowel incontinence; had unsteady gait, weakness, poor balance; and was to stand/pivot/sit using her left leg only. An admission Minimum Data Set (MDS) assessment, dated 5/15/25, indicated Resident B had severely impaired cognition; no moods or behaviors; used a walker and wheelchair; walked 10 feet with moderate assistance; and required maximal assistance for transfers to chair/bed/toilet, toileting hygiene, and putting on/taking off her footwear. The MDS assessment indicated the resident was frequently incontinent of bladder and occasionally incontinent of bowel however, no trial of a toileting program had been attempted. A Fall Care Area Assessment (CAA), dated 5/15/25, triggered for falls due to risk of injury related to balance issues. The resident was not stable and required stabilization with assistance of 1 staff member. She required help moving on and off the toilet and surface to surface. Resident B was to receive physical and occupational therapy services. She required assistance from nursing staff for care and was at high risk for falls. The care plan would address falls with a goal of no fall related injuries. A Urinary Incontinence CAA, dated 5/15/25, triggered due to Resident B being frequently incontinent of urine and requiring staff assistance of 1 for toileting. The resident was at risk for skin breakdown, falls, isolation, and urinary tract infection. The care plan would address urinary incontinence for monitoring and minimizing risks. Care plans indicated: -5/8/25: Resident B required assistance with Activities of Daily Living (ADL) from staff related to deconditioning secondary to multiple falls prior to admission. The goal was to improve her physical function with bed mobility, eating, toileting and transfers. One intervention had been put in place, dated 6/2/25, which was for staff to provide limited assistance with bed mobility. -6/2/25: Resident B was at moderate risk for falls related to confusion and gait/balance problems. The goal was to be free from falls. Interventions, all initiated on 6/2/25 after the resident's falls and discharge to the hospital, included: ensure proper footwear and call light within reach; Stat x-ray ordered and sent to hospital ER, staff to increase scheduled toileting; anticipate and meet her needs; be sure the call light is within reach and encourage her to use it; staff to provide prompt response to all requests for assistance; encourage to participate in activities to promote exercise; ensure she is wearing appropriate footwear; and follow facility fall protocol. -6/2/25: Resident B had stress bladder incontinence related to history of urinary tract infection with a goal of being free from skin breakdown due to incontinence and brief use. Intervention, dated 6/2/25, was for staff to monitor, document, and report any possible causes of incontinence-bladder infection, constipation, loss of bladder tone, weakening of control muscles, decreased bladder capacity, etc. Resident B's care plans had not indicated the amount of assistance required for ADL's other than bed mobility. The care plan hadn't indicated her weight bearing status, ability to ambulate and which assistive devices to use. She had no scheduled toileting plan but had a fall intervention to increase her scheduled toileting after being discharged to the hospital following her fall with fracture. A nurse note, dated 5/29/25 at 8:09 p.m., indicated staff heard a noise and turned around to observe Resident B falling. She had gotten up from the recliner (in her room) to toilet and had been wearing slick shoes causing her to loose balance and fall. She was assisted to her feet and walked to the bathroom per her request. She had no observed injuries and full range of motion (ROM) to her extremities. She had no complaints of discomfort. Resident B was dressed for bed and taken out to the dining room where staff could observe her. An Interdisciplinary Team (IDT) review, dated 5/30/25 at 3:09 p.m., indicated Resident B had a fall on 5/29/25 at 8:00 p.m. when she got up from her room recliner and attempted to walk to the bathroom. The IDT determined the root cause of the fall was weakness and the intervention was to ensure she wore proper footwear and her call light was within reach. A nurse note, dated 5/31/25 at 12:48 p.m., indicated at 12:00 p.m., Resident B was observed on the floor in her room. She indicated she had walked herself to the bathroom and when returning to her recliner, her legs gave out and she went down on her bottom. She complained of pain in the back of her upper leg, above the knee. She was assisted to stand up, was able to bear weight and pivot into her recliner chair, but indicated it had hurt. The nurse administered pain medication and notified the on-call Nurse Practitioner (NP) and resident's family. Resident B was educated to not get up by herself and use the call light for assistance. Staff were to monitor her more frequently to anticipate her needs. -5:28 p.m., a STAT x-ray of the resident's right leg and knee was ordered, completed, and results received at 4:38 p.m. The X-ray indicated a fracture to the resident's distal femur (above the knee). An order was given to send the resident to the hospital for evaluation and treatment. An IDT review, dated 6/2/25 at 3:20 p.m., indicated Resident B had an unwitnessed fall on 5/31/25 at 12:00 p.m. after getting up by herself and going to the bathroom. Resident B was walking in her room back to the recliner chair after using the bathroom when her legs gave out and she went down on her bottom. The root cause of the fall was weakness and poor balance. The new intervention to her care plan was to increase her scheduled toileting. On 6/23/25 at 3:00 P.M., the Executive Director, Assistant Administrator, and Unit Manager (UM) were interviewed regarding investigation of falls and development of fall interventions to prevent further falls. The Assistant Administrator indicated the IDT reviewed fall reports at morning meetings where all disciplines were present, including therapy staff. She indicated falls were reviewed, analyzed, root cause analysis determined, and appropriate interventions put into place. Review of the facility fall reports for Resident B on 5/29 and 5/31/25, indicated both falls occurred when the resident was trying to get to/from the bathroom. The UM indicated the resident had not been on a scheduled toileting plan nor had an assessment been completed to indicate the need for a plan. The Executive Director, Assistant Administrator and UM indicated Resident B's root cause of her falls was needing to use the bathroom, incontinence, and not having an established toileting plan for staff to follow. The care plan should have been updated to indicate her increased risk for falls related to need for toileting. On 6/23/25 at 3:41 P.M., the Rehabilitation Therapy Director and Physical Therapist were interviewed. Both indicated Resident B always required staff assistance for ambulation in her room. She required a staff member to stand by and provide cues and stabilization due to confusion and weakness at times. On 6/23/25 at 10:48 A.M., the Assistant Administrator provided a current copy of the facility policy, titled Fall Policy-Resident Safety which stated: This policy establishes guidelines and explains the methods used to assess/screen residents at risk for falling and develop interventions to assist in the prevention of further falls .Standard safety precautions will be implemented on all residents upon entry into the nursing home setting .non-skid shoes/slippers; mobility devices .If the resident falls: assess for injury; notify medical staff; document all factors contributing to the falls; interventions currently in place and implementation of any additional safety measures and assessments of resident; an incident report will be completed in the record .the fall care plan interventions will be reviewed and revised if necessary. The resident's fall risk will be communicated to caregivers .Additionally all resident falls will be reviewed daily by the IDT to ensure all documentation and interventions are correct and root cause analysis determined This Citation relates to Complaint IN00460903. 3.1-45(a)

Based on interview and record review, the facility failed to ensure a resident was assessed and the physician notified timely following acute changes in condition, advance directives for transfer to a hospital were followed, and physician orders followed for 1 of 3 residents reviewed (Resident B). Findings include: A report, dated 5/21/25 at 12:41 p.m., indicated Resident B had been transferred to the hospital where she passed away. A family member alleged the resident hadn't been assessed and sent to the hospital timely, per the resident's advanced directives, when she required emergency care for a change in condition. The family member alleged the resident had been administered a higher dosage of medication than prescribed which she believed, led to the resident's demise. She alleged when family spoke with facility staff about the medication, the staff's explanations were inconsistent as was documentation of the administered medication in the resident's medical record. On 5/28/25 at 11:43 A.M., Resident B's record was reviewed. Diagnoses included congestive heart failure, syncope (fainting) and collapse, hypomagnesemia (low levels of magnesium in blood), muscle weakness, and malaise. A hospital discharge summary, dated 1/2/2024, indicated Resident B had been hospitalized for weakness, syncope, and low blood levels of sodium and magnesium twice in December 2023. She was admitted to the facility for rehabilitation with the goal of returning to her home. An Admission Summary note, dated 1/2/24 at 6:54 p.m., indicated the resident had arrived at the facility via ambulance. Initially, facility transportation had attempted 2 times to bring her to the facility however, when sitting in the wheelchair, she fainted. She arrived to the facility at 5:42 p.m., accompanied by family. Family indicated the resident had a huge decline in drinking fluids. Assessment of skin turgor indicated she had slight tenting (indicator of dehydration) of her skin. Resident B was alert, able to make her needs known and was able to use her call light. Her vital signs were: Blood pressure-112/55, Pulse-84 very irregular, Respirations-16, Temperature-97.1 and blood oxygen saturation level-94%. Admission physician orders, dated 1/2/24, included Magnesium Oxide (supplement) 420 milligrams (mg)-give 1 tablet by mouth every day for 14 days. A History and Physical progress note, dated 1/3/24 and completed by the Medical Director/Physician, indicated the resident had been admitted from her home to the hospital following episodes of fainting and weakness. She was admitted to skilled care for physical and occupational therapies to restore her baseline activities of daily living (ADL) and discharge back to her home. A discussion between the Medical Director and Resident B's son, indicated concern the resident's continued weakness and eye drooping could be due to a medical condition. The Medical Director was going to order medication to treat the medical condition for 3 days and then re-evaluate. The resident was to continue on the magnesium supplement at the dose prescribed by the hospital (420 mg) in addition to her other prescribed medications. The resident was to continue with physical, occupational therapy and her progress closely monitored. A Physician Orders for Scope of Treatment (POST) form, dated 1/3/2023, indicated Resident B's wishes regarding end of life medical interventions. If she had a pulse and was breathing, she wanted to receive full interventions including transfer to the hospital and/or intensive care unit to meet her medical needs. A Nurse Practitioner (NP) progress note, dated 1/4/24, indicated the resident was visited due to being a new admission to the skilled unit. Resident B's medications were reviewed and current. The resident had been prescribed a short course of medication to treat a medical condition possibly contributing to her weakness. The resident was alert during her assessment but weak. She required 1 person assist with transfers to her wheelchair. The Assessment and Plan included: Generalized weakness-there was concern about a medical condition as potential cause of her weakness. Labs to test for the condition were ordered and a short course of medication prescribed to see if it improved her weakness; Advanced Care Planning-the resident was alert but unable to make her own medical decisions. Her family wanted her advanced directives to continue as she'd written them. Family understood if the resident would become medically unstable, she would be returned to the hospital with all life saving measures intiated. She was to continue taking her Magnesium supplement and other medications as prescribed. An NP progress note, dated 1/8/24, indicated Resident B was seen for a post-acute visit due to syncope, weakness, and fatigue. The resident had recently completed a 3 day course of medication for her weakness. During the visit, she appeared tired but was able to open her eyes, move her arms and legs and follow commands. She was still waiting on results of lab tests done last week to confirm if she had a medical condition causing her symptoms. Since her admission, she had lost weight. From 1/6-1/7/24, she experienced nausea and was started on anti-nausea medication. She was tested for respiratory pathogens due to fluctuating blood oxygen saturation levels. Assessment and Plan included: Her magnesium supplementation was temporarily discontinued due to a recent bout of diarrhea-staff were to monitor her bowel movements and her medications adjusted accordingly. Nurse progress notes, dated 1/6-1/8/24 hadn't indicated Resident B had diarrhea. A nurse progress note, dated 1/8/24 at 11:23 a.m., indicated Resident B had been involved in some therapy but remained lethargic. She was observed with low blood oxygen levels and was started on oxygen which initially, increased her oxygen levels to 97% (normal blood oxygen saturation levels >90%), but declined to the 80's with exertion. - At 5:29 p.m., the resident complained of nausea and was given medication to treat which was effective. -7:35 p.m., Resident B complained of pain in her body and she couldn't get comfortable. She was administered Acetaminophen (Tylenol) 650 mg by mouth for the pain. -8:56 p.m., the resident continued with pain. She indicated she'd had no relief from the Acetaminophen and rated her pain at a 7 on a scale of 1-10 with 10 being the worst pain. There was no documentation in Resident B's record to indicate the Physician/NP or family had been notified of the resident's unrelieved pain. A nurse progress note, dated 1/9/24 at 1:56 a.m., indicated Resident B had been assisted with care and her vital signs checked which were: blood pressure (BP)-94/70 (normal above 100/60), pulse-93, respirations-16 and blood oxygen saturation was 81%. Her oxygen was re-applied and oxygen level increased to 92%. -At 7:13 a.m., the resident's magnesium supplement was held with no reason documented. -2:38 p.m., a new order was given to restart the medication used to treat her weakness, previously administered 1/5-1/7/24. A nurse progress note, dated 1/10/24 at 3:27 p.m., indicated the resident had an episode of low blood pressure following therapy. Her BP had been 79/44. Resident B was becoming dehydrated due to not taking in what the facility gave her and she did not eat full meals. She had been sleeping most of the day with family at her bedside. A physician progress note, dated 1/10/24 at unknown time, indicated the Medical Director had visited the resident. There were no concerns relayed by the resident, staff or family. Her systolic (top number) blood pressure ranged from 89-158. Resident B had recently completed a short term medication treatment for her weakness which afforded her notable improvement. Her oxygen saturation levels had been fluctuating between 87-97% and she was currently on 2 liters of nasal oxygen. She had transitioned from requiring 1 assist to 2 assist for mobility. She was eating well and denied pain. The resident's magnesium supplement was placed on hold due to a recent bout of diarrhea otherwise, there were no changes in her medications. On 1/6-1/7/24, she had complained of nausea and was started on anti-nausea medication. She finished her therapy on 1/10/24 but appeared more lethargic afterward. Assessment and Plan included: Diarrhea-recent bout of diarrhea led to the temporary discontinuation of her magnesium supplement. There had been no other changes in her medication regimen. The plan was to continue to monitor the resident's bowel movements and adjust medications as necessary; Generalized weakness-the resident was able to move her extremities and follow commands during visit. She had responded to the 3 day medication challenge so this would be continued and she would be encouraged to continue with therapies. There was no documentation in Resident B's record to indicate the Physician/NP had been notified of the resident's episode of low blood pressure following therapy or the resident exhibiting signs of dehydration due to poor drinking/eating. A nurse progress note, dated 1/10/24 at 9:02 p.m., indicated Resident B put on her call light and reported she couldn't breathe. Nasal oxygen was applied and she indicated she felt better. Nurse progress notes, dated 1/11/24, indicated the following: -At 1:29 a.m., Resident B had been coughing and stating she was having a hard time breathing. Her lung sounds were clear but her oxygen saturation level was 88%. Oxygen was put on and her oxygen level went to 100%. Her BP was 110/62, pulse-84 and respirations 16. (There was no documentation of the resident's temperature). The resident was anxious so staff stayed with her and provided reassurance. She was administered Tylenol for general discomfort but promptly vomited it back up. Staff remained at her bedside. -2:58 a.m., the resident was given her anti-nausea medication which she stated had been helpful. -3:58 a.m., the resident was restless but denied pain. Staff had been with her frequently; most recently, the past 20 minutes, reassuring her, holding her hand, adjusting the room temperature, her blankets, etc. Her lungs remained clear, bowel sounds present, and skin without changes (sweating). The resident finally settled and staff continued to monitor her. There was no documentation in Resident B's record to indicate the Physician/NP or family had been immediately notified of the acute change in the resident's condition of difficulty breathing, anxiety, restlessness and vomiting. An NP progress note, dated 1/11/24 at unknown time, indicated the resident had been visited due to increased lethargy, poor appetite and weakness for the past 6 weeks. Her family member reported Resident B hadn't eaten, had been more tired and lethargic than usual and was mostly wanting to sleep. The resident was reportedly awake until 4 a.m. and hadn't slept much since. She had been having diarrhea and later reported vomiting. Her magnesium supplement had been put on hold due to complaints of diarrhea and she was started on a new medication for gastritis (stomach inflammation). Assessment and Plan included: Diarrhea: The resident's diarrhea was likely related to the magnesium supplementation- placed on hold; Nausea: She had been having nausea possibly related to her medications; Vomiting: She had vomited twice possibly related to nausea and decreased appetite. The plan was to monitor her vomiting and adjust medications as necessary. A nurse progress note, dated 1/11/24, indicated at 11:50 a.m., the respiratory pathogens lab result was received and were negative. A new panel of blood labs were ordered and drawn. -A late entry at 1:15 p.m., indicated the resident was given her medications in applesauce, however, her family member at the bedside, reported she vomited them back up approximately 5 minutes after given. The resident was alert; would only take sips of water and then would go back to sleep. The resident had diarrhea 4 times. She required full assistance with personal care. The resident would awaken if her name was called but her words were soft and not understandable. Her daughter remained at bedside. -At 2:47 p.m., the resident continued with diarrhea x 3. She was very tired and not communicating well. Her daughter was present to talk about options and medications. The nurse was going to message the resident's Power of Attorney (POA) about the medication suggestions made by the NP. -A late entry at 4:15 p.m., indicated Resident B's daughter was at bedside. The resident had been very fatigued and had not participated in therapy due to weakness. Her daughter asked how long had the resident been this weak and was told it had started the morning of 1/11/24 with assessment. The resident had been weak, fatigued, and unable to answer questions. The night shift nurse had reported the resident had been restless overnight. Blood work had been done but the results had not yet been received. Approximately an hour later, the daughter came to the nurse's station where the day and evening shift nurses were giving report, and asked if her mother was dying. The daughter was crying and asked the 2 nurses to be honest with her. Both nurses indicated the resident was close to dying and suggested the daughter contact other family members to advise. The daughter texted her family members at approximately 4:30 p.m. The resident's son and daughter in law/POA, texted the daughter to have the resident sent out to the emergency room . -4:41 p.m., Resident B was declining and she appeared to be dying. Family was notified and they wanted her sent to the ER. The EMS was called per family request. -5:09 p.m., the resident left with the EMS. A nurse progress note, dated 1/12/24 at 12:31 a.m., indicated the hospital had been contacted for an update on Resident B's condition. She spoke with the resident's POA who indicated the resident had passed away. A Medication Administration Record (MAR) dated January 2024, indicated by nurse initials, Resident B had been administered Magnesium Oxide, as ordered, 1 time per day on 1/3, 1/4, 1/5, 1/6, 1/7, 1/8, 1/10, and 1/11/24. The MAR, indicated on 1/9/24, the Magnesium supplement was held without documentation of reason. The MAR had not indicated Magnesium Oxide had been temporarily discontinued or held due to diarrhea. The MAR indicated an as-needed order for anti-diarrheal medication had been given on 1/8/24 but had not indicated the medication had been administered. On 5/28/25 at 3:37 P.M., Resident B's daughter was interviewed. She verbalized her continued anguish over her mother's death and belief her death could have been prevented. She had been in to see her mother the morning of 1/11/24 and had returned in the afternoon. She indicated the resident looked dreadful and was declining quickly. She had asked the day and evening shift nurses if her mother was dying because she would want to go to the hospital for treatment. The 2 nurses told her she was dying and should contact her family for further guidance. She indicated the resident was supposed to return home where she had lived with her prior to being hospitalized . The daughter indicated 6 weeks prior to her death, the resident had been driving a car and walking her dog. She alleged her mother's death was due to an excess of magnesium administered. On 5/29/25 at 10:05 A.M., Resident B's POA was interviewed. The POA was a nurse and her husband/resident's son, a physician. After her mother in laws death, copies of her medical records were requested and provided by the facility. The family had several questions about inconsistencies in the resident's care and medical records which had not been fully explained nor understood. She indicated the family had been upset because the resident's advance directives had been very clear about her wish to be hospitalized and all life saving interventions initiated. On the day of the resident's death, the evening shift nurse indicated to the resident's daughter, the resident was dying and he hadn't wanted to call the EMS, rather he wanted her to be comfortable and stay at the facility against the resident's wishes. The family felt guilt and remorse because they hadn't been able to honor her wishes even though, her death may have still occurred. The POA indicated family had been told Resident B had a fever the night before her death and her blood pressure normal but her medical record hadn't indicated this. The resident had experienced acute restlessness and anxiety the night prior to her death. This was not normal for her indicating something was wrong and neither the doctor nor family were notified. On 5/29/25 at 11:35 A.M., the Nurse Practitioner was interviewed. She indicated, on 1/11/24, she had seen the resident sometime between 12 and 2 p.m. At the time of her visit, Resident B hadn't appeared different from prior visits on 1/4 and 1/8/24. The NP indicated there had been no signs of the resident's decline or need for emergent transfer to the hospital when visited. She had been notified, the morning of 1/11/24, Resident B had been more tired and lethargic than usual. Orders had been given for labs. The labs were drawn immedicately that morning. She indicated, at the time of her visit, the lab results had not been in and weren't available. When questioned about the resident's magnesium supplement, she indicated she had not written an order, rather had verbally told the nurse to hold the medication due to diarrhea. She was not notified the resident had received the magnesium supplements every day but 1 and had not been held as verbally ordered. She indicated belief the resident's diarrhea was related to the administration of the magnesium supplements. She had been told the supplements were held on 1/11/24. She indicated she had not been notified of the resident's decline in condition following her visit. On 5/29/25 at 2:30 P.M., the Executive Director (ED) and Director of Nursing (DON) were interviewed. Neither the ED or DON had been in their positions at the time of the resident's stay and had no knowledge of the events. When asked, the DON indicated staff were expected to notify the physician/NP, resident, and families of changes in condition and follow resident's advance directives and physician orders. On 5/29/25 at 4:23 P.M., the DON provided current copies of facility policies as follows: Notification of Changes: Staff will immediately inform the resident; consult with the resident's physician; and notify the resident representative when there is a .significant change in the resident's condition .a need to alter treatment .decision to transfer or discharge the resident from the facility Advanced Directives: Resident's have the right to make decisions concerning medical care, including the right to accept, refuse, or discontinue medical treatment .Resident wishes will be communicated to the staff via the person-centered care plan noted in the medical record, and to the resident physician Electronic Medical Record-Physician Orders: Practitioners will enter orders directly into the EMR to provide timely resident care .Physician orders shall be written in a manner to clearly convey the intent of the physician to any nurse .The nurse should provide, to the practitioner, any additional information needed for the practitioner to write an effective order .The nurse is required to electronically acknowledge orders. The nurse should review the order for clarity and completeness, making an entry into the nurse notes, adding an additional care plan problem or augmenting an existing problem .Acknowledging/noting orders takes place in the EMR This Citation relates to Complaint IN00460004. 3.1-37

Based on observation, interview and record review, the facility failed to ensure dementia care and services was provided to 2 of 3 residents reviewed for dementia care (Resident J and Resident K). Findings include: On 3/10/25 at 10:30 A.M., the secured Memory Care Unit (MCU) was toured. Several residents were observed seated at tables in the dining room/activity area. Some were sleeping while others stared blankly ahead. There were no activities occurring. A television, mounted on the wall was not turned on and there was no music played. In one corner of the room, on shelves, were games and other activity equipment. The equipment was not being used by any residents in the area. One resident was observed standing near one of the tables, repetitively wiping the table while his table mate sat across from him looking on. A female resident, with a white/yellow substance on her teeth and lips, sat at another table fidgeting with her hair and clothing while another female resident, was propelling her wheelchair and asking if anyone could help her to the bathroom. The resident fidgeting with her clothing, removed her shirt, looked at it and put it back on. She remained fidgeting and moving around in her wheelchair, muttering to herself. No staff were seen in the area. -At 11:28 A.M., residents were observed to be served drinks while waiting for lunch. The area was quiet except for a few residents talking in low voices with each other. There was little conversation between staff and residents as they were served lunch. The television wasn't on nor other background music. -At 1:20 p.m., several residents were observed in the dining area, sleeping or just staring out. There were no activities occurring nor staff present in the room. 1. On 3/10/25 at 11:19 A.M., Resident J's record was reviewed. Diagnoses included dementia with mood disturbance, insomnia, major depressive disorder, anxiety disorder and diabetes. He was hospitalized ,d+[DATE]-[DATE] at a psychiatric hospital for medication management and was prescribed antipsychotic medication to control his dementia related behaviors. A quarterly Minimum Data Assessment (MDS), dated [DATE], indicated the resident had moderately impaired cognition with no mood indicators. He had physical and verbal behaviors towards others 4-6 days and rejection of care 1-3 days during the assessment. He required supervision for eating and oral hygiene, maximum assistance with dressing and personal hygiene, and was dependent for transfers, toileting, and bed mobility. He was non-ambulatory and used a wheelchair for mobility. He was prescribed antipsychotic, antianxiety, antidepressant medications as well as blood thinners for atrial fibrillation. Care plans were: -12/20/24: Resident J was resistant to care, verbally aggressive, would barricade self in room, curse at staff, yell and scream due to dementia. Interventions included: allow resident to make decisions about his care; approach him in a calm, friendly manner; educate him on outcomes of not complying with care/treatment; give clear explanation of all care activities prior to contact; if resident resists care, reassure and leave to calm; return 5-10 minutes later and try again; negotiate a time for care; offer reassurance and emotional support; update and involve staff, physician/NP, and family in care and changes. -10/23/24: the resident's preferred activities included bible study, bingo, conversing with friends, country rides, exercises, physical games, going outside, special visitors such as children and pets, student volunteers, quiet time by self, mentally challenging games, music programs, reading, social hour, worship and hymns. The goal was for the resident to be involved with activities of choice, maximizing participation with encouragement and assistance. Interventions included: assist to each activity; encourage interaction and facilitate participation with other residents of similar backgrounds/interests; provide a program of activities of interest which provides empowerment by encouraging choice, self-expression and responsibility. Resident J had no specific care plan for need to reside on a secured memory care unit or benefits of dementia care programming. On 3/10/25 at 10:38 A.M., Resident J was observed seated in his wheelchair alone in a back hallway. He moved slowly with his left arm appearing flaccid as it lay on his lap. He was drooling and had a washcloth beneath his chin. He was observed to repeatedly put his right hand on the door knob of a room with a sign stating it was a shower room. When asked, he indicated he was having a bad day and hadn't wanted to share what his name was. -At 11:28 A.M., Resident J was observed seated by himself at a dining room table in the corner of the room, facing a bookcase, where he ate his lunch. He was observed to be more alert while eating. -At 1:15 P.M., Resident J was observed seated in his wheelchair, sitting in the doorway to his room. He appeared alert, wide awake and engaged in small talk. He was then observed to quickly roll his wheelchair across the hallway, frontward's and backwards, in between the doorway of his room and another residents room. Nurse progress notes indicated: -2/26/25 at 11:20 p.m., the Resident was rolling on the mat when in bed and pushed his call light for help. He would demand staff pick him up off the floor. Staff tried to put him in his wheelchair but he would fall out of the chair and was observed with a skin tear to his right elbow. He kicked the door and trash can in his room. He was offered a snack and to watch a movie. The supervisor was notified of the behavior. -2/28/25 at 9:58 a.m., a nurse tried to enter the secured unit and when going through the door, the resident told the nurse to hold the door open so he could get out. After the door closed, the resident was upset and stated now he was stuck here. He was upset the nurse hadn't held the door open for him. He hadn't wanted to move away from the door as he was leaving and going back to his home. The nurse stayed with him while he stayed by the door and kept pushing on the handle and buttons on the key pad. An activity was offered and individual attention but were ineffective in changing the behavior. -At 8:55 p.m., Resident J was threatening to hit staff and had been found on the floor and mattress next to his bed. There were no interventions documented to respond to the behaviors. -At 10:17 p.m., the resident rolled around on his mat and refused assistance from staff to get back in bed or his chair. He told staff to leave him alone or he would punch them in the face. After an hour, the resident allowed staff to assist him back into bed. He had refused supper and assistance with care. He had been offered coffee and snack, coloring, and movie, but refused. A Psychiatric Nurse Practitioner (NP) progress note, dated 3/2/25, indicated the resident was seen for medication management. Staff reported aggression, agitation, and intermittent exit seeking. He was seen on the MCU where he was cooperative and had fair eye contact. He'd had a visitor who he indicated made him feel safe when they were present. Staff indicated his behaviors tended to worsen in the evening hours. The plan was to continue use of Risperidone (antipsychotic) for dementia with agitated and aggressive behaviors and increase medication if symptoms intensified. Staff were to provide 1:1 time, activities including card games, music, television and other activities as distraction. He was prescribed antianxiety medication (Ativan) 1 mg by mouth 2 times per day as needed for 14 days with follow up in 2 weeks. An activity report for dementia programming for the past 14 days was requested. The report provided by the Activity Director on 3/10/25 at 1:45 P.M. was for the past 11 days. The report indicated Resident J was provided with no activities on 2/25, 3/1, and 3/2/25. He was offered and participated in activities the following days/times: 2/26, 2/27, and 2/28/25-2 activities during the day and none in the evening; 3/3 and 3/4/25- 1 activity during the day and none in the evening; 3/5 and 3/6/25-3 activities during the day and none in the evening; and 3/7/25- 2 activities during the day and none in the evening. There were no activities provided in the evenings when his behaviors usually worsened nor was his dementia care plan updated with new interventions related to his behaviors. 2. On 3/10/25 at 10:30 A.M., Resident K was observed seated at a table, in her wheelchair, with legs down on the pedals. She had a white/yellow colored substance on her teeth and lips, was fidgety, putting her hands in her hair, eyebrows furrowed and she making unintelligible noises. She was playing with the a short sleeve shirt she had on and was observed with multiple bruises on her forearms. A Certified Nurse Aide (CNA) was observed to sit next to the resident and attempted to make small talk with her. When asked, the CNA indicated she hadn't known who the resident was because it had been her first day back after an extended leave. The CNA got up from the table and went to help another resident. The resident continued fidgeting with her clothing, removed her shirt, looked at it and put it back on. She remained fidgety, moving around in her wheelchair and muttering to herself. No staff were seen in the area. -At 11:28 A.M., Resident K remained in her wheelchair with her legs down on the pedals, at the same table she was observed at earlier. The white/yellow colored substance remained on her teeth and lips. A staff member placed a plate of food in front of her. She then pushed the food away across the table. She continued to be fidgety, playing with her clothes and attempting to remove her shirt. Her table mates kept telling her not to remove her clothes. The nurse tried to put the plate of food back in front of the resident but she pushed it away. The resident indicated she wanted to go lie down and didn't want any lunch. She was removed from the table and taken back to her room to lie down. -At 1:15 P.M., Resident K was observed lying in bed on her left side. Her eyes were closed and she appeared asleep. -At 3:32 P.M., the resident remained lying in bed on her left side. Licensed Practical Nurse (LPN) 2 went to the resident's room and asked her if she would turn over on her back. On 3/10/25 at 2:14 P.M., Resident K's record was reviewed. Diagnoses included dementia with behavioral disturbance, anxiety disorder, essential thrombocythemia (type of blood cancer) and venous and arterial ulcers on her lower legs/feet. A quarterly MDS assessment, dated 1/11/25, indicated the resident had severely impaired cognition. She had clear speech, was usually understood and was able to understand others when communicating. She had no mood indicators but had verbal behaviors and wandering 1-3 days during assessment. She required supervision with eating and oral hygiene; moderate assistance with dressing, personal hygiene, bed mobility and transfers; and maximal assistance with toileting. Care plans included: -1/7/25: the resident had severely impaired cognition and could have difficulty making her needs known. Interventions included: ask yes or no questions when communicating; provide mind-stimulating materials to keep mind active and provide a safe environment. -10/23/24: Resident K was dependent on staff for meeting her emotional, intellectual, physical and social needs due to physical limitations and cognitive impairments. Religious services and music were important to her. Interventions included: address the resident by her desired name; encourage staff to converse with her while providing care; encourage religious and music program attendance and provide escort to/from activities. -1/7/25: the resident used psychotropic medications due to dementia. Interventions included: observe/record occurrences of targeted behavior symptoms such as pacing, wandering, disrobing, inappropriate response to verbal communication, and aggression towards others. Resident K had no specific care plan for need to reside on a secured memory care unit or benefits of dementia care programming. An activity report for dementia programming for the past 14 days was requested. The report provided by the Activity Director on 3/10/25 at 1:45 P.M. was for the past 11 days. The report indicated Resident K was provided with no activities on 2/25, 3/1, and 3/2/25. She was offered and participated in activities the following days/times: 2/26 and 2/27/25-2 activities during the day and none in the evening; 2/28/25-1 activity during the day and none in the evening; 3/3 and 3/4/25- 1 activity during the day and none in the evening; 3/5, 3/6 and 3/7/25, the resident was provided 2 activities during the day and none in the evening. On 3/10/25 at 1:19 P.M., Registered Nurse 5 (RN) was interviewed. She indicated the MCU was her usual assigned hallway. When questioned, she indicated resident's were kept busy on the unit and provided with many activities daily. She opened a closet door filled with activity equipment and supplies and indicated staff were able to use these to keep residents engaged. There was no specific activity programming for residents on the dementia unit but they had a facility wide activity schedule on a white board facing the wall. The board was unable to be seen by staff or residents. When asked why there had been no activities on 3/10/25, she indicated on Mondays, several ladies went to the beauty shop so there were no activities on the unit until the afternoon when there would be church services. RN 5 was asked about resident behaviors on the unit and dementia interventions used to decrease them. She indicated staff documented behaviors however, there were no specific behavioral interventions other than re-direct and try and engage the resident in another activity. On 3/10/25 at 1:38 P.M., the dementia unit manager, LPN 7, was interviewed. She indicated there had been several changes in personnel at the facility, their dementia program was being reviewed and changes made. Residents were to be provided with dementia programming with activities and behavior modifications with dementia specific interventions. A current facility policy, titled Memory Care Program Philosophy and Memory Care Admission Criteria, was provided by the Administrator in Training (AIT) on 3/10/25 at 2:31 p.m. The policy indicated the following: Alzheimer's disease and related dementia disorders are relentless and irreversible .We believe that the quality of life for our residents is enriched when their days are filled with meaningful and enjoyable structured activity. We believe that this activity serves as a powerful coping mechanism in times of fear and stress .We believe that the behaviors displayed by Alzheimer's and related dementia disorders are caused by a progressive degeneration of the brain, and that these residents have very little control of their behavior. Based on this belief, we avoid reprimanding inappropriate behavior. We choose rather to modify the environment, change our expectations, and focus on intervention and redirection .It is the intent of LLV to admit residents to the memory care unit that meet the agreed upon criteria for a specialized dementia unit. This is to ensure that the resident's receive appropriate care regarding the cognitive impairment disease process .Resident should have a primary diagnosis of Alzheimer's or other related untreatable dementia, be a safety risk at home, elopement/wandering risk, and require close monitoring. Does not demonstrate danger to self or others. Communication skills and/or limited language does not prevent the resident from participating in the memory care program. Easily over-stimulated, responds best to 1:1 intervention and small groups. Behaviors are easily redirected through the use of intervention up to and including psychiatric consult, adaptive programming and treatments that are appropriate for admission. Display of behaviors that are unmanageable through therapeutic approaches or moderate medication would warrant an immediate care plan meeting to determine appropriateness of continued placement .Resident should be able to participate, even to a limited degree, in some aspects of self-care and program activities .Resident should be ambulatory whether this is walking without assistance or walking with an assistive device or wheelchair This Citation relates to Complaint IN00454576. 3.1-37

Based on observation, record review and interview, the facility failed to ensure a resident received appropriate oxygen therapy for 1 of 2 residents reviewed for respiratory care. (Resident 74). Findings include: During an observation on 9/26/22 at 11:18 AM, Resident 74 was in her wheelchair with oxygen at 3 liters per minute (LPM) on nasal cannula (tubing used to deliver oxygen through the nostrils) by her portable oxygen concentrator (a light, small and quiet device that allows you to receive supplemental oxygen). During an observation on 9/27/22 at 10:51 AM, Resident 74 was in her wheelchair with oxygen at 3 LPM via nasal cannula. During an observation on 9/28/22 at 9:57 AM, Resident 74 was in her wheelchair with oxygen at 3 LPM via nasal cannula. On 09/29/23 at 10:18 AM, Resident 74's record was reviewed. Diagnoses included chronic obstructive pulmonary disease (COPD), hypothyroidism, obesity, and a personal history of COVID-19. Resident 74's quarterly Minimum Data Set (MDS) assessment, dated 7/22/23, indicated the resident's Brief Interview for Mental Status (BIMS) score was 4 (severe impairment) and she was not interviewable. The resident's MDS indicated she wore oxygen. Resident 74's orders, dated 4/14/23, indicated she was to receive oxygen at 2 liters every shift related to COPD. Resident 74's care plan, last reviewed 7/27/23, indicated the resident had altered respiratory status with difficulty breathing related to COPD and the goal was she should have no complications related to her shortness of breath. One intervention, dated 4/14/23, indicated her oxygen settings should be via nasal cannula at 2 liter or more continuously or as needed. In an interview on 9/28/23 at 10:00 AM, RN 4 indicated Resident 74's flow rate was on 3 LPM, but the physician order indicated her oxygen flow rate should be at 2 LPM. In an interview on 9/28/23 at 10:12 AM, the Director of Nursing indicated Resident 74's physician order indicated the resident's oxygen flow rate should be at 2 LPM but her flow rate was on 3 LPM. A current policy titled Oxygen, revised 2/16/18, provided by the Administrator on 9/28/23 at 11:30 AM indicated the flow rate was to be set per the prescribed LPM of the physician. 3.1-47(a)(4)(5)(6)

Based on observation, interview and record review, the facility failed to ensure cookware was properly air dried and stored. 103 of 104 residents residing in the facility consume food from the kitchen. Findings include: During an observation with the Dietary Manager on 11/2/22 at 9:06 AM, metal pans used to contain food were observed stacked together on a storage rack. Upon separation of the pans, water dripped from each separated pan. During an interview with the Dietary Manager on 11/2/22 at 9:06 AM, he indicated the pans should be air dried prior to stacking. A current policy last revised 11/10/09 titled Handling Cleaned Equipment and Utensils indicated pots, pans and utensils should be air dried before being stored. 3.1-21(i)(3)

Based on observation, interview and record review, the facility failed to ensure care plans were updated to accommodate changes for 4 of 4 residents reviewed (Resident 19, Resident 40, Resident 53, and Resident 77). Findings include: 1. During a record review conducted on 11/2/22 at 11:21 AM, a Minimum Data Set (MDS) dated [DATE] indicated Resident 19 had diagnoses including COVID-19, non-pressure chronic ulcer of other part of right foot, unspecified severity, and peripheral vascular disease. An interview was deferred due to positive COVID-19 status. A physician's order dated 10/21/22 gave instructions to wash the right great toe and apply betadine for enzymatic debridement. The comprehensive care plan was reviewed and no records addressing care of a non-pressure ulcer of the foot were available for review. During an interview conducted with the Director of Nursing (DON) on 11/3/22 at 1:40 PM, the DON confirmed the right great toe ulcer was present and indicated the care plan should address the wound care. 2. During an interview with Resident 40 on 11/2/22 at 12:14 PM, Resident 40 indicated staff provided dressing changes to her foot. During a record review conducted on 11/2/22 at 12:16 PM, a Minimum Data Set (MDS) dated [DATE] indicated Resident 40 had diagnoses including diabetes mellitus type 2 without complications, pressure ulcer of other site, unspecified stage, and major depressive disorder. A physician's order dated 10/22/22 indicated Resident 40's left 5th toe and right great toe wounds should be washed with wound cleanser, rinsed, and treated with medihoney, covered with gauze, and wrapped with kerlix. The comprehensive care plan was reviewed and no records addressing a plan of care for the ulcers were available for review. During an interview conducted with the Director of Nursing (DON) on 11/3/22 at 1:40 PM, the DON confirmed the left 5th toe and right great toe ulcers were present and indicated the care plan should address the wound care. 3. During an observation on 11/2/22 at 1:40 PM, Resident 53 was observed sitting in her recliner with oxygen administered by a nasal cannula from an oxygen concentrator at the bedside. During a record review conducted on 11/3/22 at 11:48 AM, a Minimum Data Set (MDS) dated [DATE] indicated Resident 53 had diagnoses including end stage heart failure, pulmonary hypertension, and bradycardia. Oxygen was ordered to be administered at 3 liters per minute by nasal cannula. The comprehensive care plan was reviewed and no records addressing oxygen in the care plan were available for review. An interview on 11/3/22 at 4:48 PM with the DON indicated oxygen should be addressed in the care plan. 4. During an interview with Resident 77 on 11/2/22 at 10:15 AM, Resident 77 indicated he receives wound care and assistance with dressing, showering, and transferring in and out of his wheelchair. During a record review conducted on 11/2/22 at 4:25 PM, a Minimum Data Set (MDS) dated [DATE] indicated Resident 77 had diagnoses including Type 2 diabetes, unspecified fracture of lower end of right femur with routine healing, and muscle weakness. The MDS indicated Resident 77 received extensive assistance from staff to complete his dressing, grooming, hygiene, transferring and toileting tasks. A physician's order dated 10/21/22 indicated Resident 77's sacral ulcers should be washed with wound cleanser, patted dry and treated with santyl and bordered foam dressings. The comprehensive care plan was reviewed. Care plans pertaining to assistance with activities of daily living, such as hygiene and transfers, and wound care were not available for review. During an interview conducted with the Director of Nursing (DON) on 11/3/22 at 1:40 PM, the DON confirmed the right great toe ulcer was present and indicated the care plan should address the activities of daily living and wound care. A current policy titled Care Plans dated 11/28/16 indicated the comprehensive care plan should include measurable objectives and timeframes to meet a resident's medical needs and indicate services furnished to provide quality of care. 3.1-35(d)(2)(B)

Based on observation, record review and interview, the facility failed to ensure residents received appropriate respiratory care for 2 of 2 residents reviewed. (Resident 20 and Resident 53.) Findings include: 1. During an observation on 11/2/22 at 9:49 PM, Resident 20 was observed sitting in her wheelchair with oxygen administered by a nasal cannula (tubing used to deliver oxygen through the nostrils) from a portable oxygen tank attached to the back of her wheelchair push handles. The portable oxygen machine flow rate was set to deliver 2 liters of oxygen per minute. The oxygen pressure gauge indicated the tank was empty. A record review was conducted on 11/03/22 at 3:32 PM. The resident diagnoses included acute and chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease, unspecified systolic congestive heart failure, paroxysmal atrial fibrillation, cerebral infarction due to embolism of right middle cerebral artery and severe morbid obesity. Resident 20's quarterly Minimum Data Set (MDS) assessment, dated 8/10/22, was reviewed. The MDS indicated the resident has been on oxygen while a resident at the facility and would get short of breath while lying flat. A physician order, dated 7/8/22, indicated oxygen was ordered to be administered at 2 liters per minute nasal cannula continuous every shift related to chronic obstructive pulmonary disease. In an interview on 11/3/22 at 5:05 PM, the DON indicated when Resident 20 was assisted back to her room after breakfast the staff member should had hooked her oxygen tubing to her oxygen concentrator (a machine used to produce oxygen) at the bedside. The DON indicated the staff member should have checked the resident's portable oxygen tank to see if it needed refilled and refilled the tank as needed. 46756 2. During an observation at on 11/2/22 at 1:40 PM, Resident 53 was observed sitting in her recliner with oxygen administered by a nasal cannula (tubing used to deliver oxygen through the nostrils) from an oxygen concentrator (a machine used to produce oxygen) at the bedside. The oxygen concentrator was set to deliver 3 liters of oxygen per minute. The nasal cannula used by Resident 53 was not dated. A nasal cannula attached to a portable tank on Resident 53's wheelchair was dated 10/25/22. During a record review conducted on 11/3/22 at 11:48 AM, a Minimum Data Set (MDS) dated [DATE] indicated Resident 53 had diagnoses including end stage heart failure, pulmonary hypertension, and bradycardia. A physician's order, dated 10/7/22, indicated oxygen was ordered to be administered at 3 liters per minute by nasal cannula. In an interview on 11/2/22 at 1:42PM with Licensed Practical Nurse 2 indicated oxygen tubing should be changed and dated every seven days. A current policy titled Oxygen, last revised 2/16/18, indicated all portable tanks should be filled nightly and as needed, with levels assessed during hourly rounds and filled when needed. The policy also indicated oxygen tubing should be changed weekly on the night shift. 3.1-47(a)(6)

Based on record review and interview, the facility failed to ensure the care plan was followed for monitoring and documenting side effects and the effectiveness of psychoactive medication for 5 of 5 residents (Resident 3, Resident Resident 44, Resident 88, Resident 90, and Resident 205) reviewed. Findings include: 1. Resident 44's record was reviewed on 9/24/21 at 2:06 P.M. Diagnoses included, but were not limited to, [CONDITION(S)]. The Significant Change MDS (Minimum Data Set) assessment dated [DATE] indicated the resident was not interviewable. The Physician's Order dated 5/8/21 indicated give [MEDICATION(S)] (antidepressant) 20 mg (milligrams) 1 tablet 1 time a day. The Care Plan dated 11/4/20 indicated the side effects and effectiveness of Resident 44's antidepressant medication should have been monitored and documented every shift. The resident's record had no documentation the antidepressant medication's side effects and effectiveness had been monitored every shift. 2. The record of Resident 88 was reviewed on 9/23/21 at 3:50 P.M., indicated diagnosis included, but were not limited to, [CONDITION(S)], hallucinations and anxiety. The Annual MDS assessment dated [DATE] indicated the resident was not interviewable. Resident 88's Physician's Order indicated, but were not limited to, the following: Order dated 1/2/20 [MEDICATION(S)] 10 mg give 1 tablet 2 times a day for depression. Order dated 12/11/20 [MEDICATION(S)] 12.5 mg give 1 tablet 2 times a day for hallucinations. Order dated 4/28/21 [MEDICATION(S)] 10 mg give 1 tablet 2 times a day for anxiety. The resident's care plans indicated: The antidepressant care plan dated 3/24/20 included, the side effects and effectiveness of the medication [MEDICATION(S)] should have been monitored and documented every shift. The [CONDITION(S)] care plan dated 11/25/20 included, the side effects and effectiveness of the medication [MEDICATION(S)] should have been monitored and documented every shift. The anti-anxiety care plan dated 12/3/19 and revised on 4/29/21 included, the side effects and effectiveness of the medication [MEDICATION(S)] should have been monitored and documented every shift. The Record of Resident 88 had no documentation the antidepressant, the [CONDITION(S)] and the anti-anxiety medication's side effects and effectiveness had been monitored every shift. 3. The Record of Resident 90 was reviewed in 9/28/21 at 3:42 P.M., indicated diagnosis included, but were not limited to, [CONDITION(S)] with delusions. The Quarterly MDS assessment dated [DATE] indicated the resident was interviewable. Resident 90's Physician's Order dated 5/12/21 indicated, give [MEDICATION(S)] 0.25 mg give 1 tablet by mouth one time a day and [MEDICATION(S)] 0.5 mg give 1 tablet at bedtime. The resident's [CONDITION(S)] care plan dated 11/10/20 and revised on 5/13/21 indicated the side effects and effectiveness of the medication [MEDICATION(S)] should have been monitored and documented every shift. The Record of Resident 90 had no documentation the [CONDITION(S)] medication's side effects and effectives's had been monitored every shift. 4. On 9/27/2021 at 3:35 p.m., the record for Resident 3 was reviewed. Diagnoses included but were not limited to [CONDITION(S)], [CONDITION(S)] [CONDITION(S)], pacemaker, cerebral infarction (a stroke) with [CONDITION(S)] and [CONDITION(S)] affecting dominant side, [CONDITION(S)], dementia with behavioral disturbances, anxiety disorder, [CONDITION(S)], and long term use of anticoagulant (blood thinner.) The MDS (Minimal Data Set) assessment dated [DATE] indicated Resident 3's BIMS (Brief Interview for Mental Status) was 03/15, which indicated severe cognitive impairment. The current physician orders for Resident 3 indicated they were to receive [MEDICATION(S)] 2.5 mg (milligram, a dose measurement) by mouth 2 times a day for [CONDITION(S)] started on 6/25/2020. Resident 3 was also to receive [MEDICATION(S)] 20 mg by mouth 1 time a day for sexual behaviors started on 3/11/2021 and [MEDICATION(S)] 0.25 mg by mouth 2 times a day for unspecified dementia with behaviors disturbance started on 9/8/2020. The MAR (Medication Administration Record) dated August 2021 indicated Resident 3 had received [MEDICATION(S)] 20 mg, 1 tablet daily everyday. They had also received [MEDICATION(S)] 2.5 mg, 1 tablet 2 times daily everyday and [MEDICATION(S)] 0.25 mg, 1 tablet 2 times daily everyday. The MAR dated September 2021 through 9/28/2021 indicated Resident 3 had received [MEDICATION(S)] 20 mg, 1 tablet daily everyday. Resident 3 had also received [MEDICATION(S)] 2.5 mg, 1 tablet 2 times daily everyday and [MEDICATION(S)] 0.25 mg, 1 tablet 2 times daily everyday. The current Care Plans were reviewed and indicated on 9/23/2019 Resident 3 used an antidepressant medications, [MEDICATION(S)] 20 mg related to depression and sexual dysfunction. The first intervention listed was to administer the antidepressant [MEDICATION(S)] as ordered by the physician, monitor, document side effects, and effectiveness every shift. A Care Plan dated 10/9/2020 indicated Resident 3 used [CONDITION(S)] medications, [MEDICATION(S)] 0.25 mg 2 times a day related to behavior management. The first intervention listed was to administer the [CONDITION(S)] medication as ordered by the physician and monitor for side effects and effectiveness every shift. A Care Plan for Resident 3 dated 1/21/2021 with revision on 6/15/2021 indicated to administer the anticoagulant medications as ordered by the physician, monitor for side effects and effectiveness every shift. Review of the Psychiatric Nurse Practitioner progress note dated 7/7/2021 indicated resident was seen following a physical altercation with a peer. Resident 3 had a history of dementia with behaviors, anxiety, depression, [CONDITION(S)] and sexual dysfunction and was not having new health problems. Resident 3's memory is poor with a BIMS of 3. Resident 3 is to continue on [MEDICATION(S)] for dementia with behaviors, [MEDICATION(S)] for sexual dysfunction and to monitor for signs of agitation and aggression. Review of the Psychiatric Nurse Practitioner progress note dated 9/8/2021 indicated the assessment and plan for dementia with behaviors was for Resident 3 to receive [MEDICATION(S)] and [MEDICATION(S)] for sexual dysfunction for behaviors related to dementia. The medication is effective and will continue to monitor. Review of Resident 3's MAR/TAR (Treatment Administration Record) and records indicated the documentation was lacking for monitoring side effects and effectiveness for [MEDICATION(S)], [MEDICATION(S)] and [MEDICATION(S)] every shift. An interview with the DON (Director of Nursing) on 4/28/2021 indicated the residents were monitored for 14 days every shift after a change in medication dose. The documentation was by exception. She indicated Resident 3 was monitored for any signs and symptoms of increased behaviors related to a dose reduction of the [MEDICATION(S)] for 14 days. The DON provided the Physician Order dated 2/18/21. Review of the February 2021 MAR for monitoring and documenting any signs and symptoms of increased behaviors due to GDR (Gradual Dose Reduction) of [MEDICATION(S)] for 14 days every shift related to dementia with behavioral disturbances started on 2/18/2021, was found Resident 3's MAR lacked documentation for monitoring on 2-21-2021 evening shift, 2/27/2021 evening and night shift and 2/28/2021 evening and night shift. 5. On 9/28/2021 at 10:52 a.m., the clinical records for Resident 205 were reviewed. Diagnoses included but were not limited to [CONDITION(S)], congestive heart failure, chronic obstructive pulmonary disease, history of pulmonary embolism, major depressive disorder, and long term use of an anticoagulant. The most current MDS assessment dated [DATE] for a discharge with an anticipated return indicated Resident 205's BIMS score was 12/15 which indicated resident was cognitively intact. The current Physician's orders for Resident 205 indicated they were to receive [MEDICATION(S)] (an blood thinner) 5 mg 1 tablet by mouth 2 times a day was ordered on 10/10/2020. Resident 205 was also was to receive [MEDICATION(S)] (a diuretic, water pill) 1 mg by mouth daily for congestive heart failure, ordered on 12/20/2019, [MEDICATION(S)] (an antidepressant) 50 mg 1 tablet by mouth daily for depression. Review of the MAR for August 2021 indicated Resident 205 had received the [MEDICATION(S)] 5 mg, 1 tablet 2 times a day everyday. Resident 205 had also received the [MEDICATION(S)] 1 mg, 1 tablet daily everyday, the [MEDICATION(S)] 50 mg, 1 tablet daily. Review of the MAR for September 2021 indicated Resident 205 was in the hospital from 9/5/2021 to 9/12/2021 in the evening and had received [MEDICATION(S)] 5 mg 1 tablet 2 times a day from 9/1/2021 to 9/5/2021 then 9/12/2021 evening dose to 9/28/21. Resident 205 had received [MEDICATION(S)] 1 mg tablet daily from 9/1/2021 to 9/5/2021 then 9/13/2021 to 9/28/21. Resident 205 had also received [MEDICATION(S)] 50 mg 1 tablet daily form 9/1/2021 to 9/5/2021 then 9/13/2021 to 9/28/21. The current Care Plan for Resident 205 were reviewed and indicated on 5/26/2021 Resident 205 used an antidepressant medications, [MEDICATION(S)] 50 mg related to depression. The first intervention listed was to administer antidepressant medications as ordered by the physician and monitor and document side effects and effectiveness every shift was initiated on 11/12/2019. A Care Plan initiated on 11/12/2019 and revised on 5/11/2021 indicated Resident 205 was on anticoagulant therapy, [MEDICATION(S)] 5 mg 2 times a day related to [CONDITION(S)] and to administer anticoagulant medications as ordered by the physician and monitor for side effects and effectiveness every shift. A Care Plan initiated on 11/12/2019 and revision on 7/9/2021 indicated Resident 205 was on diuretic therapy, [MEDICATION(S)] 1 mg for [CONDITION(S)] and CHF (Congestive Heart Failure), to administer the diuretic medication as ordered by the physician and to monitor for side effects and effectiveness every shift. On 9/28/21 at 2:50 P.M., the Director Of Nursing was interviewed and indicated the monitoring of [CONDITION(S)] medication's side effects and effectiveness were documented by exception. Review of a current facility policy, provided by the DON on 9/18/2021 at 4:28 p.m., titled, Medication Administration, had a revision date on 02/09/2018, indicated, .22. Residents will be monitored for medication side effects and documented in EMR (Electronic Medical Record) accordingly Review of a current facility policy, provided by the DON on 9/18/2021 at 4:28 p.m., titled, Care Plans, had a revision date on 11/28/2016, indicated, .B .6. Services provided or arranged by LLV (Lutheran Life Villages), as outlined by the comprehensive care plan, will be provided by qualified persons in accordance with each resident's written plan of care 3.1-48(a)(3)

Based on interview and record review, the facility failed to ensure activities of daily living were completed for 1 of 3 residents reviewed. (Resident B) Findings include: The record review for Resident B began on 9-23-2021 at 2:49 p.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set significant change assessment dated [DATE] indicated Resident B had a BIMS (Brief Interview for Mental Status) score of 5/15, which indicated the resident had severe cognitive impairment. Resident B needed an extensive assist of 2 persons for bed mobility, transfers, walk in room/corridor, toilet use and for personal hygiene. The resident required a limited assist of 1 person for locomotion on unit and an extensive assist of 1 person for locomotion off unit and dressing. A review of the shower/bathing task documentation indicated showers for Resident B were scheduled for Monday and Thursday mornings. A review of Resident B's shower/bathing documentation dated 9-2021 indicated he was showered on 9-2, 6, 9, 13, and 16-2021. A bed bath was documented for 9-20-2021. On 9-27-2021 at 9:50 a.m., Community Nurse Supervisor 12 provided the documentation for Resident B's showers/baths since admission. Dated June 2021, documentation for showers was on 6-10, 14, 17 and 21-2021. Resident B was transferred to the hospital on 6-25-2021 and returned on 7-2-2021. There was no documentation regarding showers/bathing during July 2021 and August 2021. An interview with Community Nurse Supervisor 12 on 9-27-2021 at 10:20 a.m., indicated she provided all the documentation for showers/bathing in Resident B's record. A care plan for Resident B indicated he required skilled rehabilitation and would maintain his current level of functioning in ADLs (Activities of Daily Living). Interventions for showers/bathing included check nail length, trim and clean on bath day and as necessary. Report any changes to the nurse. Provide a sponge bath when a full bath or shower could not be tolerated. A confidential interview indicated when Resident B was transferred to another nursing facility, it took the nurse over 2 hours to clean up the resident. A current policy, ADL - Bathing, dated 3-19-2018, was provided by the Chief Operating Officer on 9-28-2021 at 12:30 p.m. The policy indicated, .1. The following information should be recorded on the resident's ADL record and/or in the resident's medical record: 2. The date and time the shower/tub bath was performed. 3. The name and title of the individual(s) who assisted the resident with the shower/tub bath. 4. All assessment data .obtained during the shower/tub bath. 5. How the resident tolerated the shower/tub bath. 6. If the resident refused the shower/tub bath, the reason(s) why and the intervention taken. 7. The signature and title of the person recording the data This Federal tag relates to Complaint IN 138. 3.1-38(2)(A)

Based on observation, interview, and record review, the facility failed to ensure catheter care and outputs were completed for 2 of 2 residents reviewed with catheters. (Resident 58 and Resident 94) Findings include: 1. The record review for Resident 58 began on 9-28-2021 at 2:50 p.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS (Minimum Data Set) annual assessment dated [DATE] indicated Resident 58 had a BIMS (Brief Interview for Mental Status) score of 5/15, which indicated the resident had severe cognitive impairment. The resident required an extensive assist of 2 persons for bed mobility, dressing and toilet use. The resident was dependent on 2 persons for transfers and for locomotion off unit and was dependent on 1 person for locomotion on unit and personal hygiene. The resident was totally dependent on 1 person for bathing. The resident had an indwelling catheter. A review of current physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] Change the suprapubic catheter 18 French and catheter bag on night shift every 4 weeks on Fridays ordered on 7-9-2021. Cleanse suprapubic catheter site with Therawox wound cleanser BID (twice daily) ordered on 3-16-2021. Document the suprapubic catheter output every shift related to a personal history of [CONDITION(S)] (Urinary Tract Infection)ordered on 11-16-2020. Apply [MEDICATION(S)] ointment 500 unit/gram to the suprapubic catheter stoma topically every shift. Cleanse stoma and catheter with wound cleanser, apply a thin layer of [MEDICATION(S)] to stoma and cover the stoma area with a split sponge ordered 8-2-2020 and revised on 11-27-2020. [MEDICATION(S)] (used to prevent or control recurring urinary tract infections) tablet 1 gram was ordered on 2-22-2021 to give 1 tablet by mouth two times a day related to the personal history of urinary tract infections. No discontinuation orders were given at the time when the order revised on 2-22-2021. An undated order to irrigate the suprapubic catheter with 100 milliliters of sterile water as needed if the urine was cloudy or had an increase in [MEDICATION(S)]/blood noted in tubing every 24 hours. A review of Resident 58's September 2021 TAR (Treatment Administration Record) indicated there were several shifts with missing documentation for catheter care and urinary output amounts. The treatments for the suprapubic stoma site to apply [MEDICATION(S)] were not documented on day shift for 9-4, 5, 11, 25 and 27-2021. On evening shift documentation was lacking on 9-4, 5, 11, and 12-2021 and on night shift documentation was lacking on 9-7 and 9-9-2021. Suprapubic catheter care documentation was lacking on day shift for 9-4, 5, 11, and 25-2021 and for evening shift on 9-4, 5, 11, and 12-2021. On night shift, the care was not documented on 9-7-2021. Output documentation was lacking on day shift on 9-2, 4, 5, 11, 12, 13, 25, and 27-2021. On evening shift, the output documentation was lacking on 9-4, 5, 11, and 12-2021. On night shift, the output documentation was lacking on 9-7, 9, and 10-2021. A review of Resident 58's August 2021 TAR indicated there were several shifts with missing documentation for catheter care and urinary output amounts. The treatments for the suprapubic stoma site to apply [MEDICATION(S)] were not documented on day shift for 8-11, 15, 27, and 29-2021. On evening shift, documentation was lacking on 8-7, 22, and 28-2021 and on night shift documentation was lacking on 8-17-2021. Suprapubic catheter care documentation was lacking on day shift on 8-29-2021 and on evening shift, documentation was lacking on 8-7, 22 and 28-2021. On night shift, the care was not documented on 8-17-2021. Output documentation was lacking on day shift on 8-2, 9, 15, 20, 24, 28 and 29-2021. For evening shift, the output documentation was lacking on 8-7, 22, and 28-2021 and on night shift, the outputs were not documented on 8-4, 11, 14, 15, 17, 18, 22, and 27-2021. A review of the care plans indicated Resident 58 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Staff were to encourage extra fluids per the hydration program and needed to be aware the resident did not display typical signs and symptoms of infections. Resident 58's current care plan for suprapubic catheter due to a [CONDITION(S)] bladder had the following interventions, position catheter bag and tubing below the level of bladder. Change catheter bag monthly. Do not remove catheter and contact named urologist. Do not repeat UA C&S (urinalysis test and culture and sensitivity) unless resident was symptomatic. Symptoms include: increased WBC (white blood cells), fever, rigors, abdominal pain not related to loose stools or constipation, increased confusion other than regular confusion with resident, and blood in urine without a cause. Irrigate Suprapubic Catheter with 100 milliliters of sterile water if urine was cloudy or had increased [MEDICATION(S)]/blood noted in tubing per physician orders. Ensure suprapubic catheter was draining urine and notify physician for complications. Monitor and document for pain/discomfort due to the suprapubic catheter. Provide site care as ordered. Resident 58 was observed in his room on 9-21-2021 at 1:53 p.m. The resident was yelling out help and was observed in his [NAME] chair with the catheter bag under the chair and up off of the floor. 2. The record review for Resident 94 began on 9-24-2021 at 10:00 a.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS significant change assessment dated [DATE] indicated Resident 94's BIMS score was 5/15 which indicated the resident had severe cognitive impairment. The resident required an extensive assist of 1 person for bed mobility, walk in room, locomotion on/off unit, dressing, toilet use, and for personal hygiene. For transfers, the resident required an extensive assist of 2 persons and the resident required the physical help of 1 person for bathing. The resident had occasional incontinence of urine and was incontinent of bowel. The resident was marked as receiving hospice care. A review of Resident 94's progress notes dated 7-29-2021, indicated the hospice nurse notified the facility to anchor a Foley catheter. A review of the current physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The order indicated to change the Foley drain bag every month on the 27th on night shift. An order dated 7-29-2021 for Resident 94 was to cleanse around urinary opening during pericare with Theraworx every shift for catheter care. The order was updated on 9-28-2021 and indicated to wash with Theraworx or soap and water per the resident's preference. An order dated 7-29-2021 indicated to document the Foley catheter output every shift. An order on 9-25-2021 indicated to irrigate the Foley catheter with 100 milliliters of sterile water 3 times a day to keep urine flow and maintain patency. A review of the September 2021 TAR for Resident 94 indicated there were several shifts with missing documentation for catheter care and urinary output amounts. Catheter care documentation was missing on day shift for 9-5-2021, on evening shift for 9-4, 5, 9, 11, and 12-2021 and on night shift for 9-7 and 9-2021. Foley catheter output documentation was lacking on day shift for 9-4, 5, 9, 12, 13, 14, 20, 22, and 25-2021, on evening shift for 9-4, 5, 9, 11, and 12-2021 and on night shift for 9-7, 9, and 10-2021. A review of Resident 94's August 2021 TAR indicated there were several shifts with missing documentation for catheter care and urinary output amounts. Catheter care documentation was missing on the August TAR on 8-29-2021 for day shift and on evening shift, documentation was missing on 8-7, 22 and 28-2021. Documentation was lacking on night shift for 8-17-2021. Foley catheter output documentation was lacking on day shift for 8-2, 3, 5, 8, 12, 13, 15, 16, 18, 21, 26, 28, and 29-2021. For evening shift, urine output documentation for the August TAR was lacking for 8-7, 10, 22, 26, 28, and 29-2021 and on night shift the documentation was lacking for 8-4, 11, 14, 15, 17, 18, and 27-2021. A care plan was in place for the indwelling catheter for Resident 94 with the following interventions: Position catheter bag and tubing below the level of the bladder and away from entrance room door as able to. Change Foley catheter drainage bag monthly with catheter change every night shift starting on the 27th and ending on the 27th every month and as needed. Check tubing for kinks each shift. Cleanse around urinary opening during pericare with Theraworx every shift and as needed. Foley catheter output every shift for urinary output. Monitor/document for pain/discomfort due to catheter. An observation of Resident 94 on 9-28-2021 at 9:56 a.m., indicated the resident was in his bed and the bed was in low position. The catheter bag was observed hanging on the lower rung of the bed. A cover was observed over the bag. Nurse 11 was observed to perform catheter care. Nurse 11 was interviewed on 9-28-2021 after the catheter care was completed for Resident 94 at 9:56 a.m. Nurse 11 indicated if the documentation of the catheter care was not entered on the TAR, then the care was not done. An interview with the DON on 9-28-2021 at 12:45 p.m., indicated the nursing managers and MDS coordinators were responsible to audit documentation on the MARs/TARs to ensure the documentation was complete. A current policy, Urinary Catheters, dated 11-17-2018, was provided by the DON on 9-28-2021 at 2:58 p.m. The policy indicated, .It is the intent of named facility to ensure appropriate technique in the care and maintenance of Foley catheters .keep the collection bag off the floor .clean around the catheter daily with soap and water .document color and characteristics of urine and any urinary tract symptoms 3.1-41(a)(2)

Based on interview and record review, the facility failed to ensure ordered therapy and restorative services were provided for 1 of 2 residents reviewed. (Resident B) Findings include: The record review for Resident B began on 9-23-2021 at 2:49 p.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set significant change assessment dated [DATE] indicated Resident B had a BIMS (Brief Interview for Mental Status) score of 5/15, which indicated the resident had severe cognitive impairment. Resident B needed an extensive assist of 2 persons for bed mobility, transfers, walk in room/corridor, toilet use and for personal hygiene. The resident required a limited assist of 1 person for locomotion on unit and an extensive assist of 1 person for locomotion off unit and dressing. The assessment indicated there were no therapy services or restorative services being provided. 1. A review of physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Physical Therapy evaluated Resident B on 6-10-2021. Orders were for PT to be completed 5 times a week for 6 weeks for therapeutic exercises, neuromuscular re-education, gait training, and resident/family/staff education. Occupational Therapy evaluated Resident B on 6-10-2021. Orders were for OT to be completed 5 times a week for 8 weeks for activities of daily living, therapeutic activities, neuromuscular re-education, wheel chair management for increased self-care. A progress note dated 6-25-2021 indicated Social Services had called Resident B's daughter to inform her the last covered day for therapy services would be 6-27-2021 due to his hospitalization . Resident B was admitted to the hospital on 6-25-2021 and returned to the facility on [DATE]. The post discharge orders from the hospital dated 7-2-2021, indicated PT and OT were to evaluate and treat the resident. An interview with the Rehabilitation Manager on 9-27-2021 at 12:59 p.m., indicated she didn't think she knew Resident B had PT and OT evaluation orders when he returned from the hospital on 7-2-2021. She indicated she thought there was some issue about the resident not having skilled services. The Rehabilitation Manager indicated Resident B had a restorative program set up in August 2021. 2. A PT evaluation was completed on 8-4-2021 for Resident B. Orders were for PT to treat 5 times a week for 2 weeks for gait training, therapeutic exercises, therapeutic activities, neuromuscular re-education, fall prevention, care giver education. PT services were discontinued on 8-25-2021. An ambulation restorative program was established for Resident B on 8-17-2021 and the restorative nurse aide was educated on the program. A copy of the Restorative Services Transfer Form was provided by the Rehabilitation Manager on 9-27-2021 at 1:29 p.m. The reason for the transition to restorative services was the resident had reached his maximum level of function for skilled therapy services. An interview with MDS Nurse 9 on 9-28-2021 at 9:12 a.m., indicated she thought she had entered Resident B on the restorative list, but the MDS nurse indicated did not, thus the resident did not receive the restorative services. During an interview with the DON (Director of Nursing) on 9-28-2021 at 9:50 a.m., the DON indicated the MDS Nurse 9 informed her Resident B refused the restorative services, but the refusal was not documented in the resident's record. She indicated MDS Nurse 10 informed her when Resident B was admitted to the hospital on 6-25-2021, he was cut from insurance for skilled therapy services on 6-27-2021. When the resident returned to the facility on [DATE], the DON indicated his payer source was not for skilled services. The DON indicated the resident should have had the PT/OT evaluation completed regardless of payor source. The DON indicated if the resident would have required skilled therapy services, the therapy plan would have been submitted to the payer source for authorization. A current policy, Specialized Rehab Services, last revised on 4-3-2017, was provided by the COO (Chief Operating Officer) on 9-28-2021 at 12:30 p.m. The policy indicated, .Rehabilitative Services will be provided under an individualized written plan of care, initiated by written orders of the attending physician and developed by the appropriate therapists in consultation with the physician, nursing, resident, resident representative, support services and the IDT (Interdisciplinary Team) A current policy, Restorative Nursing, last revised on 2-3-2020, was provided by the COO on 9-28-2021 at 12:30 p.m. The policy indicated, .Residents will receive restorative nursing care as needed to help promote optimal safety and independence .Residents may be started on a restorative nursing program .when discharged from rehabilitative care .Restorative goals and objectives are individualized and resident-centered, and are outlined in the resident's plan of care .The resident or resident representative will be included in determining goals and the plan of care This Federal tag relates to Complaint IN 138. 3.1-23(a)(1)

Based on observation, interview, and record review, the facility failed to implement and maintain infection control practices to prevent the transmission of COVID-19 for 1 of 5 staff reviewed for screenings (Environmental Services 7) and for 1 of 4 residents in TBP (Transmission Based Precautions.) (Resident 51) Findings include: 1. Review of Resident 51's medical records on 9-1-21 at 12:21 p.m., indicated diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident 51's current MDS (Minimal Data Set) Assessment for admission, dated 8/16/2021 indicated a BIMS (Brief Interview for Mental Status) Score was 12/15 which indicated Resident 51 had moderate impairment of their cognition. Review of Resident 51's orders provided by the DON on 9-1-2021 at 12:21 p.m., indicated to monitor for signs and symptoms of COVID-19. Monitor temperature and oxygen saturation daily and signs and symptoms of COVID 19. The DON also provided an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON did not provide a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 9/24/2021 at 4:10 p.m., during observation of medication administration for Resident 51 in the Oak Terrace (Rehabilitation Unit), the QMA (Qualified Medication Aide) 5 was observed to be wearing an N95 mask and goggles. The QMA was observed to prepare medications for Resident 51. QMA 5 was observed to knock on Resident 51's closed room door, ask to come in and gave them their medications. Observation of Resident 51's closed room door had a sign taped to the door. The sign read, Contact Precautions .IN ADDITION TO STANDARD PRECAUTIONS .1. Perform hand hygiene. 2. Apply the below listed equipment in order. (Pictured on the sign was a gown, goggles and gloves.) 3. Before leaving the room, removed and discard the PPE in the Room. 4. Perform hand hygiene A PPE (Personal Protective Equipment) caddy was not observed near the TBP room for easy access for staff. QMA 5 entered the transmission based precaution (TBP) room and did not don a gown nor gloves. The QMA was observed to give Resident 51 their medications. Resident 51 requested a [Brand] supplement carton which was sitting on the over-bed table to be put in the refrigerator for them to have later. After assisting Resident 51 with their medications, QMA 5 discarded the medication cup and exited the room carrying the supplement carton. QMA 5 was observed to walk to the unit's kitchenette, opened the refrigerator and placed the supplement carton in the refrigerator and closed the door. As QMA 5 was walking out of the kitchenette, she turned around and opened the refrigerator, retrieved the supplement carton and obtained a marker and wrote the resident's name and date on the carton and returned to the refrigerator shelf. QMA 5 was interviewed at the time and indicated she was not aware the resident was in TBP room. As she looked at sign on Resident 51's closed door, QMA 5 indicated she had not seen the sign posted on the door and indicated she should have put on a gown and gloves before she entered the room. QMA 5 indicated she did not know why the resident was in TBP, she indicated she was only aware Resident 51 was hard of hearing and sometimes confused. She also indicated it was her first time to work the Rehabilitation Unit as she usually worked on the Memory Unit. QMA 5 indicated she did not know if the supplement carton should have been put in the refrigerator with other residents' food and beverages, but she would check. QMA 5 was observed to remove the labeled supplement carton from the refrigerator, ask the LPN (Licensed Practical Nurse) 4 and CNA (Certified Nursing Assistant) 6 why Resident 51 was in TBP and what she should to with the supplement carton. CNA 6 told QMA 5 to discard the supplement carton and to get a new one when the resident wanted it. An interview with LPN 4 on 9/24/2021 at 4:30 p.m., indicated it was the first time she had worked on Oak Terrace and did not know why the resident was on Contact Precautions. LPN 4 agreed the supplement carton should have been discarded. An interview with LPN 4 on 9/24/2021 at 4:36 p.m., indicated Resident 51 was in TBP because they were admitted from the hospital and had not been vaccinated for COVID-19. LPN 4 indicated the resident was on a 14 day quarantine. LPN 4 also indicated she had not noticed the type of TBP posted on Resident 51 room door, but indicated a gown and gloves should have been worn in the room with the N95 mask and goggles they already worn. LPN 4 indicated she had not noticed the TBP sign was not for Yellow Zone Precautions. LPN 4 indicated the PPE was on the table in from of the nurse's station for use on the unit. An interview with the DON (Director of Nursing) on 9-24-2021 at 4:46 p.m., indicated for Yellow Zone TBP, all PPE should be worn when in the room and discarded before leaving the room. She indicated Resident 51 was admitted from a hospital, discharged back to the hospital and readmitted back to the facility on [DATE] and should currently be in Droplet Yellow Zone TBP. She indicated resident had not been vaccinated for COVID-19. The DON indicated she would educated the staff right away on TBP and correct PPE to be worn. An observation with the DON on 9/24/2021 at 4:55 p.m., found the Contact Precautions sign posted on Resident 51's door. The DON indicated the wrong TBP sign was hung on the door. Observed the DON change the TBP sign on Resident 51's door to a Droplet Precautions sign, which indicated the need for gown, KN95 mask, face shield and gloves. The Droplet Precautions sign also indicated Yellow Zone Review of a current facility policy, provided by the Chief Operation Officer on 9/27/2021 at 12:40 p.m., titled IC (Infection Control) Transmission-Based Isolation Precaution Precautions, with a revision date if 2/12/2021 indicated, Standard Precautions shall be used when caring for residents at all times regardless of their suspected or confirmed infection status. Transmission-Based Precautions shall be used when caring for residents who are documented or suspected to have communicable diseases or infections that can be transmitted to others .Droplet Precautions In addition to Standard Precautions, implement Droplet Precautions for an individual documented or suspected to be infected with micro-organisms transmitted by droplets .Mask .wear a mask when working within 3 feet of the resident . The facility policy lacked the PPE needed to be worn for Droplet TBP. Review of a current facility policy, provided by the Chief Operation Officer on 9/27/2021 at 12:40 p.m., titled, IC COVID-19 Infection Control, with a revision dated of 7/23/2021, indicated, .LLV (Lutheran Life Villages) will respond promptly upon suspicion of illness associated with coronavirus (COVID-19) in efforts to identify, treat, and prevent the spread of the virus. LLV will follow guidelines outlined by CDC (Centers for Disease and Control), CMS (Centers for Medicare and Medicaid), ISDH, and the local health department. LLV will utilize the ISDH Guidelines as an extension to our policy .General COVID-19 IC for LTC (Long Term Care) . 3. LLV will actively screen all HCP (Health Care Personnel), visitors, vendors entering the facility for symptoms, of COVID-19 and any history of being a close contact or exposed to COVID-19 positive or symptomatic person .Unknown COVID-19 Status (Yellow Zone) - All residents in this category warrant TBP (droplet and contact). HCP will wear single gown per resident, glove, N95 mask and eye protection (face shield or goggles) Gowns and gloves should be changed after every resident encounter with hand hygiene performed 2. The COO (Chief Operating Officer) provided COVID-19 screening information on 9-28-2021 at 12:30 p.m., for EVS 7 (Environmental Services) for the scheduled days worked from 9-22-2021 through 9-28-2021. EVS 7 was screened according to her schedule except for 9-22-2021. An interview with the COO on 9-29-2021 at 9:00 a.m., indicated EVS 7 worked on 9-22-2021 and there was not a COVID-19 screening for her. During an interview with the COO on 9-29-2021 at 11:05 a.m., the COO was asked how the facility ensured all staff were screened for COVID-19 prior to working their shift. The COO indicated the Administrator will select random staff and the corporate office will audit the time cards versus the screenings. The COO indicated she had not been aware staff screening had been an issue with the random audits. An interview with CNA 8 (Certified Nurse Aide) on 9-29-2021 at 2:36 p.m., indicated when she worked at the facility, she was screened each time at the front entrance with the electronic system which asked about COVID-19 signs and symptoms and obtained her temperature. CNA 8 was asked if she ever forgot to get screened and she indicated no, as there was always a staff member observing at the screening station by the front door. An interview with the Director of Environmental Services on 9-30-2021 at 3:04 p.m., indicated staff working in healthcare would enter the Healthcare entrance and would be screened at that entrance for COVID-19 signs and symptoms. He indicated the Assisted Living had an entrance where staff could enter and be screened for COVID-19 signs and symptoms. The Director of Environmental Services was asked if there were any other entrances staff could use to gain access to the building. He indicated on second shift, the back area was accessible, but staff were to use the main Healthcare entrance. He indicated some staff may have a key to enter one of the doors in the back area, but they would then go directly to the Assisted Living entrance to be screened. An interview with EVS 7 on 10-1-2021 at 10:00 a.m., indicated she usually entered the building at the Healthcare Entrance or the Assisted Living entrance to be screened. She indicated she must have forgot to get screened one time. She indicated she didn't know why she forgot. A current policy, COVID-19 Prevention & Response, revised on 5-13-2021, was provided by the COO on 9-29-2021 at 1:27 p.m. The policy indicated, .LTC (Long Term Care) facilities should take everyday preventative measure to help contain the spread of COVID-19 .a. Actively screen all HCP (Healthcare Providers) .entering the facility for symptoms of COVID-19 and any history of being close contact or exposed to COVID-19 positive or symptomatic person 3.1-18(a)

Based on observation, record review, and interview, the facility failed to ensure maintenance was completed for of rooms observed, and for 1 of 1 water fountain removal site observed. (Room 110, Room 113, Room 118, Room 315, and Room 419) Findings include During an observation in room 315 on 6/29/21 at 2:45 P.M., when the bed from the wall, there was a hole in the dry wall toward the window corner. The hole was approximately 8.5 x 6 inches; the dry wall below the hole but right above the baseboard appeared to be bulging. Along the top of the baseboard and toward the front of the room, there were 2 more holes; one approximately 5 x 2 inches and the other approximately 5 x 1.5 inches. A land line phone jack was observed to still have the old phone cord bunched up and attached to the jack box. Approximately 1/4 inch of the wire coating was gone to reveal colored wires. The black wire appeared to have split open about 1/4 inch. The air conditioner unit, hanging on the corner above the resident bed, had a remote on a cord coming down from it. The cord going into the remote control was missing approximately 1/4 inch of the wire coating revealing colored wires. The purple wire was disconnected and sticking out. On the wall to the right of the bathroom door, the night light cover was noted to be too small for the opening in the dry wall. Light was shining through the top of the cover to reveal rough cut drywall above the cover. During an interview on 6/29/21 at 2:50 P.M., the resident indicated she had reported the phone jack cord to the maintenance department and they said it was not live and would not hurt her. She indicated she could trip on the bunch of cord attached to the jack. She indicated the hole in the drywall had been there a long time. During an observation on 6/30/21 at 10:00 A.M., room 419's night light cover was noted to be too small for the opening in the dry wall and light was shining through the top of the cover to reveal rough cut drywall above the cover. During an observation on 6/30/21 at 10:15 A.M., room 113's night light cover was noted to be too small for the opening in the dry wall and light was shining through the top of the cover to reveal rough cut drywall above the cover. Room 118's night light was noted to be too small for the opening in the dry wall and light was shining through the top of the cover to reveal rough cut drywall above the cover. During an observation on 100 hall, the wall across from room 110 had some tiles missing. The wall tiles were approximately 1 inch x 1 inch. An electrical plug had was noted to have 2 broken tiles to the right bottom of the plug, then 2 tiles over to the left; and 1 tile down, then 3 more tiles down and 2 more down below, for a total of 10 broken tiles. Above the plug, 2 tiles were broken at the 6th row above the plug, and 2 more at 8 tiles above the plug. A rag was observed to be stuffed into the broken tiles area below the plug. The last bottom broken tiles were next to sealed off piping. During an interview on 6/30/21 at 10:20 A.M., Employee B indicated there was a water fountain in the place of the broken tiles, it was taken out a while ago, and it's been in disrepair several months. During an interview on 6/30/21 at 10:25 A.M., the Administrator indicated the water fountain was taken down during Covid, maybe last fall, and that wall needed to be replaced. She indicated she was not sure if there was a work order for it but would find out. During an interview on 6/29/21 at 3:40 P.M., the Administrator indicated she had talked to residents every Friday, but the concerns with the holes in the drywall and phone cord were never mentioned. During an interview on 6/30/21 at 9:50 A.M., the Administrator provided a completed work order # for room 315-2 dated 6/25/21 with concerns of wall messed up- wires showing- toilet leaking. The work order indicated it had been completed on 6/29 at 9:32 A.M. The comments indicated Tighten up toilet and no wires showing, painting would be very difficult to do. During an interview on 6/30/21 at 11:00 A.M., Employees C and D were asked about environmental issues. Employee C indicated a resident had shown an issue with the phone cord in room 315 once, he had explained to her that the wires were very low voltage, there were no exposed wires, no cord was hooked up but a bundle of cord was tied up and out of her way. Employee C indicated the resident's bed had been in the same spot since she moved into the room so there was no way she could trip over the cord. Employee C indicated he was not aware of the hole in the drywall, but he did see the wall by the bed had some rough areas that needed to be painted. Employee C indicated the night light spaces were cut out to big for the covers when the building was built some [AGE] years ago and they had always been that way. He indicated they could be adjusted. Employee C indicated there was not a work order for the 100 hall water fountain because they kept having a leak from it during Covid, and due to Covid no vendors had been as allowed in. Employee C indicated the plug in that location was new, was an active live plug for housekeeping to use,but the sewer line and water line had been capped off. Employee C indicated the previous maintenance employee contacted someone last month about the wall but there was not any documentation to follow up of the issue. The facility's policy titled Physical Safe Environment, revised 4/3/17, indicated ll. Definition of Terms Adequate Lighting: means levels of illumination suitable to tasks the resident chooses to perform . Comfortable Lighting: means lighting that minimizes glare and provides maximum resident control, where feasible, over the intensity, location, and direction of illumination so that visually impaired residents can maintain or enhance independent functioning. Environment: any environment at LLV that frequented by residents, including (but not limited) to residents' rooms, bathrooms, hallways, . Orderly: is defined as . physical environment that is neat and well-kept. lll. Procedure . 2. LLV will provide a safe, clean, comfortable, and homelike environment. A. This includes ensuring that the resident can receive care and services safely and that the physical layout of LLV maximizes resident independence and does not pose a safety risk. 3. LLV will provide . maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. 6. LLV will provide adequate and comfortable lighting levels in all areas. 9. LLV will ensure that the facility, its equipment, and it grounds are maintained in a way that protects the health, safety, and welfare and rights of: residents, families, staff, and others. 10. Work orders shall be submitted to repair items, as needed, to maintain the facility, its equipment, and its grounds This Federal citation is related to Complaint IN 409. 3.1-19(e)

Based on observation, record review, and interviews, the facility failed to ensure nursing staff properly applied straps on a mechanical lift before transferring a resident, resulting in a fall with a hip fracture. This affected 1 of 3 residents reviewed for falls, Resident B. The facility also failed to ensure a resident was transferred following the nursing care plan with 2 staff members present, and failed to ensure the same resident was toileted in the shower room area as designated on the care plan. This affected 1 of 3 residents reviewed for falls, Resident C. Findings include: 1. During initial tour of the facility, on 6/29/15, at 9:53 A.M., LPN #2 indicated Resident B had been moved to the Rehab Unit recently because he had a fall resulting in a hip fracture. During initial tour of the Rehab unit, accompanied by RN #1, on 6/29/15, at 10:30 A.M., Resident B was observed lying in bed and told the RN he had pain in his right hip. The resident then indicated he had slipped out of a mechanical lift during a transfer because staff had not hooked the straps correctly. The electronic record for Resident B was reviewed, on 6/29/15, at 2:00 P.M. A nurse's progress note, dated 6/9/15 at 5:23 P.M., indicated, while at med cart writer herd (sic) a thud and resident yell out CNA informed writer that resident had fell out of the hoyer lift. upon (sic) entering room resident was laying on the floor, and on a leg of the Hoyer lift . The Director of Nursing Services (DNS) provided an investigation of Resident B's fall, on 6/29/15, at 3:00 P.M. The investigation, dated 6/9/15, was reviewed on 6/29/15 at 3:02 P.M., and indicated CNA #6 and BNA(Basic Nursing Assistant) #7 were preparing to transfer Resident B in the mechanical lift per his care plan and CNA assignment sheet. During the transfer, the resident slid out of the sling and fell to the floor landing on the base of the lift on his right hip. The resident was transferred to the hospital for a possible hip fracture. Upon investigation the CNA and BNA reported they hooked the resident up to the mechanical lift but did not cross the sling between his legs according to the manufacturer's instructions. When they went to transfer the resident he slid out of the sling. Both the CNA and BNA were given written warnings immediately due to no previous performance issues. Both were then educated on the proper use of mechanical lifts and where to find the manufacturer's instructions. The DNS was interviewed, on 6/29/15, at 3:25 P.M., and indicated instructions were attached to each Hoyer lift for staff to review. She indicated CNA #6 was new to the facility at the time of the incident, and was still in training. She indicated CNA #6 was supposed to be training with CNA #11. The DNS indicated CNA #6 was still in training and had not been checked off on transfers using the mechanical lifts. She indicated BNA #7 had been checked off on the skills check list for use of mechanical lifts. The DNS provided a skills checklist for BNA #7, on 6/29/15, at 3:25 P.M., which was reviewed at this time. The checklist was updated 12/16/2014 and indicated BNA #7 had initialed the checklist for positioning/transferring residents using the Sara lift and Maxi lift on 2/26/15. The DNS provided the Performance Reports, for CNA #6 and BNA #7, on 6/29/15 at 3:25 P.M. Both of the Performance Reports were regarding an incident which occurred on 6/9/15, and were dated as issued on 6/10/15. The Performance Reports were reviewed, on 6/29/15, at 3:30 P.M., and indicated CNA #6 and BNA #7 were given a written warning which indicated, A resident was improperly placed in a sling for transfer using a mechanical lift (full body lift). Improper placement of sling and the wheelchair not being in the proper position to transfer resident resulted in resident falling from the sling and sustaining a hip fracture. CNA #6 was interviewed, on 6/29/15, at 3:47 P.M., and indicated he was in training at the time of the incident, but had worked at another facility as a CNA for almost a year. He indicated he and BNA #7 had gone into Resident B's room, with CNA #11. He indicated CNA #11 then left the room to answer a call light, so he and BNA #7 proceeded to use a Hoyer lift to get the resident up for dinner. CNA #6 indicated when they applied the Hoyer straps to the lift, they failed to cross the straps between the resident's legs. He indicated BNA #7 also had to turn around to reach for the resident's wheelchair as it was not placed properly for the transfer. CNA #6 indicated he had assisted with another resident transfer using the same type of Hoyer lift at this facility, but had not been checked off on the skill's list for transfers using mechanical lifts at this facility. BNA #7 was interviewed, on 6/29/15, at 4:10 P.M. She indicated CNA #6 and CNA #11 had gone into Resident B's room to get him up for dinner, then BNA #7 had gone in to help. She indicated CNA #11 left the room but she was not sure why. She indicated she and CNA #6 hooked up the straps to the Hoyer lift, but neglected to cross the straps before transferring the resident causing the resident to slide out of the lift. She indicated she had to turn around to reach for the resident's wheelchair, and when she looked back, the resident was sliding out of the lift. She indicated she had received training, and been checked off on Hoyer transfers, and had used the same Hoyer before and was aware the straps had to be crossed when applied. LPN #8 was interviewed, on 6/29/15, at 4:25 P.M., regarding the incident. She indicated she was working the day of the incident, and heard a big thud. She indicated she entered the resident's room and the resident was laying on the floor on his right side, and his right leg was laying on the base of the Hoyer lift. She indicated she could tell the straps were incorrectly applied as soon as she entered the room. She indicated CNA #6 and BNA #7 were in the room with the resident. She indicated she told them they should not have been in the room alone transferring the resident. She indicated CNA#6 was a new employee and was supposed to stay with CNA #11 for training, and BNA #7 needed to take her test (for CNA certification.) The DNS provided a current policy for Mechanical Lifts, on 6/30/15, at 9:20 A.M. The policy was dated as revised on 3/15/13. The policy was reviewed on 6/30/15, at 9:30 A.M., and indicated the following: This procedure required 2 staff members, one would operate the lift and the other would guide the resident and sling into the chair. Both staff would communicate with each other through out the procedure to avoid sudden movements. The policy indicated, always follow manufactures guidelines for use. The DNS provided a Lift Operating Instructions form(undated) for transferring a resident from bed to chair, on 6/30/15, at 10:20 A.M. The policy was reviewed at this time and indicated the following: Attach sling to lift - Attach the loops by the patient's shoulders to the lift using the shortest loops. The instructions also indicated, Take the wing that is lying over the left leg and hook it on the right hook on the longest loop. Then take the wing lying over right leg, cross it over and hook it on the left hook on the longest loop. 2. The clinical record of Resident C was reviewed on 6/29/15 at 10:30 A.M. [DIAGNOSES REDACTED]. The Progress Note, dated 5/10/15 at 6:39 P.M., indicated Resident C was assisted to the bathroom in her room. The resident indicated she could not stand any longer and staff lowered the resident to the floor. The progress note indicated there was no injury to the resident. The at risk for falls due to decreased mobility and history of falls Care Plan dated 10/24/14 was updated after the resident fell on [DATE] with a new intervention to take Resident C to the toilet in the shower room. The at risk for fall care plan also indicated on 10/17/14 an intervention to transfer the resident with assist of 2 staff members. The Progress Note dated 6/20/15 at 6:58 P.M. indicated .while transferring, res (resident) stated her ankle buckled and fell on her buttocks. stated she did not hit her head. denies any injuries. assisted to w/c (wheel chair). On 6/29/15 at 4:00 P.M. the Director of Nursing Service (DNS) was interviewed and indicated on 6/20/15 CNA #9 had transferred Resident C by herself in the resident's bathroom. The DNS indicated Resident C was to be transferred with assist of 2 staff members and was to use the toilet in the shower room. The Progress Note dated 6/24/15 at 12:19 P.M. indicated Nurse called to residents (sic) room where resident had been placed on the floor during ambulation to toilet. resident noted to be sitting on bathroom floor in front of toilet leaning with her head on bar for standing assistance with both legs facing the doorway. Resident stated her leg buckled so she could not stand any longer causing CNA to lower and place the resident on floor in bathroom.Resident denies any pain/discomfort however she stated she thinks she may have hit her head. Nurse notified (Resident C's Physician's name) office and new orders rec'd (received) just to monitor resident neuros and call if condition worsens. On 6/29/15 at 3:30 P.M. interview with the DNS indicated CNA #10 had transferred Resident C to the toilet by herself. The DNS indicated Resident C was a 2 person assist with a transfer. This federal tag relates to complaint IN 454. 3.1-45(a)(2)

Based on interview and record review the facility failed to assess and treat 1 resident (Resident #90) diagnosed with [REDACTED]. This deficient practice resulted in a severe hypoglycemic reaction and subsequent hospitalization . Findings include: Review of the clinical record for Resident #90 on [DATE] at 8:48 a.m., indicated the following: [DIAGNOSES REDACTED]. Admission physician orders [REDACTED]. of ,[DATE] mg/dl, 8 units for blood sugars of ,[DATE] mg/dl, and 10 units for blood sugars of 300 mg/dl and above; Humalog insulin TID before meals with the sliding scale: 2 units for blood sugars of ,[DATE] mg/dl, 4 units for blood sugars of ,[DATE] mg/dl, 6 units for blood sugars of ,[DATE] mg/dl, 8 units for blood sugars of ,[DATE] mg/dl, 10 units for blood sugars of 300 mg/dl and above; and accucheck QID(four times a day) before meals and at HS. A physician order [REDACTED]. An assessment for Resident #90, dated [DATE] and written by the Nurse Practitioner, indicated her blood sugars routinely averaged between 92 mg/dl to 209 mg/dl, with an average of 127 mg/dl. The assessment also indicated to discontinue the insulin coverage and to continue to monitor her blood sugars. A physician order [REDACTED]. A Nurse Practitioner Progress Note for Resident #90, dated [DATE], indicated nausea during the past ,[DATE] months. A physician order [REDACTED]. A Progress Note for Resident #90, dated [DATE] at 12:04 a.m., indicated a chronic pain level of 0 out of 10 and an acute pain level of 0 out of 10. A Progress Note for Resident #90, dated [DATE] at 12:07 a.m., indicated her respirations were 18 per minute, a pulse oximeter of 97%, respirations even and unlabored, nail beds pink, no [MEDICAL CONDITION], and pulses equal bilaterally. A Progress Note for Resident #90, dated [DATE] at 12:10 a.m., indicated her pupils were equal and reactive to light, she moved her extremities, her pedal pulses were equal, her respirations were even and unlabored, and she was responsive to verbal stimuli. A Dietary Progress Note for Resident #90, dated [DATE] at 9:00 a.m., indicated the resident had vomited the day before and did not accept lunch or supper. A Progress Note for Resident #90, dated [DATE] at 9:56 a.m., indicated she was not feeling well with a complaint of abdominal pain. The note also indicated emesis (vomit) was on the bed and dried on the floor. Vital signs were, blood pressure of ,[DATE], pulse of 95, respirations of 20 per minute, and temperature of 96.8 degrees were noted and her oral mucosa was pink and moist. The note further indicated her blood pressure was elevated, but the resident had refused her blood pressure medicine the day before. The note also indicated the resident attempted to take all her medications, except for the [MEDICATION NAME], with small sips of water, but immediately vomited the pills and water into the trash can. The note indicated the resident was lethargic and refused to be cleaned up by aide. The note further indicated the writer informed the resident the Nurse Practitioner would be notified. The note indicated the Nurse Practitioner was notified and a new order was received to start [MEDICATION NAME] every 4 hours PRN for nausea and vomiting. The Nurse Practitioner did not give any new orders related to Resident #90's increased blood pressure, stating she would see her when she was on the floor where she resided. A physician order [REDACTED].<60 mg/dl if not able to swallow. A Progress Note for Resident #90, dated [DATE] at 10:12 a.m., indicated the resident's family member was called to the facility. A Progress Note for Resident #90, dated [DATE] at 11:04 a.m., indicated her family member was in the facility. The note also indicated Resident #90's breathing was shallow and labored with respirations at 22 and a blood pressure of ,[DATE]. No emesis was noted at the time. The note further indicated a new order was received by the Nurse Practitioner for STAT (immediate) labs. A physician order [REDACTED]. A Progress Note for Resident #90, dated [DATE] at 11:23 a.m., indicated she had a blood sugar reading of 58 mg/dl and glucose was administered. The note also indicated the resident was requesting ice water. She took a few sips and had emesis. A Progress Note for Resident #90, dated [DATE] at 11:30 a.m.., indicated she had a blood sugar of 49 mg/dl. The note also indicated the resident was unresponsive. The note further indicated [MEDICATION NAME] was administered. A Progress Note for Resident #90, dated [DATE] at 11:45 a.m.., indicated she had a blood sugar of 41 mg/dl. The note also indicated the Nurse Practitioner was notified. The note did not indicate additional glucose had been administered. A physician order [REDACTED]. A Progress Note for Resident #90, dated [DATE] at 12:16 p.m., indicated resident's family member was updated on resident's condition and verbalized understanding after explanation of CBC, BMP and CMP all ordered STAT, and accucheck to be done ac and HS for 1 week. A Progress Note for Resident #90, dated [DATE] at 12:25 p.m., indicated a blood sugar of 39 mg/dl. The note also indicated the resident was crying out in pain. The note further indicated the resident was agreeing to go to the ER. The note did not indicate additional glucose had been administered. A Progress Note for Resident #90, dated [DATE] at 1:58 p.m., indicated 911 was called. Oxygen was placed per nasal cannula for nursing measure. The note also indicated vital signs were attempted but the resident was calling out in pain, rocking back and forth. The note did not indicate additional glucose had been administered. A Progress Note for Resident #90, dated [DATE] at 2:08 p.m., indicated Resident #90 was sent to the hospital and the STAT labs were canceled. A late entry Progress Note for Resident #90, dated [DATE] at 3:05 p.m., indicated her skin turgor was checked, tinting (sic) noted, and eyes sunken. A report from the ambulance company, provided by the Corporate Nurse on [DATE] at 1:00 p.m., indicated the call was received from the facility on [DATE] at 12:26 p.m. and the ambulance arrived at the facility at 12:36 p.m. The report also indicated they arrived on the scene to hear Resident #90 screaming down the hallway. Staff reported the resident woke up from sleeping and started screaming saying her side hurt. Staff tried to get her to take medication and she was unable to keep them down. Staff stated she had not eaten or kept anything down in days. When checked her blood sugar was 39 mg/dl. Staff tried to get her to take oral glucose and was not able to get her to keep it down. Staff then gave her 3 mg [MEDICATION NAME]. The report further indicated Resident #90 was found sitting up screaming and rocking back and forth. They attempted to communicate with patient, however she would not respond to responders and was unable to be understood. The report also indicated attempts were made to check her blood sugar but the meter read "error" several times. An attempt was made to use the facility meter but it was not working as well. At 1:42 p.m., the ambulance had arrived at the hospital ER. A hospital report for Resident #90, dated [DATE], indicated she arrived in the ER unresponsive to painful stimuli. The report also indicated she was admitted in critical condition with a guarded prognosis. A facility care plan for Resident #90, with a start date of [DATE], indicated the problem area of diabetic alert. Approaches to the problem included, but were not limited to, diet as ordered, meds as ordered, labs as ordered, monitor for signs/symptoms of hypo/[MEDICAL CONDITION], glucose scan as ordered, if blood sugar <70 mg/dl give simple carbohydrates orally or give 1 tube glucose gel, and if unable or unwilling swallow give [MEDICATION NAME] 1 mg IM (intramuscular). A family member of Resident #90 was interviewed on [DATE] at 11:21 a.m. During the interview she indicated she was called into the facility on [DATE] when resident became ill. She also indicated resident was up in a chair in the lounge area when she arrived due to vomiting in her room. She indicated resident had been experiencing nausea and vomiting and was not eating. The family member indicated resident did not look well, was experiencing labored breathing, and did not recognize her. She indicated she requested her blood sugar be checked due to resident previously receiving insulin and now receiving the oral medication of [MEDICATION NAME] for her diabetes. The family member further indicated her blood sugar was checked by staff and was low. Resident was given something for her low blood sugar, but her blood sugar kept dropping. The family member also indicated resident then began screaming due to pain. The EMS was called and resident was admitted to the hospital in critical condition. Registered Nurse #1 was interviewed on [DATE] at 9:44 a.m. During the interview she indicated on [DATE], Resident #90 was not feeling well in the morning. The Nurse Practitioner was notified and STAT labs were ordered. She also indicated before the labs could be drawn, Resident #90 began to experience extreme pain and was immediately sent to the ER and admitted to the hospital. She further indicated Resident #90 had not been eating well and refused to take her medication at times. The Corporate Nurse was interviewed on [DATE] at 10:30 a.m. During the interview she indicated blood sugar levels should be documented in the progress notes for each resident. The Corporate Nurse was interviewed on [DATE] at 11:40 a.m. During the interview she indicated it was not automatically indicated to check the blood sugar of a resident who was not feeling well. She also indicated the nurse who took care of Resident #90 on [DATE], checked her blood sugar every 15 minutes according to facility policy on [DIAGNOSES REDACTED] until the order was received by the Nurse Practitioner to check her blood sugar after 30 minutes. She further indicated staff should have continued to follow the facility policy to check blood sugars every 15 minutes according to facility policy. The Nurse Practitioner was interviewed on [DATE] at 2:00 p.m. During the interview she indicated she had received a telephone call concerning the low blood sugar of Resident #90. She also indicated the resident was given glucose at 11:23 a.m., but had vomited. She further indicated she gave instructions to give Resident #90 glucose by another route and to re-check her blood sugar in 30 minutes. She indicated if Resident #90 had not been sent to the ER, she had planned to see her but had not been able to, due to the events happening so quickly. The Nurse Practitioner did not indicate why she instructed the facility staff not to re-check her blood sugar for 30 minutes after an alternative source of glucose was given. A current facility policy "Hyper/[DIAGNOSES REDACTED] Treatment", revised on [DATE] and provided by the Corporate Nurse on [DATE] at 10:00 a.m., indicated "...It is the policy of this facility to identify those residents with the potentiality of exhibiting signs/symptoms of hyper/[DIAGNOSES REDACTED] and provide effective nursing management of symptomalogy...[DIAGNOSES REDACTED] (low blood sugar)...generalized muscular weakness...diaphoretic...confusion...For [DIAGNOSES REDACTED] (low blood sugar)...check blood glucose level...If <70, provide simple carbohydrates, then call physician...Recheck blood glucose after 15 minutes...Re-treat if blood glucose if <70 mg/dl...Administer [MEDICATION NAME] if resident is unable or unwilling to swallow...." A current undated facility policy "Diabetes, Unstable or Potential for Instability", provided by the Corporate Nurse on [DATE] at 10:55 a.m., indicated "...[DIAGNOSES REDACTED]...rapid shallow respirations...unconsciousness...low blood sugar by finger stick...Monitor the resident's blood sugar immediately at any time that the resident shows signs or symptoms of diabetic crisis (decreasing level of consciousness, signs or symptoms of infection, increasing confusion or disorientation, rapid, shallow respiration, rapid, weak pulse, warm to hot, dry, flushed skin, increased thirst, deceased skin turgor)...Report abnormalities in blood sugar to the physician immediately and provide emergency treatment as indicated or ordered...Document/describe nursing actions and intervention...describe the resident's response to nursing intervention...." 3XXX,[DATE](a)

Based on record review and interview, the facility failed to ensure 1 resident (#149) of 6 residents who met the criteria for accidents was free of an accident which resulted in a fracture. Finding Includes: On [DATE] at 9:30 a.m. review of the closed clinical record for resident #149 indicated he was admitted to the facility on [DATE] and died on [DATE]. The resident was admitted with [DIAGNOSES REDACTED]. Review of the residents plan of care dated [DATE] indicated the resident was at risk for falls due to decreased mobility and history of falls. Review of the resident's incidents of falls on [DATE] at 10:00 a.m. indicated the resident had fallen on [DATE] at 2:30 p.m. and the facility had implemented monitoring the residents whereabouts and assisting with transfers. On ,[DATE]/ 11 at 3:30 p.m. the resident fell again and the facility implemented an alarming seat belt. Review of the clinical record indicated the resident had been in physical and occupation therapy since [DATE]. On [DATE] at 11:05 a.m. the resident fell and fractured his hip. Review of the "Incident Investigation Worksheet" dated [DATE] indicated the resident was trying to ambulate without help. Review of the "Fall Committee Review", which was not dated, indicated the resident had been in a recliner without a seatbelt on, which was the previous intervention. Interview with the Director of Nursing on [DATE] at 11:12 a.m. indicated when the resident fell and fractured his hip he had been seated in a recliner with his feet up. She further Indicated the nurse had been seated next to him, and got up to answer the phone. On [DATE] at 10:30 a.m. review of the "summary of the incident" indicated the resident was seated in a recliner in the lounge. The nursing supervisor had just taken a phone call from the residents daughter. The daughter had inquired if she could come and take the resident out of the facility around 1:00 p.m. The nursing supervisor went to ask the resident if he would like to go out with his daughter later in the afternoon and he replied it was okay. The nursing supervisor went back to the phone to give the response and heard a loud thud. Upon returning, found the resident lying on his left side on the floor of the lounge. 3XXX,[DATE](a)(2)