Every finding on record at Majestic Care of Avon

Based on observations, interviews, and record reviews, the facility failed to ensure sufficient staffing for the second quarter of 2025, sufficient staffing to prevent falls and to provide routine activities of daily living (ADLs), and sufficient staffing to address ongoing resident grievance concerns. This deficient practice had the potential to affect 80 of 80 residents who resided in the facility. Findings include:1. Based on the review of the Payroll Based Journal (PBJ) staffing data for the second quarter of 2025, the facility was identified by the Centers of Medicare and Medicaid Services (CMS) as triggering for excessively low weekend staffing. PBJ data showed staffing levels on weekends were significantly lower than weekday averages falling below required thresholds for nursing coverage. Insufficient weekend staffing had the potential to negatively impact residents by delaying assistance with activities of daily living, (such as toileting, bathing, and mobility) increased the risk for falls and skin breakdown due to reduced supervision and limiting timely responses to call lights and resident needs. Reduced availability of nursing staff on weekends had the potential to affect the accuracy of clinical assessments, medication administration, and monitoring of resident's health needs thereby placing residents at risk for avoidable decline in physical mental and psychosocial well-being. 2. Resident 80 sustained a fall with multiple major injuries during the evening shift on a Sunday in the triggered quarter, when weekend staffing was identified as insufficient, placing the resident at increased risk for harm due to limited staff availability for supervision and timely assistance. On 08/19/25 at 12:01 p.m., Resident 80's record was reviewed as a discharged closed record review. She had been a long-term care resident who resided on the secured memory care unit had had diagnoses which included, but were not limited to: unspecified dementia with moderate mood disturbance, psychotic disorder with delusion related to her know physiological condition and pseudobulbar affect. Her nursing progress notes were reviewed for the second quarter of 2025. She had multiple behaviors which included, but were not limited to, excessive wandering without purpose, excessive tearfulness, agitation, altercations with other residents and repeated falls. In April 2025 she had 5 falls. On 5/25/25 at 2:09 p.m., Resident 80 was given one of her as needed (PRN) medication due to agitation. Later that evening on 5/25/25 around dinnertime, Resident 80 had a fall and sustained a laceration to the back of her head. A nursing progress note, dated 5/25/25 at 6:22 p.m., indicated a nurse was called from a separate unit to the secured memory care unit, after Resident 80 had an unwitnessed fall. Upon the nurse's assessment, Resident 80 was found to have bleeding from the back of her head with a laceration which would require further evaluation. The resident was restless, therefore her vitals were unable to be obtained, and 911 was called. Resident 80 was sent to the emergency department. A nursing progress note, dated 5/26/25 at 5:04 p.m., indicated Resident 80 had been admitted to a local trauma hospital with a subarachnoid hemorrhage and rib fractures. The schedule for 5/25/25 evening shift was reviewed and revealed, at the time of Resident 80's fall, during dinner service, there was only one Qualified Medication Aide (QMA) and two Certified Nursing Aides (CNAs). During an interview on 8/22/25 at 8:34 a.m., the Administrator (ADM) indicated when he first started employment at the facility in February of 2025, one of the first quality assurance and improvement plans (QAPI) was to address the rate of falls. Falls were identified as a systemic concern with the peak of falls taking place in March 2025. At the time of Resident 80's fall, the unit was staffed according to census. The facility could not do one-to-one because we aren't reimbursed for it, and with almost 30 residents back there we've adjusted our staffing since then, so now we have three aides on the secured unit during day and evening shift especially with behaviors and sundowning. 3. Continued sufficient staffing concerns were identified throughout the survey period as evidence by identified concerns related to ADLs specifically, observations, interviews and record reviews to address and meet resident needs for grooming, hydration and dignity. During multiple observations conducted from 8/17/25 through 8/21/25, residents in the Memory Care (MC) unit did not consistently have beverages available at bedside, in their rooms, or in common areas. During an interview on 8/21/25 at 9:15 a.m., the Director of Nursing (DON) indicated they did not typically do an Ice-Water pass for memory care, but utilized a system called Hydration Station, where staff were supposed to bring out various types of beverages like lemonade, or ice water with fresh fruit in it etc. The pitchers were kept at the nurses' station for residents to see and be able to help themselves or get staff assistance as needed to keep up with fluids and hydration needs. On 8/21/25 at 9:32 a.m., [NAME] 5 indicated, Hydration Station had not been provided that week due to staffing shortages, lack of pitchers, and confusion over whose responsibility it was to ensure the beverages were prepared and delivered. Cross reference F677 and F807. 4. Continued sufficient staffing concerns were identified related to repeat grievances regarding laundry issues, snacks not being provided in the evening, and nursing staff having poor attitudes with none or insufficient follow-up and resolutions. On 8/20/25 at 3:10 p.m. a Resident Council meeting was conducted. There were 10 Residents in attendance. Residents 11, 16, 18, 21, 24, 84, 65, 67, 77, and 12. They all agreed when grievances had been filed in the past for these issues the facility didn't follow-up. All of the residents agreed there were still many times where they do not get snacks at the nurses' station or offered to them in the evenings. All of the residents agreed there were still issues with nursing staff having poor attitudes, being rude or mean and not providing proper care. Resident 12 indicated night shift nursing staff were mean, had poor attitudes and regularly told her, When I get there I'll get there. The residents indicated it took a long time for nursing staff to come when they would put their call light on. Resident 16 indicated she had gone up to the nurses' station to ask a question and she was told, go back to your room and put on your call light by nursing staff. During an interview on 8/22/25 at 10:38 a.m. the Administrator indicated when the grievance form got to him, he would look it over to see if everything was followed up on and make sure there was a resolution. If there wasn't a resolution, he would send it back to get more details. The Administrator indicated when residents had concerns about staff having poor attitudes or being rude to them, they would educate the staff and keep record of the education staff received in their employee files. Cross reference F565 On 8/21/25 at 10:00 a.m., the DON provided a copy of current facility policy titled, Activities of Daily Living (ADLs) dated 1/2/24. The policy indicated, . Care and services will be provided for the following activities of daily living: 1. Bathing, dressing, grooming and oral care. 3. Toileting. a resident who is unable to carry out activities of daily living will receive the necessary services to maintain food nutrition, grooming, and personal and oral hygiene. On 8/22/25 at 12:15 p.m. the DON provided a copy of a current facility policy titled, Incidents, Accidents & Supervision, dated 12/12/23. This policy indicated, . the resident environment will remain as free of accident hazards as possible. On 8/22/25 at 12:15 the DON provided a copy of a current facility policy titled, Grievances, dated 10/1/24. This policy indicated, .3. Definitions 'prompt efforts to resolve' include facility acknowledgement of a complaint/grievance and actively working towards resolution of that complaint/grievance.j. The facility will make prompt efforts to resolve grievances.

Based on observations and interviews, the facility failed to ensure all kitchen equipment was in proper working order. This deficient practice had the potential to affect 80 of 80 residents who ate meals in the facility.Findings include:On 8/17/25 at 1:36 p.m. an initial tour of the kitchen was conducted. The freezer was observed; the walls, fans and ceiling of the freezer had drips of water that had been frozen over, and boxes that had been pushed up against the wall had water damage on the cardboard, ice on top of the boxes and some boxes were frozen together.During an interview on 8/17/25 at 2:20 p.m. the Maintenance Director indicated the company they used had come out to fix the freezer on 8/4/25, but he thought the problem now was a small missing piece of weather stripping that could be causing the freezer to thaw.On 8/19/25 at 2:05 p.m. the Maintenance Director indicated the company they used would be there 8/21/25 to fix the weather stripping.On 8/22/25 at 12:15 p.m. the DON provided a copy of a current facility policy titled, Equipment, dated 9/2017. This policy indicated, .All food service equipment will be clean, sanitary, and in proper working order.3.1-19(bb)

Based on observation, interview, and record review, the facility failed to appropriately follow up to grievances made by individual residents and as a group during resident council for 12 of 12 months of resident council minutes reviewed and for 2 of 2 meetings with residents observed. Findings include:On 8/19/25 at 2:00 p.m. the Activities Director provided copies of Resident Council meeting minutes going back to August 2024.A Resident Council Minutes form, dated 8/8/24, indicated under old business there were no snacks on the weekends. One grievance was filed.A Resident Council Minutes form, dated 9/20/24, indicated under old business there were no snacks on the weekends and under new business there were five residents with missing clothes from the laundry, and they still were not getting snacks on the weekends, among other concerns.A Resident Council Minutes form, dated 10/16/24, indicated under old business there were no snacks at the nurses' station and under new business there were two residents with missing clothes from the laundry.A Resident Council Minutes form, dated 11/20/24, indicated under old business there were missing clothes and under new business there were still missing clothes among other concerns. Two grievances were filed.A Resident Council Minutes form, dated 12/18/24, indicated under old business they spoke about the previous months filed grievances and under new business there were three residents with missing clothes and there were concerns with not having snacks at the nurses' station or being offered among other concerns. Five grievances were filed.A Resident Council Minutes form, dated 1/22/25, indicated under old business they spoke about the previous months filed grievances, lost items and snacks and under new business there were concerns of clothes coming back from the laundry stained. A grievance was filed.A grievance form, dated 1/22/25, received by the Activity Director indicated Resident 93 had received laundry back with marker stains on them. The laundry department head was notified and in the section for review and action taken, a marker or pen went through the wash. Nothing else found. was written. In the section for follow up, marker or paints was sent laundry. Nothing else found. was written. This grievance form was signed off by the Administrator.A grievance form, dated 1/22/25, received by the Activity Director indicated Resident 92 had received laundry back with marker stains on them. The laundry department head was notified and in the section for review and action taken, a pen or marker was sent through wash. Nothing else found. was written. In the section for follow up, pen or marker was sent through was. Nothing else found. was written. This grievance form was signed off by the Administrator.A grievance form, dated 1/22/25, received by the Activity Director indicated Resident 8 had received laundry back with marker stains on them. The laundry department head was notified and in the section for review and action taken, a possible marker was sent through the laundry or paint. Nothing else found. was written. In the section for follow up, a marker or paints got sent through laundry. Nothing else found. was written. This grievance form was signed off by the Administrator.A Resident Council Minutes form, dated 2/19/25, indicated under old business clothing stains were resolved because they found out there was a marker that had accidently gone through the washer and various concerns under new business.A Resident Council Minutes form, dated 3/19/25, indicated under old business they spoke about appropriateness in the activity room and under new business there were concerns of not having snacks at the nurses' station. One grievance was filed.A grievance form, dated 4/5/25, received by an unknown staff member indicated Resident 61 feared an unidentified Certified Nursing Assistant (CNA) because the CNA answered her call light and asked why she had her light on. The resident told the CNA she needed a dry brief, the CNA asked the resident now? and the resident told the CNA yes because she was wet. The CNA then turned the call light off and left the room and did not come back. Resident 11 put her call light on again and a different CNA assisted her. The Director of Nursing (DON) was notified and in the section for review and action taken, Team member wrote up for violating company policy for code of ethics. Educated on policy & standard of care. was written. This grievance form was signed off by the Administrator.A grievance form, dated 4/5/25, received by an unknown staff member indicated Resident 56 had concerns with an unidentified CNA on evening shift having a poor attitude and being mean to her. The Director of Nursing (DON) was notified and in the section for review and action taken, Team member wrote up for violating company policy for code of ethics. Educated on policy & standard of care. was written. This grievance form was signed off by the Administrator.A grievance form, dated 4/10/25, received by an unknown staff member indicated Resident 17 had concerns with an unidentified nurse being rude and making him feel like he was being treated as less than human. The resident indicated the nurse came in while he was eating to give his medications, eye drops, and do a dressing change. He indicated the nurse did not explain what she was doing before she did it and was just rude. The Director of Nursing (DON) was notified and in the section for review and action taken, nurse educated on code of ethics & [NAME] care standards. Nurse was educated regarding time management regarding medication administration was written. This grievance form was signed off by the Administrator.A grievance form, dated 4/11/25, received by Licensed Practical Nurse (LPN) 11 indicated Resident 8 had received laundry back with marker stains on them. The laundry department head was notified and in the section for review and action taken, It was discovered through an investigation the marks were a result of crayons getting washed which was causing permeant marks was written. In the section for follow up, Resident has asked for item be replaced. was written. This grievance form was signed off by the Administrator.A grievance form, dated 4/12/25, received by an unknown staff member indicated Resident 95 had concerns with night shift staff refusing to help him shift in the bed. The Director of Nursing (DON) was notified and in the section for review and action taken, CNA interviewed & educated on code of ethics & reiterated job duties assigned upon hire date was written. This grievance form was signed off by the Administrator.A Resident Council Minutes form, dated 4/16/25, indicated under old business they spoke about snack concerns that were still not resolved and under new business there were concerns with not having snacks at the nurses' station, staff eating the snacks, staff being rude on night shift and missing clothes among other concerns. Five grievances were filed.A grievance form, dated 5/14/25, received by an unknown staff member indicated Resident 12 had concerns with some of the night shift CNAs being rude and not holding a high standard of cleanliness. The Director of Nursing (DON) was notified and in the section for review and action taken, spoke with all staff during quarterly staff meetings regarding code of ethics and facilities handbook. Educated night [shift] regarding professionalism. was written. This grievance form was signed off by the Administrator.A grievance form, dated 5/14/25, received by CNA 12 indicated Resident 96 had concerns with an unidentified CNA because the CNA told her to have an incontinent episode instead of using the bedpan because the CNA claimed to be too busy to put the resident on the bedpan. The Director of Nursing (DON) was notified and in the section for review and action taken, staff member educated on code of ethics & gave corrective action regarding standards of care & CNA roles/expectations. Educated on time management skills/expectations was written. This grievance form was signed off by the Administrator.A Resident Council Minutes form, dated 5/21/25, indicated under old business they spoke about the previous months filed grievances and about no snacks at the nurses' station. Under new business there were concerns with receiving clothing from the laundry that wasn't theirs and still not having snacks at the nurse's station. Three grievances were filed.A Resident Council Minutes form, dated 6/18/25, indicated under old business they spoke about snacks still being unavailable most of the time and under new business the word none was written. One grievance was filed.A grievance form, dated 7/18/25, received by an unknown staff member indicated Resident 34's family member had concerns with the amount of staff available, she indicated the facility needed more help on the weekends. Resident 34's family member also indicated the staff that they did have were not well trained and she felt they ignored the falls of residents. The Director of Nursing (DON) was notified and in the section for department findings, spoke with mother explained same staffing ratio is on the weekends versus weekdays educated on MOD schedule & ability to report any issues to them as needed. was written. In the section for follow up and resolution, nothing was written. This grievance form was signed off by the Administrator.A grievance form, dated 8/5/25, received by an unknown therapy staff member indicated Residents 21 and 16 had concerns with only being allowed one cup of coffee in the morning. The head of the Dietary department was notified and in the section for department findings, first of all, they're allowed to have more than one coffee. Not my fault if they don't come back to the kitchen to get more. was written. In the section for follow up and resolution, nothing was written. This grievance form was signed off by the Administrator.On 8/18/25 at 10:37 a.m. Food council was conducted. Resident 16 had concerns regarding dietary not giving hall trays big coffee pots at breakfast, the staff say they don't have them. The Dietary Manager indicated she would educate staff on using proper coffee pots. Several residents indicated the nursing staff did not want to give them more coffee. Resident 16 indicated she was told we have 12 people on this hallway you can't have more coffee by one of the CNAs.On 8/20/25 at 3:10 p.m. a Resident Council meeting was conducted. There were 10 Residents in attendance. Residents 11, 16, 18, 21, 24, 84, 65, 67, 77, and 12. All of the residents agreed there were still major issues with the laundry. They were still missing items, getting other residents' items, and receiving stained or ruined items. They all agreed when grievances had been filed in the past for these issues the facility didn't follow-up. When they did follow-up, they offered to replace the item but it had been months and the items were still not replaced. Resident 16 indicated she had a pillowcase missing and the facility offered to replace it 3 months ago and it still had not been replaced. Resident 12 indicated she had a sweatshirt missing and the facility offered to replace it 4 months ago and it still had not been replaced. The residents indicated they had stopped complaining about it because they felt it took too long for the issue to get resolved. All of the residents agreed there were still many times where they do not get snacks at the nurses' station or offered to them in the evenings. All of the residents agreed there were still issues with nursing staff having poor attitudes, being rude or mean and not providing proper care. Resident 12 indicated night shift nursing staff were mean, had poor attitudes and regularly told her, When I get there I'll get there. The residents indicated it took a long time for nursing staff to come when they would put their call light on. Resident 16 indicated she had gone up to the nurses' station to ask a question and she was told, go back to your room and put on your call light by nursing staff.During an interview on 8/22/25 at 10:28 a.m. the Social Services Director (SSD) indicated the process for grievance follow-up was: the resident or staff member who received the grievance would give the grievance form to him, he would make a copy of it and would give it to the appropriate department head. After they reviewed it, they filled out their portion of the form and gave it back to him, and he would give it to the Administrator to sign it off. The SSD indicated after the form was complete, he then put a copy of it in the grievances binder. He indicated the department head that reviewed the grievance was responsible for doing the follow-up. The SSD indicated it usually took about two weeks from when they get the grievance to follow-up or replace missing or ruined items. He indicated he did not know what they did if they had repeat grievances. The SSD indicated the follow-ups were not great and weren't really solutions, but if the Administrator signed it he went with it.During an interview on 8/22/25 at 10:38 a.m. the Administrator indicated when the grievance form got to him, he would look it over to see if everything was followed up on and make sure there was a resolution. If there wasn't a resolution, he would send it back to get more details. He indicated he thought the follow-ups he had seen were sufficient. The Administrator indicated when residents had concerns about staff having poor attitudes or being rude to them, they would educate the staff and keep record of the education staff received in their employee files.On 8/22/25 at 12:15 the DON provided a copy of a current facility policy titled, Grievances, dated 10/1/24. This policy indicated, .3. Definitions 'prompt efforts to resolve' include facility acknowledgement of a complaint/grievance and actively working towards resolution of that complaint/grievance.j. The facility will make prompt efforts to resolve grievances.3.1-3(g)

Based on observation, interview, and record review, the facility failed to ensure residents with dementia in the secured memory care unit received necessary assistance with activities of daily living (ADLs) for 11 of 20 residents who resided on the dementia unit (Residents 27, 14, 13, 76, 20, 9, 32, 59, 19, 51, and 64). Findings include:1. On 8/17/25 at 9:50 a.m., Resident 27 was initially observed with unshaven facial stubble, long fingernails, and his hair appeared greasy and unbrushed. Upon multiple observations from 8/17/25 through 8/20/25, Resident 27 remained unshaven, and appeared to have greasy, unbrushed hair and long fingernails. When his ADLs were inquired about, a certified nursing aide (CNA) took him to his room without resistance or refusals. When Resident 27 returned to the main activity room, his face was shaved, his nails were trimmed and his hair was neatly brushed back. Resident 27's shower sheets for the month of august were reviewed with one refusal on 8/16/25 but did not indicated if any redirections or follow up attempts were made. 2. On 8/17/25 at 9:51 a.m., Resident 14 was initially observed to have long fingernails, untrimmed sideburns, and days-old facial stubble. Upon multiple observations from 8/17/25 through 8/20/25, he continued with long nails and facial stubble. When his ADLs were inquired about, a certified nursing aide (CNA) took him to his room without resistance or refusals. When Resident 14 returned to the main activity room, his face was shaved and his hair was brushed, but his nailed remained untrimmed. 3. On 8/17/25 at 9:52 a.m., Resident 13 was initially observed to have long fingernails, long hair that was unbrushed and substantia facial stubble. Upon multiple observations from 8/17/25 through 8/20/25, he continued with long nails, facial stubble and unbrushed hair. On 8/19/25 at 10:21 a.m., Resident 13 was observed wearing fleece flannel patterned long pants, and a grey sweatshirt that appears to have green marked stains on it. There was a peeling piece of what appeared to be duct tape on the back right pocket of the pants as a label with his name. Upon multiple observations until the time of exit on 8/22/25, he remained in the same outfit. On 8/20/25 at 10:56 a.m., Resident 13's records was reviewed related to their ADL abilities and preferences. Resident 13's shower sheets for the month of August were reviewed. After 8/6/25, there was no documentation of an attempted shower until 8/18. The most recent Minimum Data Set (MDS) assessments for Resident 13 was considered severely cognitively impaired and required staff reminders, cues and assistance for personal hygiene and ADL care. The resident's Kardex (information pulled from their Facesheets and Care Plan Interventions) indicated, [Resident's name] needs staff assistance with personal hygiene that can fluctuate. The Care Plans lacked revisions to include and/or specify shaving and haircut preferences. 4. On 8/17/25 at 9:53 a.m., Resident 76 was initially observed to have long fingernails, day-old facial stubble, and unbrushed long hair. Upon multiple observations from 8/17/25 through 8/20/25, he was observed to remain unshaved and had unbrushed hair. 5. During an interview on 8/17/25 at 11:50 a.m., Resident 20's family member indicated it seemed like the facility staff relied on his family to continue to do all his ADL care. When Resident 20 first admitted , the family preferred to do most of his care while he transitioned into the new setting had adjusted to the unit, but now that he had been there for a while, it seemed like if the family didn't do his showers, or shaving, oral care etc. then it didn't get done at all. When the family visited that morning, it appeared he had not been shaved or had his clothes changed since the last time family had been in the week before. The family indicated Resident 20 had always been particular about his shaving and preference to stay clean shaven. During multiple observations from 8/17/25 through 8/19/25, Resident 20 was observed in the same outfit donned by his family on 8/17/25. Resident 20's shower sheets for the month of August were reviewed, and all indicated the family provided showers, except on 8/12/25 which indicated he refused. The refusal did not indicate if he refused family, staff, and/or if any redirection or follow up attempts were made. On 8/20/25 at 10:56 a.m., Resident 20's records were reviewed related to their ADL abilities and preferences. According to their most recent Minimum Data Set (MDS) assessments Resident 20 was all considered severely cognitively impaired and required staff reminders, cues and assistance for personal hygiene and ADL care. The resident's Kardex (information pulled from their Facesheets and Care Plan Interventions) indicated, [Resident's name] needs staff assistance with personal hygiene that can fluctuate. The resident's Care Plans lacked revisions to include and/or specify shaving and haircut preferences. 6. On 8/17/25 at 9:55 a.m., the bathroom in room [ROOM NUMBER] was observed with a soiled shirt and hospital gown left strown on the floor. On 8/17/25 at 9:56 a.m., room [ROOM NUMBER] was observed with dirty bundled up linen left piled on a chair and used gloves were discarded on the floor. 7. On 8/18/25 at 11:46 a.m., Resident 9 was observed. She wore a too-large yellow T-shirt with another resident's name, which was directly visible on the front collar of the shirt. She wore a pair of too-large pair of men's basketball shorts with Resident 27's name clearly visible on the leg of the pants. On 8/20/25 at 2:01 p.m., Resident 9 was observed wearing a too-large blue T-shirt labeled with another resident's name, which was directly visible on the front collar of the shirt. Again on 8/21/25 at 9:34 a.m., she was observed wearing the same blue shirt. 8. On 8/21/25 at 10:00 a.m. Resident 76 was observed in his room. He wore the same brown flannel long-sleeve shirt and jeans that he had been observed in for the previous three days. 9. On 8/18/25 at 11:02 a.m. Resident 51 was observed in the main activity room with several other of her peers. Her pants were observed pulled down to the middle of her thighs as if they had not been pulled all the way back up. When asked about her attire, three staff members approached her and loudly explained they needed to pull her pants up. They readjusted her in her seat and pulled her pants up in front of her peers instead of taking her somewhere more private. 10. On 8/18/25 at 10:28 a.m., Resident 64 repeatedly asked to go to the bathroom. The activity staff directed her to the nurse. The nurse was busy preparing medications and both aides were busy with other residents. Resident 64 waited over 20 minutes before she was assisted to the restroom. During an interview on 8/21/25 at 9:32 a.m., the Memory Care Unit Manager, (MC-UM) indicated, CNAs should complete resident's shaving needs as a part of their routine hygiene care and document if and when the resident refused and the same things would be true for resident clothing, hair and nail care. On 8/21/25 at 10:00 a.m., the DON provided a copy of current facility policy titled, Dementia Care dated 12/12/23. The policy indicated, It is the policy of this facility to provide appropriate treatment and services in relation to ADL care to residents on the dementia unit to ensure all ADL needs are met on a daily basis, while attaining or maintaining the dementia resident's highest practicable physical, mental and psychosocial well-being. 11. On 8/17/25 at 10:45 a.m. Resident 63 was observed lying in bed resting. The resident was wearing fleece pants, with a brief sticking out of the top of the pants and appeared to be unkempt. He had a long beard with hair that appeared unwashed. Resident 63 was not visibly soiled but a strong urine smell permeated the room getting stronger closer to the resident. On 8/18/25 at 12:01 p.m. Resident 63 was observed lying in bed watching TV. The resident was wearing a shirt and a brief but was mostly covered with a blanket. He had crumbs on his shirt and appeared unkempt with a long beard and hair that appeared to be unwashed. Resident 63 was not visibly soiled but a strong urine smell permeated the room getting stronger closer to the resident. On 8/20/25 at 2:44 p.m. Resident 63 was observed lying in bed resting with his eyes open, The Resident had on a shirt and was covered from the waist up by blankets. He appeared to be unkempt with a long beard and hair that appeared to be unwashed. Resident 63 was not visibly soiled but a strong urine smell permeated the room getting stronger closer to the Resident. On 8/20/25 at 11:40 a.m. Resident 63s medical record was reviewed. He was a long term care resident whose diagnoses included but were not limited to dementia and chronic Obstructive Pulmonary Disorder (COPD). A physicians note, dated 3/12/25, indicated Resident 63 was noted to have poor hygiene. A comprehensive encounter note, dated 5/19/25, indicated Resident 63 was incontinent of bladder and required encouragement to change his clothes. Resident 63s care plans were reviewed. An Activities of Daily Living (ADL) care plan, dated 7/25/25, indicated Resident 63 needed assistance with incontinent care and personal hygiene. An incontinence care plan, dated 4/12/23, indicated Resident 63 was incontinent of bowl and bladder and required routine checks for incontinence. During an interview on 8/20/25 at 2:58 p.m. Certified Nursing Aide (CNA) 9 indicated Resident 63 would only shower once a week and would only shower if she took him. On 8/22/25 at 10:30 a.m. the Director of Nursing (DON) provided copies of shower sheets for Resident 63 from April 2025 to August 2025. Based on shower sheets, in the month of April Resident 63 received 2 showers. A shower sheet, dated 4/4/25, indicated Resident 63 refused his shower. In the blank labeled .If refused, name of 2nd CNA attempting approach. there were initials. The blank labeled .If refused x2, name of nurse attempting approach. had no response. The blank labeled .If refused x3, name of family/POA notified. had no response. A shower sheet, dated 4/11/25, indicated Resident 63 refused his shower with tomorrow in parenthesis. The blank labeled .If refused, name of 2nd CNA attempting approach. had no response. The blank labeled .If refused x2, name of nurse attempting approach. had no response. The blank labeled .If refused x3, name of family/POA notified. had no response. A shower sheet for Resident 63 dated 4/18/25 was reviewed. The blank labeled .If refused, name of 2nd CNA attempting approach. indicated this was the second offer and that the resident said tomorrow. The blank labeled .If refused x2, name of nurse attempting approach. had 2nd and 5:50 written on it with nonsensical markings. The blank labeled .If refused x3, name of family/POA notified. had no response. A shower sheet, dated 4/22/25, indicated Resident 63 refused his shower with Said he was dizzy. Nurse told written on it. The blank labeled .If refused, name of 2nd CNA attempting approach. had no response. The blank labeled .If refused x2, name of nurse attempting approach. had no response. The blank labeled .If refused x3, name of family/POA notified. had no response. A shower sheet, dated 4/11/25, indicated Resident 63 refused his shower with tomorrow in parenthesis. The blank labeled .If refused, name of 2nd CNA attempting approach. had no response. The blank labeled .If refused x2, name of nurse attempting approach. had no response. The blank labeled .If refused x3, name of family/POA notified. had no response. A shower sheet, dated 4/23/25, indicated Resident 63 received a shower. A shower sheet, dated 4/25/25, Indicated Resident 63 received a shower. Based on shower sheets from the month of May Resident 63 received 2 showers. A shower sheet, dated 5/6/25, indicated Resident 63 refused his shower. The blank labeled .If refused, name of 2nd CNA attempting approach. had no response. The blank labeled .If refused x2, name of nurse attempting approach. had no response. The blank labeled .If refused x3, name of family/POA notified. had no response. A shower sheet, dated 5/9/25, indicated Resident 63 refused his shower. The blank labeled .If refused, name of 2nd CNA attempting approach. had no response. The blank labeled .If refused x2, name of nurse attempting approach. had no response. The blank labeled .If refused x3, name of family/POA notified. had no response. A shower sheet, dated 5/12/25, indicated Resident 63 refused his shower with He says took one by himself this morning written on it. The blank labeled .If refused, name of 2nd CNA attempting approach. had no response. The blank labeled .If refused x2, name of nurse attempting approach. had no response. The blank labeled .If refused x3, name of family/POA notified. had no response. A shower sheet, dated 5/13/25, indicated Resident 63 received a shower. A shower sheet, dated 5/14/25, indicated Resident 63 received a shower. A shower sheet, dated 5/16/25, indicated Resident 63 refused his shower. The blank labeled .If refused, name of 2nd CNA attempting approach. had no response. The blank labeled .If refused x2, name of nurse attempting approach. had no response. The blank labeled .If refused x3, name of family/POA notified. had no response. A shower sheet, dated 5/20/25, only had Resident 63s name and the CNA and nurse signatures written on it. A shower sheet, dated 5/23/25, indicated Resident 63 refused his shower with Refused x2 written on it. The blank labeled .If refused, name of 2nd CNA attempting approach. had no response. The blank labeled .If refused x2, name of nurse attempting approach. had no response. The blank labeled .If refused x3, name of family/POA notified. had no response. Based on shower sheets from the month of June Resident 63 received 2 showers. A shower sheet, dated 6/6/25, indicated Resident 63 refused his shower with Refused x3 written on it. The blank labeled .If refused, name of 2nd CNA attempting approach. had a signature. The blank labeled .If refused x2, name of nurse attempting approach. had no response. The blank labeled .If refused x3, name of family/POA notified. had no response. A shower sheet, dated 6/11/25, indicated Resident 63 received a shower. A shower sheet, dated 6/13/25, indicated Resident 63 refused his shower with Bed bath written on it. The blank labeled .If refused, name of 2nd CNA attempting approach. had refused written on it. The blank labeled .If refused x2, name of nurse attempting approach. had refused written on it. The blank labeled .If refused x3, name of family/POA notified. had refused written on it. A shower sheet, dated 6/27/25, indicated Resident 63 refused his shower with Refused x3 written on it. The blank labeled .If refused, name of 2nd CNA attempting approach. had no response. The blank labeled .If refused x2, name of nurse attempting approach. had no response. The blank labeled .If refused x3, name of family/POA notified. had no response. Based on shower sheets from the month of July Resident 63 received 2 showers. A shower sheet, dated 7/1/25, indicated Resident 63 refused his shower with Told me he will at 8:30. I went & got him and he yelled at me to go away because he was 'asleep'. written on it. The blank labeled .If refused, name of 2nd CNA attempting approach. had no response. The blank labeled .If refused x2, name of nurse attempting approach. had no response. The blank labeled .If refused x3, name of family/POA notified. had no response. A shower sheet, dated 7/2/25, indicated Resident 63 received a shower. A shower sheet, dated 7/4/25, indicated Resident 63 refused his shower with Wants one tomorrow. written on it. The blank labeled .If refused, name of 2nd CNA attempting approach. had no response. The blank labeled .If refused x2, name of nurse attempting approach. had no response. The blank labeled .If refused x3, name of family/POA notified. had no response. A shower sheet, dated 7/11/25, indicated Resident 63 refused his shower. The blank labeled .If refused, name of 2nd CNA attempting approach. had no response. The blank labeled .If refused x2, name of nurse attempting approach. had no response. The blank labeled .If refused x3, name of family/POA notified. had no response. A shower sheet, dated 7/15/25, had N/A written on it. The blank labeled .If refused, name of 2nd CNA attempting approach. had no response. The blank labeled .If refused x2, name of nurse attempting approach. had no response. The blank labeled .If refused x3, name of family/POA notified. had no response. A shower sheet, dated 7/22/25, indicated Resident 63 refused his shower. The blank labeled .If refused, name of 2nd CNA attempting approach. had no response. The blank labeled .If refused x2, name of nurse attempting approach. had no response. The blank labeled .If refused x3, name of family/POA notified. had no response. A shower sheet, dated 7/24/25, indicated Resident 63 received a shower. A shower sheet, dated 7/25/25, indicated Resident 63 refused his shower. The blank labeled .If refused, name of 2nd CNA attempting approach. had no response. The blank labeled .If refused x2, name of nurse attempting approach. had no response. The blank labeled .If refused x3, name of family/POA notified. had no response. A shower sheet, dated 7/29/25, indicated Resident 63 refused his shower. The blank labeled .If refused, name of 2nd CNA attempting approach. had no response. The blank labeled .If refused x2, name of nurse attempting approach. had no response. The blank labeled .If refused x3, name of family/POA notified. had no response. Based on the shower sheets provided for August up to 8/22/25 Resident 63 had not received a shower. A shower sheet, dated 8/12/25, indicated Resident 63 refused his shower with Refused. Said he was dizzy. written on it. The blank labeled .If refused, name of 2nd CNA attempting approach. had no response. The blank labeled .If refused x2, name of nurse attempting approach. had no response. The blank labeled .If refused x3, name of family/POA notified. had no response. On 8/21/25 at 10:00 a.m., the DON provided a copy of current facility policy titled, Activities of Daily Living (ADLs) dated 1/2/24. The policy indicated, The facility will, based on the resident's comprehensive assessment and consistent with the resident's needs and choices, ensure a resident's abilities in ADLs do not deteriorate unless deterioration is unavoidable. Care and services will be provided for the following activities of daily living: 1. Bathing, dressing, grooming and oral care. 3. Toileting. a resident who is unable to carry out activities of daily living will receive the necessary services to maintain food nutrition, grooming, and personal and oral hygiene. 3.1-38(a)(3)

Based on observation and interview, the facility failed to date pharmaceuticals, remove expired eye drops from the medication cart, and stored anti-itch topical cream with eye drops and oral tablets together for 3 of 3 medication carts observed.Findings include: On [DATE] at 11:21 a.m., the 600 hall medication cart was observed. Resident 77 had a vial of fluphenazine (Prolixin, used to treat schizophrenia) without a date to indicate when it was opened.Resident 47 had a bottle of refresh tears eye drops with no date to indicate when it was opened.Resident 75 had an albuterol inhaler without a date to indicate when it was opened.Resident 55 had an albuterol inhaler without a date to indicate when it was opened. RN 37 validated items were not dated and removed items from the medication cart.On [DATE] at 11:35 a.m., the 800 hall medication cart was observed. Anti-itch topical cream was stored beside eye drops and oral medications.On [DATE] at 11:50 a.m., the [DATE] medication cart was observed. Resident 42 had an albuterol inhaler (two of them) with no date to indicate when it was opened.Resident 64 had latanoprost eye drops (used to treat glaucoma) that was opened on [DATE] and expired.Resident 25 had incruse elpt inhaler 62.5mg with no date to indicate when it was opened.Resident 23 had atropine sulfate solution 1% with no date to indicate when it was opened. A policy titled Medication Storage was provided by the Director of Nursing (DON) on [DATE] at 11:04 a.m. It indicated, .External products: disinfectants and drugs for external use are stored separately from internal and injectable medications.

Based on observation, interview, and record review, the facility failed to ensure residents in the Memory Care unit had sufficient and accessible fluids made available throughout the day for 5 of 5 days observed on the Memory Care unit. This deficient practice had the potential to affect 20 of 20 residents residing on the Memory Care unit (Residents 32, 27, 59, 10, 19, 70, 28, 64, 74, 20, and 39). Findings include:During multiple observations conducted from 8/17/25 through 8/21/25, residents in the Memory Care (MC) unit did not consistently have beverages available at bedside, in their rooms, or in common areas. On 8/18/25 at 1:33 p.m., Resident 32 was observed. She approached the nurses' station, got a plastic cup from a stack on top of the cart, and used the pitcher of water designated for medication administration to pour herself a cup of water. She drank it all at once. She placed the cup and pitched back on the cart. On 8/18/25 at 1:37 p.m., Resident 27 approached the nurses' station and asked for water several times, before the nurse on the cart returned, and poured him a small plastic cup of water from the pitcher, which he drank all at one time. During an interview on 8/19/25 at 10:17 a.m., Resident 27 was at the nurses' station and requested a cup of water. On 8/19/25 between 10:17-10:56 a.m., multiple resident rooms were observed without fresh water at bedside. Resident 59's room contained multiple uncovered cups with old liquids and gnats on the rims. Resident 10 approached the nurses' station and asked repeatedly for a cup of ice. On 8/19/25 at 11:02 a.m., a family friend of Resident 19 came to the nurses' station and asked if residents were not allowed to have ice water in their rooms. He requested a cup of ice and a pen to get Resident 19 some water for his room. During an interview on 8/21/25 at 9:15 a.m., the Director of Nursing (DON) indicated they did not typically do an Ice-Water pass for memory care, but utilized a system called Hydration Station, where staff were supposed to bring out various types of beverages like lemonade, or ice water with fresh fruit in it etc. The pitchers were kept at the nurses' station for residents to see and be able to help themselves or get staff assistance as needed to keep up with fluids and hydration needs. On 8/19/25 at 10:42 a.m., random room checks revealed, Residents 59, 70, 28, 64, 32 and 27 had no fresh water in their rooms. There were no communal hydration options available at that time. On 8/19/25 at 10:21 a.m., random room checks revealed, Residents 59, 70, 28, 64 and 74 had no fresh water in their rooms. There were no communal hydration options available at that time. On 8/20/25 at 10:53 a.m., random room checks revealed, Residents 20, 28, 39, 27 and 32 had no fresh water in their rooms. There were no communal hydration options at that time. On 8/21/25 at 9:32 a.m., [NAME] 5 indicated, Hydration Station had not been provided that week due to staffing shortages, lack of pitchers, and confusion over whose responsibility it was to ensure the beverages were prepared and delivered. On 8/21/25 at 10:00 a.m., the DON provided a copy of current facility policy titled, Dementia Care dated 12/12/23. The policy indicated, It is the policy of this facility to provide appropriate treatment and services in relation to ADL care to residents on the dementia unit to ensure all ADL needs are met on a daily basis, while attaining or maintaining the dementia resident's highest practicable physical, mental and psychosocial well-being. 3.1-46(b)

Based on observation and interview, the facility failed to prevent the potential for accidents related to staff leaving personal items with unknown smoking substances in a resident's room who wore oxygen for 1 of 5 residents reviewed for the potential for accidents (Resident 35).Findings include:On 8/17/25 at 10:45 a.m. Resident 35 was observed as she lay in bed resting, there was an oxygen concentrator next to the bed that was running with oxygen tubing connected and draped on the bed next to the resident. The resident indicated she could not find her cellphone; upon observation of her room a cell phone was found plugged into a charging cable on the empty bed next to Resident 35. The Resident indicated the cell phone was not hers, it was Certified Nursing Aide (CNA) 7s. There was also a backpack sitting on a guest chair, the resident indicated she thought it was her daughter's and wanted to look inside to see if it was. When Resident 35 looked inside, she indicated there was a strong odor of marijuana omitting from the bag. The resident took out a notebook, and upon observation the notebook had CNA 7s name in it. All items were immediately placed back in the bag and the bag was placed back on the chair.During an interview on 8/17/25 at 2:00 p.m. the Director of Nursing (DON) indicated it would not be appropriate for staff to store their personal items in a resident's room. The DON indicated CNA 7 had been suspended pending a drug test.During an interview on 8/22/25 at 10:38 a.m. the Administrator indicated he and another staff member went into Resident 35's room to ask her about the incident with CNA 7 storing her personal belongings in her room. When they spoke to the resident they found a vaporized smoking device with unknown substances inside of it on the resident's chest.On 8/22/25 at 12:15 p.m. the DON provided a copy of a current facility policy titled, Incidents, Accidents & Supervision, dated 12/12/23. This policy indicated, . the resident environment will remain as free of accident hazards as possible.3.1-45(a)

Based on record review and interview, the facility failed to ensure a resident (Resident 89) received timely notification that his Medicare coverage was ending for 1 of 3 residents reviewed for Notice of Medicare Noncoverage (NOMNC). Findings include: On 8/18/25 at 11:25 a.m., Resident 89's NOMNC notice was reviewed.The NOMNC was dated 5/1/24 (sic, meant to be 2025). The form was signed by Resident 89's wife and legal representative the same day that his services ended.During an interview on 8/18/25 at 11:49 a.m., the Social Service Director (SSD) indicated NOMNCs should be issued at least two days before services end, so that residents had the opportunity to appeal if needed. Resident 89's representative requested that he be discharged on 5/2/25.Even at the resident/representative's request to discharge on a certain date, his services were coming to an end on 5/1/25 and should have received notice as late as 4/29/25.On 8/18/25 at 12:07 p.m., the Administrator (ADM) provided a copy of current facility policy titled, Notice of Medicare Non-Coverage (NOMNC) revised 6/30/25. The policy indicated, To ensure that residents/patients are notified and properly informed when Medicare-covered services are terminating and to explain their rights to an appeal process. the NOMNC must be issues to the resident/patient at least two calendar days before the termination of services. This allows residents/patients sufficient time to understand the notice and take any necessary actions.3.1-4(f)(3)

Based on observations and interview, the facility failed to serve food at an acceptable temperature to residents residing on the 600 hall. This deficiencyhad the potential to affect residents 14 of 14 residents who had their trays delivered to their rooms. Findings include: During an observation on 6/25/25 at 1:14 p.m., CNA 4 was passing lunch hall trays on the 600 hall by herself. She indicated she was by herself passing the 600 hall trays. A request was made to check the temperature of the lunch trays on the 600 hall cart. The temperatures were checked by [NAME] 6. The temperature of the chicken was 122 degrees. The temperature of the mashed potatoes was 122.7 degrees. The temperature of the mixed vegetables was 117.0. A policy was provided by the Executive Director (ED) on 6/25/25 at 1:25 p.m. It indicated, .Time/Temperature Control for Safety (TCS) hot food will be to a minimum temperature for 15 seconds, as follows: Poultry and stuffed foods 165 degrees F All foods will be held at appropriate temperature, greater than 135 degrees F (or as state regulation requires) This citation relates to Complaint IN00459625. 3.1-21(a)(1) 3.1-21(a)(2)

Based on observations, record review, and interview, the facility failed to serve a resident her diet as ordered for 1 of 3 residents reviewed for diets (Resident B). Findings include: On 6/25/25 at 11:03 a.m., a record review was completed for Resident B. She had the following diagnoses which included but were not limited to weakness, hypertension, and weight loss. She had orders for regular diet, ground meat, double portions with a magic cup at lunch. On 6/25/25 at 1:30 p.m., Resident B was observed receiving her lunch tray. She did not have double portions or a magic cup on her tray. CNA 8 confirmed she did not have double portions or a magic cup on her tray and went to retrieve those items. A policy was not provided at the time of exit. This citation relates to Complaint IN00459625. 3.1-21(b)

Based on observation, interview, and record review, the facility failed to label and date medications when opened and remove expired medications from use for 3 of 5 medication carts and 1 of 2 refrigerators observed for medication storage. Findings include: 1.On 8/4/24 at 10:14 a.m., the 600 hall medication cart was observed for medication storage. a. Resident 26 had an albuterol AER 90 mg (milligram) inhaler (used to treat breathing conditions) with no date to indicate when it was opened. b. Resident 26 had trelegy ellipta (used to treat breathing conditions) 100/62.56/25 mcg (microgram) without a date to indicate when it was opened. c. Resident 22 had a bottle of fluticasone nasal spray (used for allergies) 50 mcg without a date to indicate when it was opened. 2.On 8/4/24 the 700 hall medication cart was observed for medication storage. a. Resident 32 had a Humalog insulin pen with a date opened of 5/24/24. It had expired on 6/23/24. b. Resident 2 had a Humalog insulin pen with a date opened of 5/29/24. It had expired on 6/27/24. c. Resident 2 had a glargine insulin pen with a date opened of 5/26/24. It had expired on 6/23/24. d. Resident 39 had a bottle of carboxymethyl solution 0.5% (natural tears) without a date to indicate when it was opened. 3. On 8/4/24 the 800 hall medication cart was observed for medication storage. a. Resident 18 had a basaglar insulin pen with no date on it to indicate when it was opened. b. Resident 18 had a NovoLog insulin pen with no date to indicate when it was opened. c. Resident 9 had a bottle of deep sea nasal spray with no date to indicate when it was opened. 4.On 8/4/24 the 600, 700 and 800 medication room refrigerator were observed for medication storage. a. Had a vial of tuberculin (used to administer tuberculosis testing) that expired on 7/3/24. b. Had a bottle of aplisol (used to administer tuberculosis testing) with an unclear date on it. On 8/8/24 at 2:10 p.m., the Director of Nursing Services (DNS) and Corporate Clinical Specialist (CCS) indicated they have conducted education regarding medication labeling and dating and indicated they are conducting daily auditing. A policy titled, Interdisciplinary Team (IDT) Risk Review Meeting, was provided by the Executive Director (ED) on 8/8/24 at 10:09 a.m., It indicated, .It is the policy of this facility to ensure all medications housed on our premises will be stored in the pharmacy and/or medication rooms according to manufacturer's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security 3.1-25(j) 3.1-25(m) 3.1-25(n)

Based on observation, interview, and record review, the facility failed to ensure the facility's non-smoking policy was followed and allowed unassessed residents who smoked to smoke on the facility grounds and keep smoking materials in their rooms for 6 of 6 residents reviewed for smoking (Resident 6, 22, 26, 67, 77, and 79). Findings include: A list of smokers in the facility was requested from the Executive Director (ED) and Director of Nursing (DON) several times on 8/4 and 8/5/24. The facility provided the list on 8/6/24 at 1:52 p.m. 1. On 8/6/24 at 1:08 p.m., Resident 6 was observed smoking a cigarette. He was in his wheelchair, in the parking lot in front of the facility. On 8/6/24 at 10:14 a.m., Resident 6's record was reviewed. His diagnosis included, but were not limited to, chronic obstructive pulmonary disease (COPD), hemiplegia and hemiparesis of left non-dominant side (partial paralysis), epilepsy (brain disorder with recurring seizures), diabetes mellitus (DM) (blood sugar disorder), and tobacco use. A smoking care plan, dated 4/23/24, indicated Resident 6 was a smoker. He had been educated on the, smoking policy. The goal was for him to comply with the facility policy. A few approaches were to complete a smoking assessment quarterly and as needed, instruct the resident regarding the facility policy on smoking: facility designated locations, times, and safety concerns, and with his smoking materials to be kept by the facility. Another care plan, dated 3/4/24, indicated Resident 6 was at risk for respiratory distress related to COPD. The goal was for him to free from symptoms of respiratory distress. Resident 6's electronic record lacked documentation of a smoking assessment nor was a smoking assessment provided by the facility during the survey or at survey exit. 2. On 8/6/24 at 10:29 a.m., Resident 22's record was reviewed. Her diagnosis included, but were not limited to, schizoaffective disorder (mental disorder with hallucinations, false beliefs, with depression or mania), COPD, and delusional disorder (mental health condition in which a person can't tell what's real from what's imagined). Resident 22's electronic record lacked documentation of a smoking assessment nor was a smoking assessment provided by the facility during the survey or at survey exit. A smoking care plan, dated 4/23/24, indicated Resident 22 was a smoker. She had been educated on the, non-smoking policy. The goal was for her to comply with the facility policy. A few approaches were to instruct the resident regarding the facility policy on smoking: facility designated locations, times, and safety concerns and to notify the nurse immediately if it was suspected the resident had violated the facility smoking policy. During an interview, on 8/6/24 at 2:22 p.m., Resident 22 indicated she kept her cigarettes in her room with her. 3. On 8/6/24 at 2:04 p.m., Resident 7's record was reviewed. His diagnosis included, but were not limited to, COPD, morbid obesity, DM, and chronic kidney disease (CKD). Physician orders indicated Resident 7 may go on LOA (leave of absence) with medications with responsible party. A smoking care plan, initiated on 8/6/24, was a smoker and was at risk for not following the facility smoking policy. The goal was for her to comply with the facility policy. A few approaches were to instruct the resident regarding the facility policy on smoking: facility designated locations, times, and safety concerns and to notify the nurse immediately if it was suspected the resident had violated the facility smoking policy. Resident 7's electronic record lacked documentation of a smoking assessment nor was a smoking assessment provided by the facility during the survey or at survey exit. During an interview, on 8/6/24 at 2:27 p.m., Resident 7 indicated he had his cigarettes in his room but, he kept his lighter in his car in the parking lot. He smoked in front of the building yesterday, but sometimes went to the sidewalk in front of nearby houses. On 8/7/24 at 2:45 p.m., Resident 7 was observed smoking outside. He was on facility grounds, sitting in the shade of an evergreen tree, unobservable from the front of the building. 4. On 8/6/24 at 2:16 p.m., Resident 67's record was reviewed. Her diagnoses included, but were not limited to, schizophrenia (serious mental health disorder affecting how one thinks, feels, and behaves), psychosis (symptoms that happen when a person is disconnected from reality), dementia (progressive loss of intellectual functioning, especially with impairment of memory, abstract thinking), and nicotine dependence. A smoking care plan, initiated on 8/6/24, was a smoker and had been educated on the facility's smoking policy. The goal was for her to comply with the facility policy. A few approaches were to complete a smoking assessment quarterly and as needed, instruct the resident regarding the facility policy on smoking: facility designated locations, times, notify the charge nurse immediately if it was suspected the resident had violated the facility smoking policy, and smoking material to be kept with facility staff. Resident 67's electronic record lacked documentation of a smoking assessment nor was a smoking assessment provided by the facility during the survey or at survey exit. During an interview, on 8/6/24 at 2:33 p.m., Resident 67 indicated she had her cigarettes in her room. On 8/7/24 at 1:09 p.m., Resident 67 was observed sitting outside, on a white bench, smoking on front of the building. 5. On 8/6/24 at 2:49 p.m., Resident 77's record was reviewed. He was admitted with moderate cognitive impairment. His diagnoses included, but were not limited to, dementia, a history of psychoactive substance abuse with an induced mood disorder, tobacco use, anxiety disorder, and post-traumatic stress disorder (PTSD). A new care plan, dated 8/6/24, indicated Resident 77 was a smoker and he was educated on the facility's non-smoking policy with a goal to have him comply with the facility smoking policy daily. Approaches included quarterly assessments, instruction about smoking risks and hazards, and cessation. Instructions regarding the facility policy on smoking: designated locations time, safety concerns. Notify the charge nurse immediately if it was suspected resident had violated facility smoking policy, and smoking material to be kept with facility staff. A care plan, dated 6/12/24, indicated Resident 77 received psychotropic medication (or psychotropic like medication) and was at risk for adverse side effects. An approach was to observe for adverse reactions to an antidepressant with change in behavior/mood cognition, hallucinations/delusion, social isolation, and suicidal thoughts. A mental health care plan, dated 6/13/24, indicated Resident 77 had a PASRR (preadmission screening and resident review) Level II concern related to serious mental illness. The goal was for him to receive appropriate specialized services to attain or maintain his highest psychological and psychosocial well-being. A fall care plan, dated 6/12/24, indicated Resident 77 was at risk for fall related to ad lib ambulation,, used of medication, poor safety awareness, and impaired memory. A PTSD care plan, dated 6/14/24, indicated Resident 77 exhibited the following due to history of trauma: feelings of guilt and flashbacks (sudden, vivid, distracting memories). An approach included maintain a safe environment for him. Resident 77's electronic record lacked documentation of a smoking assessment nor was a smoking assessment provided by the facility during the survey or at survey exit. During an interview, on 8/6/24 at 2:23 p.m., Resident 77 indicated he had his cigarettes in his room. The facility staff took his lighter, he could get his lighter back at the front desk. He could not smoke in front of building, but had to go into the outside corners of the building. He pulled a box of cigarettes out of his pocket. 6. On 8/7/24 at 2:45 P.M., Resident 26's record was reviewed. His diagnosis included, but were not limited to, dementia with psychotic disturbance, COPD, asthma, and generalized anxiety disorder. A smoking care plan, dated 4/10/24, indicated Resident 26 was a smoker and had been educated on the facility's smoking policy with a goal for him to comply with the facility's smoking policy daily. Approaches included a complete smoking assessment quarterly, educate him on the non-smoking facility policy as outlined by his behavior contract initiated on 7/25/23, instructions about smoking risks, hazards, and smoking cessation including designated locations, times, and safety concerns, notify charge nurse immediately and if it was suspected the resident had violated the facility smoking policy. Observed clothing and skin for signs of cigarette burns. A care plan, dated 11/14/23, indicated Resident 26 exhibited signed of cognitive impairment due to his score on the Brief Interview of Mental Status (BIMS) with a goal to be able to make simple decision regarding care. Approaches included to give to direction or question at a time, provide him with cues and reminder to assist with decision making and recall, repeat questions or comments as needed, and use simple yes or no questions and allow resident time to respond. A medication care plan, dated 4/3/23, indicated Resident 26 received psychotropic medication (or psychotropic like medication) and was at risk for adverse side effects: sleep aid. A PASRR care plan, dated 6/12/23, indicated Resident 26 had a serious mental illness and with received specialized services to attain or maintain their highest practicable psychological and psychosocial well-being. A behavioral care plan, date 4/3/23, indicated Resident 26 had past behavioral symptoms of suicidal ideation with a goal of demonstrating effective coping skills. An approach was to maintain a safe environment. Resident 26's electronic record lacked documentation of a smoking assessment nor was a smoking assessment provided by the facility during the survey or at survey exit. A document, titled, Resident Behavioral Contract, with no date, was provided by the Executive Director (ED), on 8/8/24 at 9:50 a.m. The ED indicated the facility was unaware he had a behavioral contract in place. A review of the contract, indicated the specific issue with smoking by put himself/others at risk for burns, etc (further smoking issues included). Specific thing he would not do was to smoke on facility grounds. The things he would do were to not smoke on facility ground and turn in my cigarettes/lighter to facility staff. If he chose not to comply with this contract he could expect the following results: a 30 day notice issued for discharge of the facility. It was signed by Resident 26 on 8/9/23. During an interview, on 8/6/24 at 2:36 p.m., Resident 26 indicated he did not have any cigarettes to smoke. When he did smoke he would ask another resident for one. On 8/7/24 at 2:45 p.m., Resident 26 was observed smoking outside. He was on facility grounds, standing in the shade of an evergreen tree, unobservable from the front of the building. Resident 7 provided a cigarette for him and lit it. During an interview, on 8/5/24 at 2:30 p.m., the ED indicated this was a non-smoking facility, residents signed out to smoke, and they kept their smoking utensils with them. A list of residents that signed out to smoke and kept smoking materials in their rooms was requested from the ED multiple times on 8/4/24, 8/5/24, and twice on 8/6/24. During an interview, on 8/6/24 at 11:39 a.m., the ED indicated the facility was not a smoking building. He indicated the Director of Nursing (DON) provided a smoking policy in error. They did not have smoking assessments for residents who signed out and smoked. The residents kept their smoking materials in their rooms and signed in and out to go smoke. During an interview, on 8/8/24 at 11:25 a.m., the receptionist in the lobby, who could observe the residents in front of the building, indicated she observed residents smoking in the front of the building routinely. During an interview, on 8/8/24 at 1:29 p.m., the ED indicated the facility staff had not yet implemented removing cigarettes out of resident rooms yet. During an interview, on 8/8/24 at 1:33 p.m., the Regional Nurse Consultant (RNC) indicated the staff needed time to prepare the residents for a change in policy with behavioral management preparations. On 8/5/24, admission documents provided by the facility upon resident entry indicated the residents received smoking information with their admission packet. The smoking information, titled, Non-Smoking Policy - Residents. A review of the policy indicated, This facility shall establish and maintain safe resident smoking practices .The facility is a NON-SMOKING facility and residents are not permitted to smoke on the premises .If a resident chooses to smoke they must sign out LOA [leave of absence] with a responsible party (if applicable) and leave the facility property 3.1-45(a)(1) 3.1-45(a)(2)

Based on interview and record review, the facility failed to ensure Resident Council Grievance concerns related to call light wait and response times was addressed in a timely and effective manner to prevent ongoing concerns for 5 of 82 residents who attended the Resident Council Meeting and complained on behalf of all 82 residents who resided in the facility. Findings include: During an interview on 8/7/24 at 8:53 a.m., the Executive Director (ED) indicated, he could not find Resident Council Minutes from October 2023 through (-) February 2024. The ED indicated, since he and the new Activity Director (AD) started, they had been keeping track of and organized the minutes. At that time, the ED provided copies of the minutes from March 2024 - July 2024. Minutes from a meeting held on 3/26/24 at 2:30 p.m. indicated, .overnight staff call lights on for 1-2 hours- staff on phones all the time including during resident care Minutes from a meeting held on 4/29/24 at 1:30 p.m., indicated, .night shift, rude-'companionate-less' call lights- on over an hour or more, on phone while providing patient care Minutes from a meeting held on 5/29/24 at 1:55 p.m., indicated, .old business reviewed . night shift- call light wait times not getting better. Phones- still talking and texting while providing care Minutes from a meeting held on 6/19/24 at 3:00 p.m., indicated, .old business reviewed . night shift: call lights still not being answered . new business: night shift call lights too long, phones during care or in hallway [NAME] lights are going off Minutes from a meeting held on 7/23/24 at 2:10 p.m., indicated, .call lights still not being answered at night During a Resident Council Meeting on 8/8/24 at 10:00 a.m., the Resident Council President and 4 other residents who regularly attended the meetings indicated, they had ongoing concerns related to nightshift call light wait and response times. They indicated they had to wait a long time for call lights to be answered, and sometimes if the nurse came in, they would turn the light off, say they would come right back, but never did. Three of the five residents in attendance indicated they had to wait too long, and on several occasions they had accidents in their briefs while waiting for assistance to the bathroom. The residents indicated they complained about call lights at every meeting, but nothing was ever done about it because it never seemed to get better. During an interview on 8/8/24 at 10:38 a.m., the AD indicated, since she had started the biggest ongoing concern had been related to call lights not answered in a timely manner and residents had to wait a long time. Residents also complained that staff would be on their phones at inappropriate times especially during resident care. The AD indicated when the Resident Council group had shared concerns, like the call lights and phone use, she would fill out a grievance form and submit it to the Social Service Director, who would review the grievance and facilitate delegation to appropriate Department Heads for responses. The AD indicated sometimes she got grievances responses, and sometimes she didn't. On 8/8/24 at 11:00 a.m., the ED provided copies of Grievance responses from the Resident Council Meetings. A Grievance Response, dated 4/5/24, to address concerns from the 3/26/24 meeting indicated, Department Head review and action taken: Staff has been educated on call lights and not using phone/earbuds on floor A Grievance Response, dated 5/15/24, to address concerns from the 4/29/24 meeting indicated, Department Head review and action taken: Staff has been educated on rounding and answering call lights A Grievance Response, dated 5/12/24, to address concerns from the 5/8/24 meeting indicated, Department Head review and action taken: Staff education on making sure call light in reach and answered in kind and timely manner There were two Grievance Response forms which addressed concerns from the 6/19/24 meeting. The first was related to a specific resident's request for snacks, and the second was related general dietary/food concerns. There was no Grievance Response form to address 6/19/24 concerns related to call light and staff response times. There was a Grievance Response form, dated 7/24/24, to address an individual concern from the 7/23/24 meeting. There was no Grievance Response related to the 7/23/24 concern related to call lights and staff response. During an interview on 8/8/24 at 11:15 a.m., the Assistant Director of Nursing (ADON) indicated, she had come in a couple times for night shift observations, but never had concerns related to call lights, and that staff had been educated multiple times. On 8/8/24 at 1:53 p.m., the Regional Nurse Consultant (RNC) provided a copy of current facility policy titled, Grievances, with an effective dated of 1/2/24. The policy indicated, It is the policy of this facility to support each resident's and family member's right to voice grievance without discrimination, reprisal or fear of discrimination or reprisal . the Grievance Official is responsible for overseeing the grievance process; receiving and tracking grievances through to their conclusion; leading any necessary investigations by the facility; maintaining the confidentiality of all information associated with grievances; issuing written grievance decisions to the resident . the facility will make prompt efforts to resolve grievances 3.1-3(k)

Based on observation, interview, and record review, the facility failed to ensure two cognitively impaired residents who wished to have a relationship and resided on the secured memory care unit had assessments for appropriateness, ongoing supervision, and person-centered goals and interventions for 2 of 3 residents reviewed for dementia services (Residents 53 and 55). Findings include: On 8/6/24 at 2:07 p.m., Resident 53 was unable to be located after looking in her room, her private bathroom, the secured memory care (MC) activity/dining room and in the therapy gym. During an interview on 8/6/24 at 2:08 p.m., the MC Facilitator (MCF) indicated, Resident 53 was probably visiting with her friend, Resident 55, and asked two passing Certified Nursing Aides (CNAs) to find Resident 53. CNA 17 and CNA 18 went to Resident 55's room. Resident 55 and Resident 53 were observed lying in bed together with Resident 55's arm wrapped around Resident 53's waist. The CNAs indicated Resident 53 visited Resident 55 all the time and they liked to sleep together. The CNAs indicated Resident 55 was in love with Resident 53. When the CNAs asked Resident 53 to get out of his bed, Resident 53 refused, so the CNAs allowed the residents to remain in bed together. During an interview on 8/6/24 at 2:10 p.m., the MCF indicated both residents' families were ok with the residents' relationship, and it was care planned. The MCF indicated Resident 53 would sometimes wander into other resident's room, but had only laid down with Resident 55. During an interview on 8/7/24 at 11:16 a.m., CNA 19 indicated Residents 53 and 55 were very good friends and she believed Resident 53 thought Resident 55 might have looked like her late husband, and Resident 55 enjoyed her company. CNA 19 indicated staff was supposed to encourage them to visit in common areas for more supervision, but Resident 53 would sneak into his room. Even if Resident 55's stop sign was up, Resident 53 would duck under it. CNA 19 never observed anything untoward or inappropriate. Their relationship seemed to be more about companionship. 1. During an interview on 8/7/24 at 11:25 a.m., Resident 53's family member indicated Resident 53 did like to spend time with Resident 55 and often went into his room. Resident 55 seemed to be friendly with her and the family did not mind if they continued to see each other, or conducted a more intimate relationship i.e. held hands, and snuggled in bed. Resident 53's family indicated they would want Resident 53 to be monitored and supervised sufficiently enough to prevent the possibility of her getting hurt. On 8/6/24 at 2:18 p.m., Resident 53's medical record was reviewed. She was a long-term care resident who resided on the secured MC unit with diagnoses which included, but were not limited to, Alzheimer's disease with late onset (Alzheimer's is a type of dementia, dementia is an irreversible degenerative brain disease which affects memory and cognitive function), unspecified dementia with other behavioral disturbances, insomnia (sleep disorder when one wakes often and easily through the night), nightmare disorder, and psychotic disorder with delusions, (thinking or believing things that are not real). A significant change Minimum Data Set (MDS) assessment, dated 6/17/24, indicated Resident 53 was severely cognitively impaired with a Brief Interview for Mental Status (BIMS) score of 3 out of 15. A routine Psychiatry assessment, conducted on 1/3/24 at 7:19 p.m., indicated, .[Resident 53] is assessed in peers room - resting in bed- she is alert and pleasant. Staff reports patient has periods of low frustration tolerance. Staff reports patient becomes physically violent when redirected. Reviewed medications- noted patient with GDR [gradual dose reduction] 11/6/23- plan to consider that a failed GDR and increase fluoxetine to previous dosing . A routine Psychiatry assessment, conducted on 1/15/24 at 4:14 p.m., indicated, .staff reports patient has been overly sexual- attempting to kiss multiple male residents on the unit. Staff have intervened- however patient behavior continues/repeats. Prozac increased - to decrease sexual libido and stabilize mood . started on cimetidine [an antiacid, gastric acid reducer which has been reported to decrease libido and hypersexual behavior] A routine Psychiatry assessment, conducted on 4/8/24 at 12:11 p.m., indicated, .staff reports resident is having periods of verbal aggression. Staff reports patient is difficult to redirect and inflicts self-harm at times. Plan to introduce low-dose Zyprexa to address obsessiveness, self-harm, and physical and verbal aggression. Likewise resident receiving fluoxetine to address sexual inhibition, plan to transition resident to Zoloft. Sexual inhibition being managed with cimetidine in place . A routine Psychiatry assessment, conducted on 4/22/24 at 5:56 p.m., indicated, .Staff reports patient continues to display physical aggression towards staff - recently assessed for UTI [urinary tract infection] but specimen was contaminated- ordered repeat UA [urinalysis]. Started on Zyprexa [an antipsychotic medication with side effects which can include, but are not limited to; dizziness, weakness, difficulty walking and restlessness]] to address physical aggression and delusional behaviors. Received a pharmacy recommendation to decrease fluoxetine [an antidepressant medication]- recommendation declined at this time The assessment indicated she already received: a. Namenda (a medication used to treat dementia, which can cause dizziness and fatigue) 10 mg twice a day b. Aricept (a medication used to treat dementia, which can cause fatigue, insomnia, muscle cramps and fainting), 10 mg every night c. terazosin (a medication used in the treatment of trauma-related nightmares which can cause drowsiness, blurred vision, dizziness and fainting) 2 mg at night d. melatonin (a supplemental hormone used as a sleep aide) 5 mg every night A routine Psychiatry assessment, conducted on 5/6/24 at 4:38 p.m., indicated, .Staff reports resident is cooperative with care continues to seek affection from male resident however she is easily redirected . At that time, the pharmacist recommended a dose decrease of cimetidine from 200 mg twice a day, to 200 mg once a day. The Psychiatrist accepted and put the order in place. Resident 53's behavioral assessments were reviewed from January 2024 through current date. The Behavioral assessments reviewed psychotropic medication management and adjustments related to her psychiatric related diagnoses, the assessments lacked documentation of Resident 53's seeking affection, from her male peer. Resident 53's Activity Assessments were reviewed from January 2024 through the current date. The Activity Assessments lacked documentation of her preference to have a meaningful relationship with Resident 55 as an overall part of her life enrichment program. Resident 53's comprehensive care plans were reviewed, which included, but were not limited to the following: a. a comprehensive care plan initiated 1/25/22 which indicated, [Resident 53] resides on a secured memory care unit due to diagnosis of dementia and benefits from specialized activity care programming. Interventions for this plan of care included but were not limited to: keep resident involved in activities and o socialization to divert behaviors, loneliness, sadness. No new interventions for this plan of care had been added/revised since the initial implementation to include her preference to maintain an ongoing relationship with Resident 55 which may include more intimate contact such as snuggling in bed. b. a compressive care plan initiated 2/13/24 indicated, [Resident 53] exhibits behavior symptoms of wandering in and out of other resident's rooms and refusing to leave. The care plan lacked revision to include Resident 53's preference/habit of going to Resident 55's room, and that it may be allowed as tolerated by Resident 55. c. a comprehensive care plan initiated on 3/24/23 indicated, [Resident 53] has difficulty sleeping related to [diagnosis] of insomnia as evidenced by sleep disturbance. The care plan was not revised to include Resident 53's habit/tendency to go to Resident 55's room and/or that she may sleep better with her companion. A nursing progress note 5/14/24 at 5:53 a.m., indicated, Resident 53, .was up in the hall several times in the night, and escorted back to bed. During a.m. bed check she was seen in a male patient's bed, while being escorted back to her room she fell on her right hip that had a brush in the pocket and c/o pain at that hip . On 5/14/24 at 10:39 a.m., the Interdisciplinary team (IDT) met to review Resident 53's fall.review for witnessed fall on 5/14. Resident had been up and down throughout night shift and had to be re-directed back to room. During last bed round, it was noted that she had wandered into another resident's room and was in their bed. Resident again redirected back to her room. Staff assisted resident, showing resident location of room. While ambulating back to room, she stumbled and fell . the IDT team determined, .Resident resides on a secured unit, has poor safety awareness and a dx [diagnosis] of dementia . therapy to evaluate 2. During an interview on 8/7/24 at 1:10 p.m., Resident 55's family member indicated they were aware Resident 55 and Resident 53 were close. In fact, Resident 55 often indicated, he was in love with [Resident 53], but in May and June of 2024, Resident 55 had experienced a progression in the worsening of his dementia and started to have aggressive physical and verbal outbursts. The family thought he would never hurt Resident 53, but was concerned about the safety of anyone who might try to intervene between the two or make perceived advances towards Resident 53. Resident 55 was very protective, of Resident 53. Resident 55's family indicated they wanted Resident 55 to be able to continue his relationship with Resident 53, but was worried that when his dementia got worse he might be more of a danger to her or other residents. On 8/7/24 at 3:18 p.m., Resident 55's medical record was reviewed. He was a long-term care resident who resided on the secured MC unit with diagnoses which included, but not limited to, vascular dementia, unspecified mild dementia with psychotic disturbance, psychotic disorder with delusion, other problems related to lifestyle, mood disturbance, anxiety. A quarterly MDS assessment, dated 7/2/24, indicated Resident 55 was moderately cognitively impaired with a BIMS score of 10 out of 15. A routine Psychiatry assessment, conducted on 5/15/24 at 4:06 p.m., indicated, .[Resident 55] is alert and pleasantly confused. States he is doing well- makes good eye contact- conversation is logical and linear. Patient focused on female resident he keeps company with at times. States he enjoys her, but she is a 'two -timer.' The psychiatry note indicated Resident 55 was to continue taking cimetidine 200 mg twice a day for inappropriate sexual behavior. A nursing progress note, dated 6/18/24a t 6:51 a.m., indicated, Resident asking for his social security check, staff attempted to tell resident that bank was not open yet, resident became combative attempting to strike at staff with closed fist and screaming names at nurse. Resident than went to his room and slammed door A nursing progress note, dated 6/24/24 at 10:11 a.m., indicated, .Resident making delusional statements, believes that other residents are conspiring against him and making plans to 'mess up' his life. Resident aggression increased toward staff. Resident has been making statements that he will 'mess them up.' Resident states he isn't talking about anyone in particular. POA said that when she took res [resident] to BINGO, he was ranting and punching her car An acute Psychiatry progress note, dated 6/25/24 at 1:27 p.m., indicated, .Staff reports patient is displaying acute changes in mood and anxiety. Medications reviewed with no recent changes in psychotropic medications since 2/2025. Patient with recent outing with family - where he was reported as verbally and physically aggressive. This was not witnessed during the assessment today A nursing progress note, dated 6/26/24 at 9:22 a.m., indicated, .Resident having increased [behaviors] becoming verbally aggressive with staff and threatening to 'hu' them this day. Redirection difficult, resident hyper-fixated on another male resident, he states that this resident 'wants to date him,' said resident is friendly and non-verbal. All attempts to encourage resident to understand that his thinking is not correct are met with resistance as he believes this to be true. Resident in activity room playing game, other resident entered room to also participate, which set resident off, he instantly became agitated, other resident had not said or done anything. When asked why resident became agitated, he said that he just 'knows he wants me, and I don't want to be around that' . Notified psych NP [Psychiatric Nurse Practitioner] yesterday of ongoing increased bx [behaviors], order obtained for labs to r/o medical cause, resident had GDR of antipsychotic medication in [DATE]. Will notify NP of bx On 6/26/24 the Psych NP started Resident 55 on Trazadone (an antidepressant medication) 50 mg daily and 25mg as needed every 6 hours for 14 days for agitation. A nursing progress note, dated 6/30/24 at 9:08 p.m., indicated, .patient was upset and vented to me in his room saying he thinks we are drugging people that he takes a baby aspirin in the morning for his heart and that was all he was ever going to take. He talked about a woman here that he likes calling her his girlfriend and that she does not return the feeling working himself up into a frenzy Resident 55's behavioral assessments were reviewed from January 2024 through current date. The Behavioral assessments reviewed psychotropic medication management and adjustments related to his psychiatric related diagnoses. The assessments lacked documentation of Resident 55's feelings towards Resident 53 and his preference to visit with her, or that he sometimes considered her a two-timer. Resident 55's Activity Assessments were reviewed from January 2024 through the current date. The Activity Assessments lacked documentation of his preference to have a meaningful relationship with Resident 53 as an overall part of her life enrichment program. Resident 55's comprehensive care plans were reviewed, which included, but were not limited to the following: a. a care plan initiated . He prefers to be involved in in mostly independent interest he enjoys sitting by the window in his room and looking out, he likes to talk with his daughter on the phone. Seems to enjoy the daily chronicle. Enjoys westerns, action movie, coffee and conversations, socialization, music, and snacks and hydration. [He] goes to Bingo with his daughter every Thursday and enjoys this. This plan of care lacked revision to address/include person-centered goals/interventions for his preference to visit with and have a meaningful relationship with his peer, Resident 53. b. a care plan initiated 4/4/23 which indicated, . he has difficulty sleeping related to dx of sleep disorder as evidenced by awakens frequently during the night. The care plan lacked revision/documentation to address Resident 53's behaviors of coming into his bed at night. c. a care plan initiated on 4/28/24 which indicated, .he exhibits behavior symptoms of wanting a STOP sign placed outside door to prevent residents from wandering into room The care plan lacked revision/documentation to address his preference that Resident 53 was allowed to come in his room if the STOP sign was up. d. a care plan initiated on 7/18/23 which indicated, .he exhibits behavior symptoms of: behavioral symptoms thinking he has a girlfriend on the unit and will hold hands with female residents. The care plan lacked revision/documentation of goal/interventions to ensure an appropriate and meaningful relationship with Resident 53 could be maintained. On 8/8/24 at 1:53 p.m., the Regional Nurse Consultant (RNC) provided a copy of current facility policy titled, Comprehensive Care Planning, with an effective dated of 1/2/24. The policy indicated, It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objective and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment . 'person-centered care' means to focus on the resident as the locus of control and support the resident in making their own choices and having control over their daily lives . The care planning process will include an assessment of the resident's strengths and needs and will incorporate the resident's personal and cultural preferences in developing goals of care. Services provided or arranged by the facility, as outlined by the comprehensive care plan, shall be culturally competent and trauma-informed . the comprehensive care plan will describe, at a minimum, the following: . resident specific interventions that reflect the resident's needs and preferences and align with the resident's cultural identity, as indicated The Facility Assessment tool, dated 5/20/24, indicated, Specific Care and Practices, included but not limited to, .Mental Health and Behavior: Manage the medical conditions and medication-related issues causing psychiatric symptoms and behavior, identify and implement interventions to help support individuals with issues such as dealing with anxiety, care pf someone with cognitive impairment Provide person-centered/direct care: psych/social/spiritual support: build a relationship with resident/get to know him/her; engage resident in conversation. Find out what resident's preferences and routines are; what makes a good day for the resident; what upsets him/her and incorporate this information in to the care planning process . record and discuss treatment and care preferences . identify hazards and risks for residents 3.1-37(a)

Based on interview and record review, the facility failed to ensure sufficient licensed nurse coverage was available on the weekends for 1 of 4 quarters of staffing reviewed which had the potential to effect 82 of 82 residents who resided in the facility. Findings include: On 8/6/24 at 9:30 a.m., the facilities CASPER report was reviewed and indicated, staffing concerns had been triggered in the second quarter of 2024 for low weekend staffing. On 8/8/24 at 8:36 a.m., the actual worked licensed nursing schedule was request for the month of May 2024. On 8/8/24 at 10:47 a.m., the above requested schedule was provided by the Executive Director (ED) and reviewed at that time. For the first week of the month, May 1 through (-) 7th, the licensed staff per-patient-per-day (licensed staff PPD- the number of hours a licensed nursing staff member is granted per patient, per day) averaged to 0.74. For the second week of the month, May 8th-14th, the licensed staff PPD averaged 0.62. For the third week of the month, May 15th-21st, the licensed staff PPD averaged 0.61. For the fourth week of the month, May 22nd-28th, the licensed staff PPD averaged 0.54. Upon review for patterns, the schedule revealed PPD trended down throughout the month. Starting on Thursdays, and through the weekends the schedule did not meet the minimum 0.50 PPD as evidenced by the following: Thursday the 2nd, PPD= 0.48. Saturday the 4th, PPD= 0.49. Saturday the 11th, PPD= 0.37. Sunday the 12th, PPD= 0.36. Friday the 17th, PPD= 0.45. Saturday the 18th, PPD= 0.39. Sunday the 19th, PPD= 0.38. Thursday the 23rd, PPD= 0.43. Saturday the 25th, PPD= 0.27. Sunday the 26th, PPD= 0.19. Friday the 31st, PPD= 0.39. During an interview on 8/8/24 at 11:38 a.m., the ED reviewed the above schedule review and indicated, it appeared there were an appropriate amount of staff, such as leadership staffing like the Medical Records Coordinator, (MR), who was a licensed practical nurse, (LPN) the Minimum Data Set (MDS) Coordinator, who was a Registered Nurse (RN), several Licensed Nurse Preceptors (LNPs) and the Assistant Director of Nursing, who was a LPN were mainly scheduled Monday - Thursday for routine office hours. The ED indicated some of those weekday nursing hours could be moved and/or rearranged to help cover the weekends as well. On 8/8/24 at 12:02 p.m., the Facility Assessment Tool, dated, 5/20/24, Part 3 indicated, .Facility Resources needed to provide competent support and care for our resident's populations every day and during emergencies . RNs to acuity = 0.54 and LPNs to acuity = 0.74 During an interview on 8/8/24 at 1:23 p.m., the ED indicated, the Facility Assessment Tool was up to date, and it was his understanding that the minimum PPD of RNS and LPNs to acuity of care, meant according to the Facility Assessment and Resident Population Review, the facility required a minimum of the above RN and LPN PPD daily coverage. The ED indicated the Facility Assessment tool served as the policy for facilities staffing policy and requirements.

Based on record review and interview the facility failed to accurately code falls on the MDS (Minimum Data Set) for 1 of 2 Residents reviewed for MDS accuracy (Resident 53). Findings include: On 8/6/24 at 2:18 p.m., Resident 53's medical record was reviewed. She was a long-term care resident who resided on the secured Memory Care (MC) unit with diagnoses which included, but were not limited to, Alzheimer's disease with late onset (Alzheimer's is a type of dementia, dementia is an irreversible degenerative brain disease which affects memory and cognitive function). A nursing progress note, dated 5/14/24 at 5:53 a.m., indicated, Resident 53, .was up in the hall several times in the night, and escorted back to bed. During a.m. bed check she was seen in a male patient's bed, while being escorted back to her room she fell on her right hip that had a brush in the pocket and c/o [complains of] pain at that hip . A hospital History & Physical, dated 5/15/24, indicated, Resident 53 sustained a fall and had suffered an acute, impacted, nondisplaced right subcapital femoral neck fracture. Resident 53 underwent surgical repair. A significant change Minimum Data Set (MDS) assessment, dated 5/30/24, section J1800, Any falls since admission or prior assessment . was answered no. A significant change MDS assessment, dated 6/17/24, section J1800, Any falls since admission or prior assessment . was answered yes, but did not indicate she had sustained a fall which resulted in a fracture. On 8/8/24 at 10:09 a.m. the Executive Director (ED) provided a copy of current facility policy titled, Accurate Assessment, with an effective date of 1/2/24. The policy indicated, The purpose of this policy is to assure that all residents receive an accurate assessment, reflective of the resident's status at the time of the assessment, by staff qualified to assess relevant care areas

Based on observation, interview, and record review, the facility failed to ensure resident assessments were completed for 1 of 1 resident who self-administers medications (Resident 15). Findings include: On 8/4/24 at 12:01 p.m., Resident 15 was observed to have medications in her room and bathroom. On her over the bed table, she had fluticasone nasal spray (treats chronic rhinosinusitis) and carboxymethylcellulose eye drops (treats dry eyes), and on her bathroom counter she had metronidazole (treats facial rosacea). On 8/6/24 at 10:28 a.m., Resident 15's record was reviewed. Her physician orders included, but were not limited to: fluticasone nasal spray dated 1/3/24, may keep at bedside to self-administer; carboxymethylcellulose eye drops dated 1/3/24, may keep at beside and self-administer; and metronidazole lotion dated 5/17/24, unsupervised self-administration. A document titled, Medication Self-Administration Safety Screen, dated 1/3/24, indicated Resident 15 could keep at bedside and self-administer fluticasone nasal spray. It indicated eye drops and topical creams were not applicable. No other medications were listed or assessed. Resident 15's electronic medical record lacked documentation of quarterly self-administration assessments for fluticasone. Resident 15's electronic medical record lacked documentation of quarterly self- administration assessments for carboxymethylcellulose and metronidazole. A new document titled, Medication Self-Administration Safety Screen, dated 8/5/24, indicated Resident 15 could keep at bedside and self-administer carboxymethylcellulose eye drops. The fluticasone and metronidazole were not listed or assessed. A medication care plan, dated 4/4/24, indicated Resident 15 could self-administer eye medication and face cream, the names of the medication were not specifically listed. The metronidazole lotion was not listed. The goal was to take medications safely as prescribed. An approach included to assess the residents ability to safely self-administer medication specified on admission, quarterly, and with significant changes in condition. During an interview, on 8/8/24 at 12:10 p.m., Resident 15 indicated the facility staff took away her rosacea medication on 8/8/24. Previously, they let her keep it in her room because her rosacea flared up so much and she just bugged and bugged them until they gave it to her. She still had her fluticasone nasal spray and carboxymethylcellulose eye drops in the her room. They were observed on her over the bed table. A current policy, titled, Self-Administration of Medications, with no date, was provided by the Executive Director (ED), on 8/8/24 at 9:50 a.m. A review of the policy indicated, .A resident may only self-administer medications after the facility's interdisciplinary teams has determined which medications may be self-administered safely .The results of the interdisciplinary team assessment are recorded on the Medications Self-Administration Assessment Form, which is placed in the resident's medical record All nurses and aides are required to report to the charge nurse on duty any medication found at the bedside not authorized for bedside storage. Unauthorized medications are given to the charge nurse for return to the family or responsible party 3.1-11(a)

Based on observations, interviews and record review, the facility failed to ensure the secured memory care unit provided person-centered care, supervision, and engaging activities to prevent resident-to-resident altercations and/or accidents. These deficient practices had the potential to affect 30 of 30 residents who resided in the secured memory care unit (Residents L, B, EE, GG, X, M, N, W, FF, and HH). Findings include: During a confidential interview, a visiting family member indicated, there were a lot of residents that wandered on the locked memory care unit. When they came to visit their loved one, they would be interrupted several times by residents who would wander into the room while they visited. It had really bothered their loved one when they first moved in, but they have since gotten used to it. It could be problematic for some other residents and the visitor sometimes heard other residents yelling at their peers to get out. The family member indicated the unit was usually staffed with two aides and a nurse, but they could use more help especially since there were no activities. There needed to be extra sets of eyes to help with supervision. 1. During a confidential interview, Resident L's family member indicated, Resident L had experienced a decline in her cognitive abilities and an increase of verbal and physical aggression against other residents in the previous months which led up to her move to the facility. She didn't like men and had gotten into an argument with one guy at a previous facility, then got into a second altercation with another, where she pushed him, and he fell . Because of that, she was sent to an in-patient psychiatric facility. Shortly after her return, she was transferred from another skilled nursing facility to [NAME] care of [NAME]. The family member was hopeful that it would be a good fit, as he had been told by the Admissions and Marketing Coordinator, the facility had a specialized and secured memory care unit as well as Doctor on site to help with behaviors and could make medication adjustments as needed. They had her in a room right there near the activity room and a lot of people would wander in and out of her room and she would call me and tell me she didn't like it. They tried to put up one of those Velcro stop-signs but she would take it down, and sometimes when it was up it confused her about leaving or going into her own room. Then they talked like they would try to move her to a less busy area, or at the end of the hall farther away from the commotion, but it didn't happen the family member got a call and was told, she had pushed some guy down, made him fall and he got hurt bad. During a confidential interview, Resident B's family members indicated, he had experienced increased confusion and had a seizure, which resulted in a hospitalization . During his hospital stay, the family realized they could no longer care for him at home and looked for a place for him to go. They were able to find placement at [NAME] Care of [NAME] since they had an open bed in the secured memory care unit. Resident B didn't want to go, but he couldn't go home. He had a hard time adjusting and was very stubborn. He wandered and walked up and down the hallways a lot and would go into other resident's rooms. The night of the accident, he had been really agitated and upset since around dinner, and the girls thought putting him to bed would help but he didn't want to go to bed then. They kept trying to put him back in bed, and that probably made him more mad. He tried to go into another female resident's room and she pushed him. He fell and hit his head really hard, it caused bleeding on the brain and they even tried to drill a hole in his skull to relieve the pressure, but he just never recovered. The family members indicated, we have nothing against that lady she was in Memory care for a reason too, she was confused, and [Resident B] was just so bull-headed. He had been wandering around that unit from day one, so why couldn't they keep him out of that room? During a confidential interview, it was indicated, Resident L had not been at the facility long, she was very particular about her things and her room. She did not like people going into her room. It was hard to keep wandering residents out of her room. When residents went into her room, she would yell at them and cuss at them. It was indicated, it seemed like most of Resident L's behaviors occurred in the evenings, like many other residents who Sundown (a common clinical phenomenon manifested by the increase of confusion/anxiety/aggression and other neuropsychiatric symptoms, usually occurring in the evening or at night). She would turn fast and could be unpredictable. During a confidential interview, it was indicated, Resident L did not like other resident going into her room, it made her mad and she would lash out. She seemed worse in the evenings. She mostly stayed in her room, to keep other residents out, and when she came out of the room, she always asked if she could leave or go home. During an interview on 3/12/24 at 10:30 a.m., Certified Nursing Aide (CNA) 14 indicated she worked the night of the accident but did not witness the fall. She had just walked back onto the unit from break and heard CNA 15 calling out for help and for someone to go and get the nurse. She saw Resident B face down on the floor, there was a lot of blood, and she ran to the other side of the building to get the nurse. CNA 14 indicated there were no activities or other materials for redirection on night shift because most of the residents would be asleep. The activity room door was usually closed and there were no prepared activities to use if needed. During an interview on 3/13/24 at 11:15 a.m., Qualified Medication Aide (QMA) 16 indicated she worked the night of the accident. She had been told during shift report that Resident B seemed more agitated than usual, and the aides had tried to put him to bed. But he refused to stay in bed. He was up and walked around the unit like normal. It was usual for him to wander and try to go into other rooms. At the time of the accident, she had been sitting at the nurse's station, but faced the front door and did not see Resident B behind her when he tried to go into Resident L's room. A sound first alerted her, but then a second sound made her get up and by the time she turned around, Resident B was already on the floor. During an interview on 3/13/24 at 11:27 a.m., CNA 15 indicated she worked the evening of the accident, but did not witness the altercation. She had been in the activity room across the hall from Resident L's room, but her back was to the door because she had to sit with another resident who could not be left alone in the activity room. She heard a loud noise and got up to go see what happened. Resident B was on the floor face down outside of Resident L's room. He was bleeding badly, and Resident L was yelling that he was coming into her room. Before the accident, Resident B had been up because he refused to go to bed, he was agitated and cussed at the staff, he said, F*** you, I'm not F****** going to sleep! CNA 15 indicated it was hard to keep residents in their rooms, and at night even if there were only a few people wandering on the unit, there was nothing to give them to do besides offer a snack and talk to them. The activity room would be closed most of the time, and the cabinets were locked. There were no activity boxes or ideas to help distract or redirect residents for nighttime shifts. On 3/11/24 at 10:15 a.m., Resident B's medical record was reviewed. He was admitted to the facility on [DATE] for long-term care on the secured memory-care unit. He had diagnoses which included, but were not limited to, unspecified dementia, vascular dementia, and a psychotic disorder with delusions due to known physiological condition. A hospital discharge summary, dated 8/15/23, indicated, .he was lying in a Soma enclosure bed due to agitation . On 8/14 trial off Soma bed, patient reluctant to go to [Nursing Home] . 8/15 failed trial off Soma bed, not cooperative, wanting to go home. An IDT Admission/Readmission Review and Care Plan Initiated/Update form, dated 8/22/23, indicated, Resident B had a diagnosis of dementia, a physician's order to reside on a secured dementia unit, and was at risk for elopement. There was no review of his sustained agitated demeanor and the failed trial off a Soma bed. The form lacked documentation or review of any potential or history of psychiatric behaviors. A nursing progress note, dated 8/23/23 at 8:33 a.m., indicated Resident B refused all Activities of Daily Living (ADL) care and was difficult to redirect and .wandering on unit and entering other resident's rooms . He arrived in only a gown and had no belongings or clothes. Staff continued to redirect resident out of rooms. Staff reported he did not sleep well and had been up and attempted to enter resident's rooms last night. A Medical Doctor (MD) progress note, dated 8/30/24 at 3:25 p.m., indicated, .nursing reports wandering and grumpy demeanor. Continues to look for his wife and sometimes thinks another female resident is his wife A MD progress note, dated 9/13/24, indicated Resident B continued with a grumpy demeanor, insomnia, and thought another female resident was his wife. The MD note indicated, .ordered close observation Resident B had care plans which included the following, but were not limited to: A care plan, initiated 8/24/23, which indicated, he exhibited behavior symptoms of wandering in and out of rooms. Interventions for this plan of care included, but were not limited to: a. encourage family involvement but lacked revision to specify what family, when and how to contact, or types of involvement to expect. b. familiarize resident with own belongings and surrounding, although he had no belongings. c. Give the resident as many choices as possible about care and activities, but lacked revision to specify why kind of activities to attempt. A nursing progress note, dated 9/22/23 at 9:21 p.m., indicated Resident B had been wandering on the locked unit when he wandered into another resident's room. They startled one another which resulted in the resident's making contact with each other and Resident B fell on to the floor. Resident B was assessed and had a head injury to the right side of his face with moderate bleeding and he had altered mental status as he was alert but hard to arouse. 911 was called and Resident B was sent out. Corresponding hospital records were obtained and revealed, Resident B was first sent to the closest local hospital where a CT scan (a type of diagnostic medical imaging) showed multiple life-threatening injuries and he was immediately referred for transfer to a level 1 trauma hospital. While waiting for the transfer, he experienced an episode of vomiting and required intubation to protect his airway, (intubation, the placement of a flexible plastic tube into the trachea to maintain an open airway). Upon arrival to the trauma hospital his initial Glasgow Coma Scale was 3 and improved to 7 after pausing sedation (GCS) a score of 8 or less represents severe brain injury) and was found to have sustained the following injuries upon evaluation: An intracranial hematoma (ICH- a collection of blood within the skull), subdural hematoma (SDH- the result of a severe head injury), Parafalcine and tentorial hemorrhage, bilateral hemorrhagic contusions, Subarachnoid hemorrhage (SAH- a life-threatening type of stroke caused by bleeding into the space surrounding the brain), superior right orbit fracture, right maxillary hematosinus with intraorbital small bone fragment just above the optic globe and bilateral maxillary sinus anterior lateral wall nondisplaced fractures. On 3/11/24 at 11:00 a.m., Resident L's medical record was reviewed. She admitted to the facility on [DATE] into the secured memory care unit. She had diagnoses which included, but were not limited to, Vascular dementia with moderate mood disturbances, unspecified dementia, recurrent and moderate major depressive disorder and generalized anxiety. Pre-admission documentation from her previous facility and her in-patient psychiatric hospital stay were reviewed and revealed the following. Nursing progress notes from the previous facility: a. on 7/31/23 at 2:13 p.m., during video surveillance review it was observed that this resident pushed another resident in the dining room in the early morning of 7/30/23 . b. on 7/31/23 at 2:26 p.m., during camera surveillance from over the weekend, this resident was seen trying to block another resident from passing in the dining room on 7/29/23 c. on 8/10/23 at 1:17 p.m., resident being placed on one on one care due to behaviors d. on 8/10/23 at 1:17 p.m., during video surveillance of another resident's fall that occurred on 8/8/23 at approximately 6:32 a.m., it was observed that this resident had been verbally arguing with the other resident in the hall about 10 minutes prior and were redirected by staff. After being redirected, once staff had exited the hall, this resident went into the other resident's room for approximately 7 minutes. This resident can be seen trying to pull the door closed but experiencing some tension possible from the resident on the other side. This resident walked down the hall and on the other resident can be seen on the ground in the doorway e. on 8/10/23 at 1:28 p.m., .Resident's Power of Attorney (POA) thinks where she is at now triggers her to have more anxiety and aggression because the resident's there seem more out of it and she is not so much out of it for memory, she is just out of her head completely. POA agreed for psychiatric evaluation and she was transferred to in-patient psych. Psychiatric progress notes from her in-patient stay were reviewed and revealed, .the patient has been displaying the following behaviors physical and verbal aggression, increased anxiety and increased aggression over the last 72 hours. On 8/8, patient was observed verbally arguing with another resident for about 10 minutes. After patient was redirected, she went back to the other patients room to continue the argument. It was discovered that this patient pushed the other resident into the wall, which injured him. The patient has been unable to walk, later the patient went to his room and attacked him with the door. He had to get three stitches in his head. The facility attempted to redirect, provided 1:1 and reassure with no success . Suggestions to redirect behaviors: patient enjoys participating in activities. Allow patient her own personal space as needed An IDT Admission/Readmission Review and Care Plan Initiated/Update form, dated 9/11/23, indicated Resident L had a diagnosis of dementia, a physician's order to reside on a secured dementia unit, and was at risk for elopement. There was no review of her previous incidents, behaviors, and psychiatric care. A MD progress note, dated 9/13/23 at 12:25 p.m., indicated, .Resident was being seen as a new admission . patient presented to [in-patient psych] hospital from 8/10-8/18 for physical and verbal aggression, anxiety, agitation, and physical altercation with another resident. Stabilized with addition of Buspar and discontinuation of Aricept and Depakote A social Service progress note, dated 9/23/23 at 8:53 a.m., indicated the Memory Care Facilitator (MCF) met with Resident L to discuss the incident that occurred on 9/22. Resident L stated that he entered her room without her knowledge and it scared her. MCF placed stop signs outside of her door which this appeased resident Resident L's comprehensive care plans were reviewed and lacked revision to include person-centered identification and interventions for her history of verbal and physical aggression towards other residents. Resident L had a comprehensive care plan initiated 9/11/23 which indicated, [Resident L] is newly admitted to the facility. An intervention for this plan of care initiated on 9/11/23 lacked revision and was left blank as follows: Behaviors: (SPECIFY) Behavior Interventions: (SPECIFY). During an interview on 3/12/24 at 1:30 p.m., the Director of Nursing Services (DNS) indicated, she got a call from Registered Nurse (RN) 13 who told her about Resident B's fall. The laceration and injury looked severe enough to require stiches to the DON advised to call 911 immediately and he was transported to the hospital shortly after. The DON indicated, when she initiated the investigation she realized there were some troubling circumstances which surrounded both newly admitted residents. Resident B had transferred from a local hospital, and the facility had been told he no longer required the Soma bed, however, when the Emergency Medical Technicians (EMT)s dropped him off at the facility, they told her Resident B had been in the Soma bed when they went to get him. When the DON looked further into Resident L's history, she came across a hospital note that she had gotten into altercations with other residents and had been an in-patient psychiatric resident. The DON indicated all new referrals for admission were sent first to the Corporate Intake and given a Green, Yellow, or Red light for admission. Green meant the referrals had been reviewed and were Okay for admission. Yellow meant admission was dependent on the review of and discretion of the facility Interdisciplinary team (IDT), and Red meant No. Both Residents B and L had been Green Light approved and were reviewed with a standard IDT Admission Review and Care Plan Initiation. The DON indicated the Memory Care Facilitator (MCF) at the time of the residents' admissions should have reviewed the records more comprehensively so that person-centered and appropriate interventions/approaches could have been considered. 2. Three additional resident-to-resident altercations which occurred in the secured memory care unit were reviewed and revealed the following. a. Indiana Department of Health incident report indicated, on 10/27/23, Resident EE wandered into Resident GG's room and went into his closet. Resident GG made contact with Resident EE's upper right lip. Resident EE sustained an abrasion to his upper lip. On 3/13/24 at 2:55 p.m., Resident EE's record was reviewed. He had Diagnoses which included, but were not limited to, moderate unspecified dementia with mood disturbance, and other behavioral disturbance. A Wandering/Elopement Risk Assessment, dated 2/22/24, indicated Resident EE was at risk to wander, had a history of wandering, and could propel himself in his wheelchair. A Minimum Data Set (MDS) assessment, dated 2/12/24, indicated Resident EE had the ability to make himself understood. Brief Interview for Mental Status (BIMS) score was a 5/15, which indicated severe cognitive impairment. No behaviors of wandering were coded for the look-back period of review. On 3/13/24 at 2:55 p.m., Resident GG's record was reviewed. He had diagnoses which included, but were not limited to, unspecified dementia with psychotic disturbance. A Wandering/Elopement Risk assessment dated [DATE] indicated, he was at low risk to wander, he was able to propel himself in his wheelchair. A MDS assessment, dated 3/1/24, indicated, Resident GG was usually able to make himself understood. He had a BIMS score of 9/15 which indicated moderate impaired cognition. No behaviors of wandering were coded for the look-back period of review. Residents EE's and GG's comprehensive care plans were reviewed for memory care and resident-to-resident altercations and revealed identical interventions as follows: A care plan which indicated they benefited from residing on the secured memory care unit for structured and specialized programming and each intervention for diversion and redirection were the same: Daily activity programming, encourage family to bring in photos and items to cue and alert of past roles and lifestyles, keep resident involved in activities and or socialization to divert behaviors, loneliness, sadness, maintain room as homelike as possible, provide activity calendar with reminders of daily events and provide snacks and fluids as tolerated. A care plan for behavioral symptoms of resident-to-resident altercations and each intervention for diversion and redirection were the same: administer medications as ordered, allow resident to vent feelings/needs, approach resident in a calm and friendly manor, assess resident's needs: food thirst, toileting needs, comfort level, body positioning, pain etc. treat as indicated, document behaviors per behavior management program, explain to resident what you are going to do before initiating task, family resident with own belongings and surroundings, maintain a safe environment for resident, Notify MD and psych services for increase in behavioral symptoms, provide resident personal space and remove resident from situation. The residents care plans lacked revision to include person-centered, specialized/meaningful interventions for dementia care services and intrusive wandering. b. Indiana Department of Health incident report indicated, on 11/10/23 Resident X wandered into Resident M's room. He made contact with her right arm and right eye. Resident X sustained a skin tear which measured 1.2 centimeter (cm) long, 0.4 cm wide and 0.1 cm deep. Resident X sustained bruising around her eye described on a skin sheet as dark purple and red, and measured 1.1 cm long and 0.3 cm wide. On 3/13/24 at 2:55 p.m., Resident X's record was reviewed. She had a diagnosis which included, but was not limited to, moderate unspecified dementia with psychotic disturbance. A Wandering/Elopement Risk Assessment, dated 12/7/2023, indicated she was at risk to wander, she had a history of wandering, and was able to propel herself in her wheelchair. A MDS assessment, completed on 2/29/24, assessed the resident as usually making herself understood. BIMS score 1/15 indicated severe cognitive impairment. No signs or symptoms of delirium, behaviors, rejection of care, or wandering. On 3/13/24 at 2:55 p.m., Resident M's record was reviewed. Resident M had diagnoses which included, but were not limited to, unspecified dementia with a mood disturbance, recurrent/moderate major depressive disorder and generalized anxiety. A Wandering/Elopement Risk Assessment, dated 3/7/24, indicated he was at low risk for wandering and was able to propel himself in his wheelchair. A significant change MDS, dated [DATE], indicated Resident M had the ability to make himself understood. He had a BIMS score of 5/15 which indicated he had severe cognitive impairment. No behaviors of wandering were coded for the look-back period of review. Residents M's and X's comprehensive care plans were reviewed for memory care and resident-to-resident altercations and revealed identical interventions as follows: A care plan which indicated they benefited from residing on the secured memory care unit for structured and specialized programming and each intervention for diversion and redirection were the same: Daily activity programming, encourage family to bring in photos and items to cue and alert of past roles and lifestyles, keep resident involved in activities and or socialization to divert behaviors, loneliness, sadness, maintain room as homelike as possible, provide activity calendar with reminders of daily events and provide snacks and fluids as tolerated. A care plan for behavioral symptoms of resident-to-resident altercations and each intervention for diversion and redirection were the same: administer medications as ordered, allow resident to vent feelings/needs, approach resident in a calm and friendly manor, assess resident's needs: food thirst, toileting needs, comfort level, body positioning, pain etc. treat as indicated, document behaviors per behavior management program, explain to resident what you are going to do before initiating task, family resident with own belongings and surroundings, maintain a safe environment for resident, Notify MD and psych services for increase in behavioral symptoms, provide resident personal space and remove resident from situation. The residents' care plans lacked revision to include person-centered, specialized/meaningful interventions for dementia care services and intrusive wandering. c. Indiana Department of Health incident report indicated, on 2/12/23, staff heard a verbal altercation between two residents and were unable to identify the second resident. Staff immediately responded to the noise and Resident N was found on the floor. Resident N was offered a personalized evening activity. Resident N sustained a laceration to the back of her head. An IDT progress note, dated 2/12/24 at 4:34 p.m., indicated an investigation was completed. The fall was unwitnessed, and staff were unable to confirm if any physical altercation took place. On 3/13/24 at 2:55 p.m., Resident N's record was reviewed. She had diagnoses which included, but were not limited to, Alzheimer's Disease, Schizophrenia, and generalized anxiety disorder. A Wandering/Elopement Risk Assessment, dated 2/14/2024, indicated she was at low risk for wandering. A quarterly MDS, dated [DATE], indicated she was able to make herself understood and her BIMS score was 8/15 which indicated moderate impaired cognition. No behaviors of wandering were coded for the look-back period of review. Resident N's comprehensive care plans were reviewed for memory care and resident-to-resident altercations and revealed identical interventions as follows: A care plan which indicated they benefited from residing on the secured memory care unit for structured and specialized programming and each intervention for diversion and redirection were the same: Daily activity programming, encourage family to bring in photos and items to cue and alert of past roles and lifestyles, keep resident involved in activities and or socialization to divert behaviors, loneliness, sadness, maintain room as homelike as possible, provide activity calendar with reminders of daily events and provide snacks and fluids as tolerated. A care plan for behavioral symptoms of resident-to-resident altercations and each intervention for diversion and redirection were the same: administer medications as ordered, allow resident to vent feelings/needs, approach resident in a calm and friendly manor, assess resident's needs: food thirst, toileting needs, comfort level, body positioning, pain etc. treat as indicated, document behaviors per behavior management program, explain to resident what you are going to do before initiating task, family resident with own belongings and surroundings, maintain a safe environment for resident, Notify MD and psych services for increase in behavioral symptoms, provide resident personal space and remove resident from situation. Resident N's care plans lacked revision to include person-centered, specialized/meaningful interventions for dementia care services and intrusive wandering. 3. During the survey period, the secured memory care unit was observed on multiple occasions for varying lengths of time for review of dementia care services and life enrichment. The following concerns were observed: Continuous unsafe and unsupervised intrusive wandering by Residents W, FF, and HH. Upon an initial visit to the secured memory care unit (MC) on 3/11/24 from 9:42 a.m. until 10:00 a.m., the following was observed. There were no activities occurring at that time. There was no music and/or other sensory stimulation being provided at that time. QMA 8 was passing medications from a cart and the end of the 300 hall, and two CNAs were busy with private resident care. The Nurse Practitioner (NP) was also on the unit, making clinical rounds. There were several residents seated in chairs at the nurses' station, some ambulated up and down the halls and in and out of the activity room. Residents W, FF, and HH were observed to walk almost in a single file line, one behind the other, up and down the halls and dipped into other residents' rooms if their doors were open. Staff did not appear to notice, and the residents were not redirected. On 3/13/24 from 9:45 a.m., until 11:00 a.m., the following was observed. There was no music and/or other sensory stimulation being provided at that time. No staff were observed at the nurses' station, and an unidentified Resident independently ambulated in and out of the nurses station area. There were approximately 9 unsupervised residents in the activity lounge and Residents W, FF and HH walked up and down the halls. They went in and out of other resident's rooms without awareness or redirection. Resident HH wandered into Resident N's room, and Resident N could be heard and she yelled, Help me! Someone help me! Get her out! CNA 12, who had just come out of another resident's room went to help. Resident N was upset and complained that Resident HH came into her room and tried to steal her lipstick. CNA 12 took Resident HH by the hand and walked her away from Resident N's room. She escorted Resident N to the activity room, but then left to provide resident care. Resident HH left the activity room and continued to wander up and down the halls. On 3/13/24 from 1:10 p.m. until 3:20 p.m., the following was observed. At 1:20 p.m., Resident W wandered in and back out of Resident X's empty room. At 1:27 p.m., Resident W wandered in and out Resident HH's empty room and into the room across the hall where Resident QQ was asleep in her bed. At 1:30 p.m., Resident's FF and HH stood together in Resident Q's empty room. When they walked out, Resident W wandered in, fidgeted with the pillow on Resident Q's bed and then walked out. At 1:33 p.m., Resident W wandered into Resident GG's empty room. She unfolded the blanket back from his bed, picked up his sweatshirt from the bed, played with the sleeve material and draped it over the end of his bed and walked out. At 1:36 p.m., Resident W wandered in and out of Resident X's empty room. At 1:37 p.m., Resident W wandered into DD's room and Residents FF and HH fell in line behind her and wandered into Resident DD's room. Resident FF and HH left the room, and Resident W came out of the room with a magazine in her hand. At 1:40 p.m., Resident W wandered into T's room, opened the bottom of a dresser drawer and rummaged through Resident W's personal items. She left the drawer open and walked out. At 1:42 p.m., Resident W wandered into AA's room who was asleep in her bed. Resident W pushed a button on the P-Tac unit and the turned it off. At 1:43 p.m., Resident W wandered into Resident DD's room, she picked up two more magazines from his dresser and took them out of his room. At 2:24 p.m., Resident W began to push Resident QQ's wheelchair. At 2:29 p.m., Resident W wandered in and back out of Resident NN's room. At 2:39 p.m., Resident W wandered in and out, back and forth between Resident HH and QQ's room. At 2:45 p.m. Resident W entered the activity room where several residents were gathered. Without recognizing personal boundaries, she aimlessly wandered through the crowd of seated and standing residents, often almost bumped into them. When trying to go around the table, she took the handles of NN's wheelchair and attempted to push her out of the way, but the chair was stuck on a cabinet handle and the back of a chair in which a resident was seated. Resident W pushed back and forth several times with enough force to cause the cabinet to knock loudly. This was brought to the attention of staff who were in the activity room, but spoke to each other and did not realize Resident W attempted to move Resident NN out of the way. At 2:51 p.m., Resident HH opened Resident EE's closed bedroom door, then entered his room. She opened Resident EE's closed bathroom door, where Resident EE had just finished using the bathroom. Resident EE left his room and Resident HH went in and used his restroom. At At 2:54 p.[TRUNCATED]

Based on interview and record review, the facility failed to ensure staff immediately reported to the Administrator witnessed abuse by another staff member to a resident for 1 of 3 residents reviewed for abuse (Resident B). Findings include: During the survey, the family provided the video from Resident B's web camera showing the abuse on 2/4/24. In the video Qualified Medication Aide (QMA) 11 was standing on the left side of the bed next to Resident B. The blankets were off of Resident B and QMA 11 was preparing to change the resident's incontinence brief. Certified Nurse Aide (CNA) 12 came to the right side of the bed from the bathroom. CNA 12 was smiling and talking with QMA 11. Resident B was calm and watching QMA 11 and CNA 12. Once CNA 12 was next to Resident B, CNA 12 reached over and grabbed Resident B's left arm and left hip to pull her toward her while QMA 11 pushed the resident's back and left shoulder to turn her onto her right side toward CNA 12. Resident B slid her legs down off the edge of the bed like she was getting out of bed. Resident B moved her hands toward CNA 12's lower arm and elbow and then behind CNA 12's back. The residents hands were no longer visible in the video. Suddenly, CNA 12 pushed Resident B's arms away from her body and hit Resident B on the left arm and upper abdomen with both open hands and yelled at the resident about grabbing and tearing her clothes. QMA 11 let go of Resident B to allow the resident to be on her back. QMA 11 shook her left hand side to side over the resident while CNA 12 was yelling at her but was not observed to verbally stop or physically intervene during the incident. CNA 12 and QMA 11 did not reposition Resident B's legs or reassure the resident that she was not falling. Resident B was turned onto her right side by CNA 12 again grabbing her left hip and pulling the resident towards her. She did not reposition the residents' legs. QMA 11 took off the soiled brief and started to clean Resident B. A male's voice was heard in the room and indicated there is no reason for smacking her! Another female's voice was heard indicating the resident had just woken up and staff did not need to be so rough. CNA 12 indicated they were not being rough and Resident B was trying to fall by putting her foot down on the ground. The female voice indicated Resident B did not understand what the staff were doing. Then the video ended. An interview during the survey from Family Member 1 indicated voices heard in the video telling CNA 12 her behavior was inappropriate were from the camera where Resident B's family members were watching the incontinence care. The family members were not in the room but were able to see the care live from the camera and speak directly to staff during care. A handwritten Witness Statement, dated 2/5/24, indicated it was written and signed by QMA 11. The statement indicated, QMA 11 had worked on the memory care on February 4, 2024, night shift. At about 5:40 a.m., QMA 11 and CNA 12 entered Resident B's room to provide care. QMA 11 turned Resident B towards CNA 12 to be able to clean her up. Resident B rolled towards CNA 12 and CNA 12 hit Resident B. QMA 11 told CNA 12 not to hit the resident. They finished the resident's incontinence care together. When QMA 11 went to the nurses' station she got the Administrator's number and placed a call, but there was no response. During an interview with the Administrator and Director of Nursing (DON), on 2/6/24 at 9:01 a.m., the Administrator indicated he received 3 phone calls around 10:06 a.m. on 2/4/24 reporting the abuse allegation. One call was from Certified Nurse Aide (CNA) 8, one was from Licensed Practical Nurse (LPN) 10, and one was from Resident B's family. Qualified Medication Aide (QMA) 11 indicated in her written statement she had called the Administrator during her shift, but the Administrator did not call back. The Administrator indicated he had no record of QMA 11 calling him. QMA 11 said she called from the nurses' station, but there was no record of the call. The Administrator pulled out his cell phone's call log and showed there were no missed calls on 2/4/24. The first record of receiving a call on 2/4/24 on his phone's call log was at 10:06 a.m. Management was going to address with QMA 11 that there was no evidence of a missed call and re-educate QMA 11 on if she attempted to call the Administrator she was to continue her attempts to call until the Administrator answered and/or she was to call the DON to get an answer. The Administrator indicated if staff witnessed any unsafe behavior from staff to residents, the staff were to remove the alleged staff person away from the residents immediately and then call the Administrator. He indicated he would have preferred for CNA 12 to have been moved to the front lobby instead of completing care and then he would have come to the facility to address the abuse allegation with CNA 12. During an interview with the Administrator and Director of Nursing (DON), on 2/6/24 at 9:01 a.m., The DON indicated she was called around 10 a.m. by the dayshift nurse LPN 10 and the dayshift CNA 8. During an interview on 2/6/24 at 5:33 a.m., Licensed Practical Nurse (LPN) 13 indicated if she had concerns with staff or witnessed abuse she would separate the staff from the residents and call the Administrator. Staff were to call the Administrator repeatedly until he answered. Since they worked night shift the Administrator may be sleeping and it could take a couple of times for him to wake up to the phone, but he would answer. LPN 13 had never had to call about abuse but had called the Administrator regarding other issues before. During an interview on 2/6/24 at 12:05 p.m., QMA 11 indicated she went to Resident B' room with CNA 12 to assist with cleaning the resident. QMA 11 was helping CNA 12 with her work since Resident B needed 2 people for care. QMA 11 turned the resident toward CNA 12 and the resident moved her arms and was sliding out of bed. CNA 12 hit the resident. QMA 11 told the CNA 12 no don't do that. Then QMA 11 heard a voice from somewhere asking why they were treating Resident B rough. QMA 11 told them she was not being rough, and they would finish care. CNA 12 stayed quiet and would not answer. Once care was done they left the room. QMA 11 tried to call the Administrator but there was no answer. It was the end of the shift and shift change. It had been a chaotic night, and she did not try to call again. She did tell the oncoming nurse what happened. She did not believe Resident B was trying to hit CNA 12. The resident did not know what she was doing she was just moving her arms. Resident B was not a violent person. QMA 11 believed CNA 12 was having a rough night and hit Resident B due to frustration. On 2/6/24 at 10:22 a.m. Resident B's record was reviewed. Resident B's diagnoses included, but were not limited to, Pick's disease (frontotemporal or front lobe dementia), general anxiety disorder, depression, and psychotic disorder with delusions. A quarterly Minimum Data Set (MDS) assessment, dated 1/29/24, indicated Resident B had adequate hearing, was not comatose, did not speak, sometimes understood others, and sometimes made others understand her. Resident B had adequate vision, wore corrective lenses. A Brief Interview for Mental Status (BIMS) assessment was not completed by the resident nor staff. Resident B had no behaviors, no impairment of extremities, and used a wheelchair for mobility. On 2/5/24 at 3:09 p.m., the Director of Nursing (DON) provided a current policy titled, Abuse Prevention Program. The policy indicated, .Our facility is committed to protecting our residents from abuse by anyone including, but not necessarily limited to: facility staff .Our abuse prevention/intervention education program include .Expect all personnel, residents, family members, visitors, etc., to report any signs or suspected incidents of abuse to facility management immediately .Reporting and Response .2. All personnel, residents, family members, resident representatives, visitors, etc., are encouraged to report incidents of resident abuse or suspected incidents of abuse. Such reports may be made without fear of retaliation from the facility or its staff. 3. Employees, facility consultants and/or attending Physicians must immediately report any suspected abuse or incidents of abuse to the Administrator. In the absence of the Administrator, such reports may be made to his/her designee. 4. The Administrator must be immediately notified of alleged abuse/neglect or incidents of abuse/neglect. If such incidents occur or are discovered after hours, the Administrator and Director of Nursing Services must be called at home or must be paged and informed of such incident .25.Any staff member or person affiliated with this facility who has witnessed or who believes that a resident has been a victim of mistreatment, abuse, neglect, or any other criminal offenses shall immediately report or cause a report to be made of, the mistreatment or offense. Failure to report such an incident may result in legal/criminal action being filed against the individual(s) withholding such information This citation relates to Complaints IN00427703 and IN00427705. 3.1-28(c)

Based on observation, interview, and record review, the facility failed to ensure a non-verbal, cognitively impaired resident was free from abuse for 1 of 3 residents reviewed for abuse (Resident B). Findings include: During the survey, the family provided the video from Resident B's web camera showing the abuse on 2/4/24. In the video Qualified Medication Aide (QMA) 11 was standing on the left side of the bed next to Resident B. The blankets were off of Resident B and QMA 11 was preparing to change the resident's incontinence brief. Certified Nurse Aide (CNA) 12 came to the right side of the bed from the bathroom. CNA 12 was smiling and talking with QMA 11. Resident B was calm and watching QMA 11 and CNA 12. Once CNA 12 was next to Resident B, CNA 12 reached over and grabbed Resident B's left arm and left hip to pull her toward her while QMA 11 pushed the resident's back and left shoulder to turn her onto her right side toward CNA 12. Resident B slid her legs down off the edge of the bed like she was getting out of bed. Resident B moved her hands toward CNA 12's lower arm and elbow and then behind CNA 12's back. The residents hands were no longer visible in the video. Suddenly, CNA 12 pushed Resident B's arms away from her body and hit Resident B on the left arm and upper abdomen with both open hands and yelled at the resident about grabbing and tearing her clothes. QMA 11 let go of Resident B to allow the resident to be on her back. QMA 11 shook her left hand side to side over the resident while CNA 12 was yelling at her but was not observed to verbally stop or physically intervene during the incident. CNA 12 and QMA 11 did not reposition Resident B's legs or reassure the resident that she was not falling. Resident B was turned onto her right side by CNA 12 again grabbing her left hip and pulling the resident towards her. She did not reposition the residents' legs. QMA 11 took off the soiled brief and started to clean Resident B. A male's voice was heard in the room and indicated there is no reason for smacking her! Another female's voice was heard indicating the resident had just woken up and staff did not need to be so rough. CNA 12 indicated they were not being rough and Resident B was trying to fall by putting her foot down on the ground. The female voice indicated Resident B did not understand what the staff were doing. Then the video ended. An interview during the survey from Family Member 1 indicated voices heard in the video telling CNA 12 her behavior was inappropriate were from the camera where Resident B's family members were watching the incontinence care. The family members were not in the room but were able to see the care live from the camera and speak directly to staff during care. On 2/5/24 at 4:04 p.m., the Administrator provided the Grievance log for January and February 2024. On 2/4/24 a grievance was filed by a family member related to Resident B as a care concern. The Administrator indicated the grievance had not been completed as they were still completing the abuse investigation, but he had an appointment scheduled to meet with the family. A handwritten Witness Statement, dated 2/5/24, indicated it was written and signed by QMA 11. The statement indicated, QMA 11 had worked on the memory care on February 4, 2024, night shift. At about 5:40 a.m., QMA 11 and CNA 12 entered Resident B's room to provide care. QMA 11 turned Resident B towards CNA 12 to be able to clean her up. Resident B rolled towards CNA 12 and CNA 12 hit Resident B. QMA 11 told CNA 12 not to hit the resident. A typed document without a title, indicated QMA 11 was interviewed by the Administrator and the Director of Nursing (DON). QMA 11 indicated she had not abused a resident but had witnessed CNA 12 hit Resident B on her arm. During a telephone interview on 2/6/24 at 2:52 p.m., Resident B's Family Member 2 indicated the family had had problems with Resident B's care previously, so the family had decided to get a web camera. Multiple family members had access to the camera and the videos were also uploaded to a shared cloud drive (remote storage). On Sunday 2/4/24, Family Member 3 got notified on her phone of movement in Resident B's room and pulled up the video to check on the resident. Family Member 3 observed CNA 12 hit Resident B while providing care. Family Member 2 was able to pull the video from the cloud. The family contacted the facility and filed a grievance with the Administrator. The family provided the video to the facility. The family was told CNA12 would be fired, her license would be reported, and the police were called. The family had an appointment with the facility scheduled for 2/7/24 at 10 a.m. He was told CNA 12 was going to be charged with a felony. During an interview on 2/6/24 at 12:05 p.m., QMA 11 indicated she went to Resident B' room with CNA 12 to assist with cleaning the resident. QMA 11 was helping CNA 12 with her work since Resident B needed 2 people for care. QMA 11 turned the resident toward CNA 12 and the resident moved her arms and was sliding out of bed. CNA 12 hit the resident. QMA 11 told the CNA 12 no don't do that. Then QMA 11 heard a voice from somewhere asking why they were treating Resident B rough. QMA 11 told them she was not being rough, and they would finish care. CNA 12 stayed quiet and would not answer. Once care was done they left the room. QMA 11 tried to call the Administrator but there was no answer. It was the end of the shift and shift change. It had been a chaotic night, and she did not try to call again. She did tell the oncoming nurse what happened. She did not believe Resident B was trying to hit CNA 12. The resident did not know what she was doing she was just moving her arms. Resident B was not a violent person. QMA 11 believed CNA 12 was having a rough night and hit Resident B due to frustration. During an interview on 2/6/24 at 5:33 a.m., Licensed Practical Nurse (LPN) 13 indicated she was the nurse working on the locked unit. She had worked with CNA 12 numerous times in the past and had no concerns about her treatment of residents. She was surprised to hear of the incident Resident B was not combative and allowed care to be done to her. She was not able to help with care much anymore and she got scared or confused easily. Resident B may tug on clothing or hold on to staff, but she was not combative. Resident B tried to communicate that she could not help, or she was scared by moving her hands. Resident B did not verbally speak anymore due to her disease progress. She communicated nonverbally with facial expressions, tapping on things, and hitting the table if she wanted to go to sleep when sitting in activities or at dining. She was a 2 person assist for care due to her not being able to help much with her own care. It was safer for her to have 2 people assisting her. She was the only resident on the unit with a web camera. LPN 13 believed it was the family's request and the facility allowed it. It was a good thing since it showed abuse when no one was aware that was happening. All of the staff were shocked and surprised. During an interview on 2/6/24 at 5:33 a.m., CNA 14 indicated she had worked with CNA 12 previously and never had any concerns about her treatment of residents. Resident B was not combative and did not resist care. During an observation on 2/6/24 at 5:52 a.m., morning care was observed for Resident B with LPN 13 and CNA14. A sign was posted on the outside of the door and in the room on the wall indicating that the room was being recorded by video. As the staff entered the resident's room and turned on the lights a family member came on over the web camera and said, good morning. The family member asked staff to unclip the call light from Resident B's blanket since the resident was unable to use it and the family member was afraid she would get tangled up in cord. During the observation of incontinence care and dressing of the resident LPN 13 and CNA 14 informed Resident B of what they were doing before they did it. When LPN 13 turned Resident B onto her right side, Resident B moved her legs off the bed and attempted to try to slide her legs down to the floor like she was getting out of bed. CNA 14 moved her legs back onto the bed and explained again they were going to lay her on her right side. The resident remained calm and did not resist care. Resident B would clap her hands together when she was unsure of what was happening and when she had been on her side for several minutes. LPN 13 and CNA 14 reassured Resident B and explained what they were doing. LPN 13 and CNA 14 were able to provide incontinence care, cleaned her face and armpits, dressed the resident for the day, and provided a clean top sheet and blanket without concerns. The skin on Resident B's arms and stomach were free from skin impairments and there were no signs of bruising or redness. During a telephone interview on 2/6/24 at 3:48 p.m. CNA 12 indicated she did not abuse Resident B. She had worked with the resident for a year. The early morning of 2/4/24 she was in the room with QMA 11, and they were changing Resident B. The QMA had turned the resident toward her to clean the resident. The resident's feet were falling down off the bed. The resident grabbed CNA 12's shirt and was holding onto it. When CNA 12 went to turn the resident back toward the QMA the resident was holding onto her and it was hard to turn her, so CNA 12 had to get the resident's hand off her shirt and push her hard to get her to turn. CNA 12 did not hit Resident B and would not hit her. CNA 12 was just trying to get Resident B off of her so she could turn her to finish cleaning her. On 2/6/24 at 10:22 a.m. Resident B's record was reviewed. Resident B's diagnoses included, but were not limited to, Pick's disease (frontotemporal or front lobe dementia), general anxiety disorder, depression, and psychotic disorder with delusions. A quarterly Minimum Data Set (MDS) assessment, dated 1/29/24, indicated Resident B had adequate hearing, was not comatose, did not speak, sometimes understood others, and sometimes made others understand her. Resident B had adequate vision, wore corrective lenses. A Brief Interview for Mental Status (BIMS) assessment was not completed by the resident nor staff. Resident B had no behaviors, no impairment of extremities, and used a wheelchair for mobility. A care plan, initiated on 8/3/21 and revised on 9/14/21, indicated Resident B needed assistance with activities of daily living. Interventions included, but were not limited to, assist with incontinent care, staff assistance with bed mobility, and staff assistance with personal hygiene and toileting. A care plan, initiated on 8/12/21 and revised on 6/21/22, indicated Resident B exhibited signs of cognitive impairment. Interventions included, but were not limited to, staff were to allow extra time for the resident to respond, always approach the resident in a friendly gentle manner, and be alert to nonverbal cues. A care plan, initiated on 4/25/23, indicated Resident B exhibited impulsivity of frequent jerking movements and rocking back and forth. Interventions included, but were not limited to, staff were to approach the resident in a calm and friendly manner, explain to the resident what they were going to do before starting the task, allow the resident to regain their composure if she became combative or resistive and postpone care or activity and re-approach as needed, maintain a safe environment, and listen to the resident's needs and adjust the plan of care as needed. A care plan, initiated on 4/25/23, indicated Resident B had difficulty with communication due to neurological symptoms and diagnoses of Pick's disease, dementia, anxiety, and psychotic disorder with delusions. Interventions included, but were not limited to, do not rush and observe for physical and nonverbal indicators of discomfort or distress. A care plan, initiated on 4/25/23, indicated Resident B's family requested a camera to be in the room and signs notifying the staff that recording was in progress would be posted in and outside the room. Interventions included, but were not limited to, staff were to allow the resident to vent feelings and needs, approach the resident in friendly calm manor, assess the resident's needs for toileting and body positioning, provide care in pairs, explain to the resident what they were going to do before initiating the task, maintain a safe environment, and if the resident became combative or resistive staff were to postpone care and allow the resident to regain composure. Focused charting, dated 2/4/24 at 12:33 a.m., indicated Resident B did not have signs or symptoms of emotional distress or tearfulness. There were no changes in the resident's facial expressions or resistance with care. A General Progress Note, dated 2/4/24 at 2:46 p.m., indicated Resident B did not have signs of distress or tearfulness. A skin assessment was completed with no new areas of concern. The resident's record lacked documentation of the incident. On 2/5/24 at 3:09 p.m., the Director of Nursing (DON) provided a current policy titled, Abuse Prevention Program. The policy indicated, .Our residents have the right to be free from abuse, neglect .Our facility is committed to protecting our residents from abuse by anyone including, but not necessarily limited to: facility staff .Our abuse prevention/intervention education program includes .Training staff to understand and manage a resident's verbal or physical aggression .Monitoring staff on all shifts to identify inappropriate behavior toward residents (e.g., using derogatory language, rough handling of residents, ignoring residents while giving care This citation relates to Complaints IN00427703 and IN00427705. 3.1-27(a)(1) 3.1-27(b)

A. Based on observation, interview, and record review, the facility failed to ensure a resident with a history of suicidal ideation (thinking about or planning suicide) and verbal threats of harming himself was supervised and free from items that could be used to harm himself for 1 of 3 residents reviewed for behavioral symptoms which resulted in an immediate jeopardy when Resident D while on 15-minute checks injured himself by breaking a glass plate and cutting his neck and verbalized he would commit suicide if he did not leave the facility; and after verbalizing threats of suicide again and while on 15 minute checks Resident D stabbed himself in the abdomen multiple times with a fork and was observed with a corded telephone in his room during multiple observations. B. Based on observation, interview, and record review, the facility failed to ensure a master code to secured doors was not provided to a resident for 1 of 3 random resident interviews and observations (Resident H). C. Based on observation, interview, and record review, the facility failed to ensure 2 of 3 memory care (MC) biohazard rooms were locked, one with a bottle of Restroom Disinfectant (hazardous chemical for cleaning) for 1 of 2 observations of the memory care. The immediate jeopardy began on 5/6/21 when Resident D made verbal threats of suicide and was placed on 15-minute checks. On 5/7/21 Resident D had a glass plate in his room unsupervised that he broke and cut his neck and verbalized he would commit suicide if he did not leave facility. He was sent out for psychological services on 5/8/21 and returned on 5/26/21 with 15-minute checks. On 6/10/21 Resident D indicated he would kill himself. On 6/11/21 resident was attempting to remove pictures from the wall. On 6/28/21 family requested the telephone be taken out of the resident's room. On 6/30/21 resident indicated he had stabbed himself in the abdomen with a fork a week ago, his abdomen was observed with bruising and pinpoint wounds; and the resident was observed with a corded telephone in his room multiple times before being sent out to the hospital. The Interim Executive Director (ED), Director of Nursing Services (DNS), and Corporate Consultant were notified of the immediate jeopardy at 5:49 p.m. on 7/1/21. The immediate jeopardy was removed on 7/2/21 at 4:40 p.m., but noncompliance remained at a lower scope and severity of isolated no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: A. During an observation, on 6/30/21 at 10:21 a.m., Resident D was observed in his room sitting on his bed, no call light was observed in the resident's room. The resident indicated a staff member had told him his family did not want him to come home and they did not love him anymore. He was unable to remember the staff member's name but believed it to be someone in charge of things at the facility. When the staff member made the statement, Resident D stabbed himself in the abdomen with a fork. At that time, he pulled up his t-shirt and exposed his abdomen. An area was observed to the resident's left middle, lower quadrant that was oblong shaped with dark purple discoloration noted around the border. The discoloration lightened toward the center, into a light green then yellow and lead to the resident's skin color. In the center of the flesh-colored area was five ball point pen sized puncture marks that were dark red in color and appeared shallow. A telephone was observed in the resident's bedside table drawer. The telephone had a stretchy coiled cord from the base to the receiver and cord connected to the bottom of the base of the phone and was draped out of the drawer, hung down the side of the bedside table, and was connected to the wall. The resident indicated he was not supposed to have a call light because the staff were afraid, he would choke himself. The resident's bathroom was observed to have a red emergency pull cord that hung on the wall. During an interview, on 6/30/21 at 11:47 a.m., Patient Care Associate (PCA) 7 indicated Resident D had not had any behaviors that she was aware of and if resident had behaviors the staff were required to report it to the nurse in charge of caring for the resident. During an interview, on 6/30/21 at 11:50 a.m., Licensed Practical Nurse (LPN) 6 indicated Resident D had an order for 15-minute checks and had not had a behavior since the time he had thrown things. She was not aware if the resident had ever tried to harm himself while at the facility. The resident had behaviors on occasions. She believed it was because the resident was frustrated because his family would not tell him if he had to live at the facility permanently. She was unaware of what interventions his care plan had and how to access his care plans. She was able to redirect the resident by talking to him. The resident was alert and oriented. During an observation, on 6/30/21 at 11:55 a.m., Resident D was observed in his room on the telephone. A stretchy coiled cord and a cord connected to the bottom of the base of the phone was draped over the side of the bedside table and connected to the wall. No staff were observed in the resident's room at this time. During an observation, on 6/30/21 at 12:21 p.m., Resident D was observed ambulating down the 800 hall with a walker. Resident D indicated he had to 'get out of this place, and he could not be kept against his will anymore. He proceeded to exit the doors off the unit down the hallway towards the front entrance area. Staff attempted to redirect the resident and he continued off the unit. The Director of Nursing Services (DNS) was able to stop the resident before he entered the main lobby area and asked him what was going on. The resident sat down on the floor and indicated it was another resident that had triggered his mood. The resident was assisted back to his room. At 12:33 p.m. Resident D's lunch tray was delivered. A plastic plate and plastic utensils were noted on the resident's tray. The resident was observed to have a telephone in his room. No staff were observed to be providing one on one (1:1) care at this time. During an interview, on 6/30/21 at 2:58 p.m., the Interim Executive Director (ED) indicated Resident D had voiced prior he did not like the social worker and felt the social worker had not been truthful with him. During the interview a resident was heard from the hallway getting loud and indicated he was leaving the facility. The Interim ED checked to see what was going on and indicated it was Resident D who was being assisted by staff. At 3:15 p.m. an ambulance and fire truck were observed at the facility to transfer Resident D to the hospital emergency room for evaluation and treatment for his behaviors. A record review was completed for Resident D on 7/1/21 at 9:13 a.m. A facility census indicated the resident admitted to the facility on [DATE]. Diagnoses included, but were not limited to, unspecified dementia with behavioral disturbance (a mental disorder in which a person loses the ability to think, remember, learn, make decisions, and solve problems), [CONDITION(S)] disorder (a mental health condition including [CONDITION(S)] and mood disorder symptoms), generalized anxiety disorder (severe ongoing anxiety that interferes with daily activities), major depressive disorder (a mental disorder characterized by persistently depressed mood and long term loss of pleasure or interest in life, often with other symptoms such as disturbed sleep and suicidal thoughts), and sleep disorder. A physician/nurse practitioner note, dated 5/5/21 at 6:39 p.m., indicated, Patient presented as to [local hospital name] on 4/28/21-5/4/21 for suicidal ideation, paranoia, depression without [CONDITION(S)]. Pt had been previously treated at [second local hospital name] for [CONDITION(S)] and was noted to have paranoid behaviors. A communication note, dated 5/6/21 at 11:25 p.m., indicated the resident was at the nurses' station screaming racial slurs at the nursing staff and was redirected back to his room by a nurse. The resident indicated if his spouse or daughter did not come to pick him up, he wanted to hurt himself. The resident stated he did not have a plan and just wanted to get out of the facility and requested his medication to help him calm down. Nursing staff removed potentially harmful items from the resident's room and writer continued to talk to resident and reassure him. A snack and coffee were offered to the resident and he was placed on 15-minute checks. Resident was pleasant when followed up with by nursing staff. A Situation, Background, Appearance, Review (SBAR) and Notify Communication Summary, dated 5/6/21 at 3:07 p.m., indicated there was a change in the resident's condition reported that consisted of behavioral symptoms. A mental status evaluation indicated the resident had increased confusion. A behavioral status evaluation indicated the resident had verbal aggression and other behavioral symptoms. A nursing observation, evaluation, and recommendation indicated the daughter had reported these types of behaviors had happened for the last [AGE] years. The primary care provider responded with a new order for [MEDICATION(S)] (antipsychotic medication). A communication with family form, dated 5/6/21 at 11:25 p.m., Resident D indicated if his spouse or daughter did not come to pick him up, he would hurt himself. Nursing staff removed potentially harmful items from his room. The resident's daughter indicated that the resident had been this way for [AGE] years and is attention seeking. Resident D's daughter indicated that he had been calling her and stated he was going to snap her neck and calling her mother and telling her that she was a lazy no-good wife. A care plan, initiated on 5/6/21 and revised on 6/28/21, indicated the resident exhibited behavior symptoms of verbal aggression, threatening others, and using racial slurs. Per wife and family, resident would call on phone constantly day and night saying hateful things to them. Per family's request, room phone took out at this time. Interventions included, but were not limited to, approach resident in a calm friendly manner, document behaviors per behavior management program, assess residents needs for food, thirst, toileting needs, comfort level, body positioning, pain, maintain a safe environment for resident and treat as indicated. A care plan, initiated on 5/6/21, indicated the resident had behavior symptoms of delusions. Interventions included, but were not limited to, maintain a safe environment, and notify physician and psych services for increase in behavioral symptoms. A care plan, initiated on 5/7/21 and revised on 5/26/21, indicated the resident exhibited psychosocial well-being problem as evidenced by related to history of suicide ideation and suicide attempts. Interventions included, but were not limited to, 15-minute checks as needed and ensure a safe environment for resident. Remove any objects that the resident could use for self-harm such as call light cords, knives, sharp objects, blind strings, shoelaces. Resident would have plastic silverware, paper plates and a bell to use as a call light. A care plan, initiated on 5/7/21, indicated the resident had behavior symptoms of physical aggression, kicking doors, and throwing objects. Interventions included, but were not limited to, document behaviors per behavior management program, notify physician and psych services for increases in behavioral symptoms and maintain a safe environment for resident. A health status note, dated 5/7/21 at 4:25 p.m., indicated the resident was at the nurses' station throwing his arms in the air and stated if his daughter did not get there to pick him up, he was going to break the window. Resident threw items in his room breaking things and was kicking and swinging at staff. Resident was offered personal space, reassurance, and offered snack and drink which were not effective. An as needed (PRN) mediation was administered. The note lacked documentation of which PRN medication was administered and lacked documentation the family or physician had been notified. A Medication Administration Record (MAR), dated May 2021, indicated [MEDICATION(S)] solution 5 milligrams (mg)/ milliliter (ml), start dated 5/7/21 and discontinued on 5/8/21, inject 0.5 ml intramuscularly (IM) every 6 hours as needed for agitation. The MAR lacked documentation this medication had been administered. A health status note, dated 5/7/21 at 8:28 p.m., indicated the resident broke a glass plate in his room and cut himself and the cut was superficial. The area was cleaned with normal saline and patted dry. Resident indicated he wanted to kill himself if he could not leave. Resident would be referred to psych services and was placed on 1:1 supervision. A review of the resident's clinical record, dated 5/7/21, lacked documentation of an assessment and measurements of the resident's superficial cut to the neck. A SBAR Communication Summary, dated 5/7/21, indicated the resident was a danger to self or others, had suicide potential, and other behavioral changes. A health status note, dated 5/8/21 at 12:30 p.m., indicated the resident may be sent to for psychiatric evaluation and treatment. A psychiatric evaluation note, dated 5/9/21 from 8:50 a.m. to 9:50 a.m., indicated the resident had stated he was going to kill himself since he was not able to see his wife in the emergency department about a week ago. Behaviors started on 5/8/21 at a long-term care facility and resident was redirected with communication and food. Resident had verbal aggression, screaming, racial slurs and was redirected back to his room. The resident stated if had to stay there he would hurt himself and pointed to the call light and said he would use it. He was placed on 15-minute checks and ligature risks were removed. The resident had been yelling and was administered as needed [MEDICATION(S)], he flipped table and broke a clock on the wall and threw it. The intervention was communicated. The resident used broken glass to a glass plate and cut himself, unsure if it was intentional. The resident was placed on 1:1 supervision. A health status note, dated 5/8/21 at 1:41 p.m., indicated the resident remained on 1:1 care until transportation arrived. A health status note, dated 5/26/21 at 3:36 p.m., indicated Resident D was admitted to the facility via ambulance. Resident was alert to staff, had his call light in reach. Resident was assisted to bed with an assist of 2. Resident needed help with all his activities of daily living. A social service note, dated 5/27/21 at 2:49 p.m., indicated the resident stated he was feeling a little better and had no plans to end his life. Resident would be placed on 15-minute checks. Room was searched for any objects that could be used for self-harm and none were found. A MAR, dated May 2021, indicated 15-minute checks every shift. The MAR indicated this had been completed each shift from 5/27/21 through 5/31/21. A 15- minute safety check off sheet, dated 5/27/21 through 5/28/21, indicated Registered Nurse (RN) 28 had signed off every 15 minutes from 5/27/21 at 2:45 p.m. through 5/28/21 at 2:15 p.m. An employee timesheet, dated 5/27/21 through 5/28/21, indicated RN 28 clocked in at 2:34 p.m. on 5/27/21 and clocked out at 6:43 a.m. on 5/28/21. The timesheet lacked documentation she had worked from 6:44 a.m. to 2:15 p.m. during the times RN 28's initials were documented on the 15-minute safety check off sheet. A physician/nurse practitioner note, dated 5/28/21 at 10:06 p.m., indicated Hospital History [Patient] presented to [psych hospital] 5/8/21-5/26/21 for suicidal ideation, verbal aggression, screaming, racial slurs, and breaking a plate in an attempt to slit throat. A MAR, dated June 2021, indicated 15-minute checks every shift. The MAR indicated this had been completed each shift from 6/1/21 through 6/30/21. An Admission Minimum Data Set (MDS) Assessment, dated 6/1/21, indicated the resident was cognitively intact. The resident required physical assist of two plus staff. A Psychiatry Initial Consult, dated 6/7/21, indicated resident was admitted to facility on 5/4/21 following an acute inpatient hospitalization and neruopsych hospital stay.On 5/7/21 while eating his supper meal, patient broke a plate and attempted to cut his throat with the broken dish he was immediately sent back out to psych and returned to [NAME] of [NAME] on 5/26/21 Current risk factors indicated history of suicidal ideation, intent, plan, and recent attempt. The resident's mood was agitated, anxious, depressed, hopeless, overwhelmed, remorseful, tearful, tense. Assessment and plan for the resident indicated the resident's anxiety disorder was minimally stable and he was at increased risk of suicidal thinking. A social service note, dated 6/10/21 at 5:07 p.m., indicated the resident stated if he could not leave the facility that he was going to kill himself. The resident did not have a plan. He was now on 15- minute checks. The room was searched, and no items were found the resident could use for self-harm. The note lacked documentation for any resident centered interventions being used. The note lacked documentation the family or physician had been notified at this time. A health status note, dated 6/10/21 at 10:09 p.m., indicated the resident requested medication to help him sleep because he was able to calm down. The resident was currently on 15-minute checks for stating he wanted to kill himself earlier that afternoon. He was not receiving any scheduled sleep medications and did not have any as needed sleep medications. The nurse practitioner provided an order for [MEDICATION(S)] (sedative), give 50 mg one time. A Psychology Diagnostic Assessment, dated 6/10/21, indicated, .Resident was recently returned from psychiatric hospitalization after he broke a plate and attempted to cut himself with it in an apparent suicide attempt or gesture (likely the latter since he did this in front of staff who intervened before he hurt himself) .Resident was specifically angry about not having a phone installed in his room .Resident also reported that he has struggled with depression since his teens, but has never been suicidal until coming to the facility. He also stated that his suicide attempt at facility was a 'mickey mouse act' because he wanted to get out of the facility .He made several suicidal statements today .Resident does not appear to have suicidal intent, but rather making threats and gestures for secondary gain purposes. However, unsafe behaviors such as this could result in injury. Resident only make suicidal statements in reference to getting out of the facility A health status note, dated 6/11/21 at 1:39 p.m., indicated the resident was attempting to remove a picture from the wall in the room. Resident was redirected but very anxious. Resident was offered medication to calm him, the resident stated the only thing that worked was [MEDICATION(S)] (antianxiety). A new order was obtained from the nurse practitioner. The note lacked documentation how the resident was redirected and if any other resident centered interventions were used prior to obtaining an order from the nurse practitioner. A social service note, dated 6/15/21 at 9:34 a.m., indicated the note was a late entry and the resident had no further thoughts of suicide ideation. He no longer needed 15- minute checks. A nursing skin assessment, dated 6/23/21, indicated the resident had no skin concerns. A health status note, dated 6/24/21 at 1:06 p.m., indicated the resident was verbally aggressive when he was told he could not go home. Attempted to schedule care plan with family but unsuccessful. The daughter requested the resident not call her or his spouse due to him being verbally abusive when he called. The resident wanted to review his chart and after reading a few items stated he was getting out of the facility that day and staff could not stop him. Resident then threatened and lunged at writer; other staff members attempted to redirect. After leaving room the resident threw his lunch tray against the wall and attempted to throw a chair in the room at the window. The nurse practitioner was called and new orders were obtained for a one-time dose of [MEDICATION(S)]. Resident agreed to take the medication to calm him down. The note lacked documentation the family had been notified. The note lacked documentation any other resident centered interventions were used and failed to indicate what the staff done to try and redirect the resident. A MAR, dated June 2021, indicated [MEDICATION(S)] solution 5 mg/ml, inject 1 ml IM one time only for agitation and aggression. The MAR indicated the medication had been administered on 6/24/21 at 1:30 p.m. A shower sheet, dated 6/26/21, indicated the resident had not skin concerns. A social service note, dated 6/28/21 at 12:55 p.m., indicated the resident's wife stated the resident would call on the phone constantly day and night stating hateful things to them. The family requested the resident's telephone be taken out of his room to decrease the number of calls per day. The wife stated he could use the nurses' station phone a couple of times a day to call if needed. The writer spoke with maintenance to remove the phone and the resident's care plan was updated. A health status note, dated 6/30/21 at 11:01 a.m., indicated the resident had a phone in his room in his drawer. The resident stated he had taken it from another room and the staff better not take it that he was not going to kill himself. Upon an assessment of the resident's skin the resident was observed to have four small puncture wounds within an area of discoloration. When the resident was asked what happened he indicated he stabbed himself with a fork and that it had happened when he was told he could not go home last week. No noted items present that could cause harm to resident except phone. The staff were instructed to check on resident every 15 minutes, the resident denied suicidal ideations. The nurse practitioner was notified. A non-pressure ulcer note, dated 6/30/21 at 11:30 a.m., indicated the resident had an acquired area to the left lower abdomen. No drainage or odor noted. The area measured 9 centimeters (cm) length by 3 cm width by 0.1 cm depth and was yellow/purple in color. Skin was intact and open to air. A social service note, dated 6/30/21 at 11:46 a.m., indicated the resident was having signs and symptoms of anxiety and verbal distress with staff and requested to speak with social services. The writer went and spoke with resident and he was upset about wanting a plan of care and where he was going from here. Writer explained to resident he was working with therapy services to get stronger, and his family wished for him to stay there at that time. Resident was able to recall having anxiety the night before and that day. Staff would continue to ensure resident was safe and writer would follow up and give support as needed. A social service note, dated 6/30/21 at 3:20 p.m., indicated the resident had 1:1 care provided when he got out of bed and threw a bedside table towards the writer's stomach area and walked of the room and paced quickly to the font lobby area. Resident was easily redirected back to the nurses' station and was awaiting the paramedics arrival. During an interview, on 6/30/21 at 3:55 p.m., Resident H's family member indicated the facility had notified her of an incident where they had to remove the resident's phone from his room because he had indicated he was going to strangle himself. He had been placed on 15-minute checks and this was the first incident she recalled being notified of. During an interview, on 7/1/21 at 10:42 a.m., the DNS indicated she was unsure why the same nurse had documented 15-minute checks for a 24-hour period because staff do not work a 24-hour shift. The 15-minute checks were documented on paper, but a physician's order was also added where staff were documenting on the MAR every shift that 15-minute checks had been completed. She had determined the paper charting had discrepancies and that was why they switched to documenting it on the MAR. She was unaware prior to 6/30/21 that Resident D had stabbed himself with a fork. Once it was brought to her attention, she completed an investigation and found the resident had not reported it to staff that had cared for him. The resident was a set up only for showers and CNAs would document and report to the nurse any new skin conditions they observed during a set up for a shower. A reportable was not completed for the incident of the resident breaking a plate and cutting his neck because it was looked at as a behavior and not a suicide attempt. The resident's phone had been removed from his room and he was able to take a phone out of another resident's room. The resident should not have had a phone in his room for safety reasons. Behaviors would be documented by nursing staff in the progress notes and CNAs would document in their daily charting. Any behaviors would be reported to the Social Services Director (SSD) and addressed at that point. During an interview, on 7/2/21 at 2:12 a.m., LPN 29 indicated he was unaware Resident D had previously attempted suicide or had been hospitalized for severe depression and suicidal ideation. That information could be found in care plans, but the staff had never seen it. He was unsure why they resident had not had a phone in his room and had assisted the resident to use the phone at the nurses' station. The resident had been on 15- minute checks but he was not sure why. The resident or other staff had not mentioned to him the resident had stabbed himself with a fork until this week when a manager brought up the concern. During an interview, on 7/2/21 at 2:12 a.m., RN 28 indicated Resident D was always restless, agitated, and often made threatening statements he would kill himself. The resident had things removed from his room that he could have used to harm himself. The resident was on 15- minute checks and staff would walk past the resident's room and make sure he was okay. They would not enter the room unless the resident needed something. During an interview, on 7/1/21 at 5:50 p.m., the DNS indicated the resident was completely ambulatory and known for going into other resident rooms and that was how he was able to get a phone in his room and had done this before. He was known for doing that how were we supposed to keep someone like that safe. During a telephone interview on 7/2/21 at 2:04 p.m., Psychiatrist 36 indicated he was aware of the two incidents with Resident D. He indicated the plate incident was an attempt to get out of the facility. This had been repetitive manipulative gestures of suicide to get what he wanted. He had never actually harmed himself where it required the resident to be hospitalized for injuries. He had very well-established manipulative gestures to get out of the facility. He was trying to manipulate the environment. In his opinion the resident was not seriously suicidal. It was complicated with a depressed [CONDITION(S)] resident due to them being unpredictable. The probability of him intentionally harming himself was extremely low. What happens to these type of patients was they accidently harm themselves. They see that a lot with borderline suicide because gesture suicide by accident did happen. It would be accidental miscalculation not intention. On 7/1/21 at 4:37 p.m., the DNS provided a document, revised on 6/1/18, and titled, Accidents and Incidents - Investigating and Reporting, and indicated it was the policy currently being used by the facility. The policy indicated, Policy Statement: All accidents or incidents involving residents occurring on our premises shall be investigated and reported to the Administrator .2. The following data, as applicable shall be included on the Report of Incident/Accident form: a. The date and time the accident or incident took place; b. The nature of the injury .c. The circumstances surrounding the accident or incident; d. Where the accident or incident took place; e. The names of witnesses and their accounts of the accident or incident; f. The injured person's account of the accident or incident; g. The time the injured person's attending Physician was notified, as well as the time the physician responded and his or her instructions; h. The date/time the injured person's family was notified and by whom; i. The condition of the injured person, including his/her vital signs .k. Any corrective action taken; l. Follow up instructions; m Other pertinent data as necessary or required On 7/1/21 at 4:37 p.m., the DNS provided a document, revised on 6/1/18, and titled, Dementia- Clinical Protocol, and indicated it was the policy currently being used by the facility. The policy indicated, .Monitoring and follow-up: 1. The staff should monitor the individual with dementia for changes in condition and decline in function and will report these findings to the physician The immediate jeopardy that began on 5/6/21 was removed on 7/2/21 when the facility assessed all residents for suicidal ideation and self-harm, all resident rooms were observed for hazards, and staff were in-serviced on behavior management for residents that voice suicidal ideation and/or self harm. The noncompliance remained at the lower scope and severity level of isolated no actual harm with the potential for more than minimal harm that is not immediate jeopardy because of the facility's need for continued monitoring. B. During an interview, on 6/30/21 at 12:52 p.m., Resident H indicated one of the staff on night shift had grown tired of getting sodas and snacks for him from a secured vending area, so she provided him with the master code to get into secured door in the facility. At this time, Resident H went to a door with a sign that indicated biohazard on the door, attempted to open the door and the door did not open. The resident then put a code into the locked keypad and the door opened. The resident demonstrated this same activity with another door that had a sign that indicated janitor. There were unlocked electric panels observed in this secured room. The resident indicated he could not believe staff had provided him with the master door code and had went around at night and tried it on various doors, each time he had tried it on locked keypad door the door opened. During an observation, on 6/30/21 at 3:19 p.m., the Interim Executive Director (ED) toured the facility with this surveyor. During the observation the Interim ED entered the master code into various keypads and was the same code Resident H had provided during an interview. The master code opened the following locked keypad doors: The Social Services office, the ED's office, the Minimum Data Set (MDS) office, the Director of Nursing Services (DNS) office, the Human Resources (HR) office, the kitchen, and the laundry room which included, but was not limited to cleaning supplies and the Janitor's office. The Janitor's office included 2 unlocked electric panels and a mechanical storage room that included unlocked electric panels and cleaning supplies. The cleaning supplies included, but were not limited to, a neutral quat disinfectant labeled with hazardous ingredients, an array ultimate sanitizer labeled with hazardous ingredients, and a concentrated no-rinse floor cleaner labeled with hazardous ingredient. At this time, the Interim ED indicated residents should not have the master code to enter the secured rooms and should not have access to hazardous cleaning supplies. The staff should not have provided the master code to any resident regardless of the resident's cognitive status. During a record review, on 7/2/21 at 11:11 a.m., a safety data sheet for a neutral quat disinfectant indicated the cleaner had hazardous ingredients that caused serious eye damage and skin irritation. A safety data sheet for an array ultimate sanitizer indicated the cleaner had hazardous ingredients that caused severe skin [CONDITION(S)] and serious eye damage. A safety data sheet for a concentrated no-rinse floor cleaner that indicated hazardo[TRUNCATED]

Based on observation, interview and record review, the facility failed to ensure water temperatures did not exceed 120 degrees Fahrenheit (F), in the main dining room, resident room bathroom sinks, and resident shower rooms. This deficient practice had the potential to effect 10 of 53 Residents who had a [DIAGNOSES REDACTED]. The immediate jeopardy began on 7/17/19 at 1:53 p.m., when the Environmental Services Director (ESD) checked water temperatures in multiple resident bathrooms and shower rooms and they exceeded 120 degrees F. The Administrator (ADM), and Regional Vice President (RVP) were notified of the immediate jeopardy on 7/17/19 at 4:30 p.m. The immediate jeopardy was removed on 7/19/19, but noncompliance remained at the lower scope and severity level of pattern, no actual harm with potential for more than minimal harm that is not Immediate Jeopardy. Findings include: On 07/17/19 at 11:03 a.m., the Main Dining Room sink faucet temperature was measured at 130.4 F (Fahrenheit). Steam was visible as it came off the running water. On 07/17/19 at 11:18 a.m., during an observation Resident 11's bathroom sink faucet temperature was measured at 127.8 F. During an interview, Resident 11 indicated the hot water got too hot after running a while. In the shower room once there was hot water they had to shut the water off during the shower because it was too hot. On 07/17/19 at 11:25 a.m., the 800 hall shower room's sink faucet temperature was measured at 128.9 F. On 07/17/19 at 12:35 p.m., Resident 6's and Resident 202's bathroom sink faucet temperature was measured at 129.3 F. Steam was visible as it came off the running water. On 07/17/19 at 12:36 p.m., Resident 34's and Resident 3's bathroom sink faucet temperature was measured at 129.3 F. Steam was visible as it came off the running water. On 07/17/19 at 12:38 p.m., Resident 24's and Resident 9's bathroom sink faucet temperature was measured at 129.5 F. Steam was visible as it came off the running water. On 07/17/19 at 12:40 p.m., Resident 5's bathroom sink faucet temperature was measured at 129.1 F. Steam was visible as it came off the running water. On 07/17/19 at 12:44 p.m., Resident 27's and Resident 199's bathroom sink faucet temperature was measured at 124.4 F. On 07/17/19 at 12:48 p.m., Resident 203's and Resident 8's bathroom sink faucet temperature was measured at 126.8 F. During an interview on 07/17/19 at 12:56 p.m., the Environmental Services Director (ESD) indicated he adjusted water temperatures on the South Hall on this date, because they were getting ready to move residents down there. No other halls had been adjusted on this date. He then checked the following room temperatures, with a digital laser (infrared) thermometer. He held the thermometer 3 to 4 inches from the running stream of water, as he measured the temperature. The following temperatures were observed with the ESD using the infrared thermometer (IRT): a. Resident 27 and Resident 199's bathroom sink faucet temperature was measured at 113.0 F. b. Resident 203's and Resident 8's sink faucet temperature was measured at 113.0 F. c. Resident 23's and Resident 4's sink faucet temperature was measured at 105.0 F. On 07/17/19 at 1:12 p.m., after measuring the rooms' sink faucet temperatures, the Environmental Services Director (ESD) indicated the laser thermometer worked different than a probe thermometer, therefore the temperatures would read differently. The thermometer was battery powered, and the battery was changed once a month. On 7/17/19 at 1:20 p.m., the ESD provided copies of water temperature logs and indicated he had used the infrared thermometer to check water temperatures on a weekly basis. On 7/17/19, during a continuous observation, from 1:53 p.m. until 2:15 p.m., the ESD went into the kitchen to get a digital probe thermometer to take temperatures for resident shower sinks and resident rooms. The findings were as follows: a. The 600 Hall shower sink water temperature reading was 128.8 degrees F. b. The 700 Hall shower sink water temperature reading was 128.3 degrees F. c. The 800 Hall shower sink water temperature reading was 126.5 degrees F. d. Resident 25's bathroom water temperature was 128.1 degrees F. e. Resident 10's resided, the water temperature was 124.7 degrees F. During an interview, on 7/17/19 at 2:01 p.m., the ESD indicated the water temperature should have been 113 to 115 degrees F. During an interview, on 7/17/19 at 2:06 p.m., the ESD indicated the 600, 700, and 800 resident halls were all on the same hot water heaters. New mixing valves were put in by (name of) plumbing company, about 5 months ago. He indicated he was going to keep the kitchen's digital probe thermometer because it was reading about 10 degrees hotter than the digital infrared thermometer. He indicated he would go back around and re-check everything with the digital probe thermometer from the kitchen instead of the digital infrared thermometer. During an interview, on 7/17/19 at 4:00 p.m., Regional Vice President (RVP) indicated he was not aware the digital infrared thermometer was for solid surfaces. During an interview, on 7/17/19 at 4:33 p.m., the RVP indicated the digital infrared thermometer manual indicated you could not just aim the infrared thermometer in the air, there had to be an ambient reading. He indicated the facility called the manufacturer of the digital laser thermometer, and they indicated the thermometer was a plus or minus of 3 degrees. During a dining observation on 7/17/19 at 11:55 a.m., the Social Service Director (SSD) was observed as she began to wash her hands in the dining room sink. She put her hands under the water but recoiled her hand quickly and indicated to the Administrator (ADM), who was standing next to her, dang, that's hot, it will scorch your hands off. During a dining observation on 7/17/19 at 12:16 p.m., Certified Nursing Assistant (CNA) 5 was observed as she began to wash her hands in the dining room sink. She put her hands under the running water, but jerked her hands away and indicated, Ouch! She indicated she burned her hands because the water was too hot. On 7/17/19 at 3:15 p.m., the ADM provided a list of 10 residents, Residents 9, 13, 16, 20, 26, 30, 42, 44, 198, and 201, and indicated they each had a [DIAGNOSES REDACTED]. On 7/17/19 at 3:15 p.m., the ADM provided a document titled, Non-contract Infrared Thermometer Item IRT207. The document indicated, .IRT's only give temperature readings of solid materials During an interview on 7/17/19 at 3:56 p.m., the ADM indicated the SSD was standing beside her at the dining room sink when she indicated the water was too hot, and CNA 5 did not report any hot water concerns to her. During an interview on 7/17/19 at 3:56 p.m., the ADM and Regional Vice President (RVP) indicated water temperatures should not exceed 120 degrees F., and the ESD had been using the digital laser thermometer for several months but was unaware its manual recommended use for solid surfaces only. During an interview on 7/18/19 at 10:02 a.m., the Activity Assistant (AA) 3 indicated if the resident water was too hot she would have contacted the ESD and the ADM. About a month ago, the AA 3 informed the ESD that the water was too hot. On 7/18/19 at 10:03 a.m., an email from the Technical Support Team for the infrared thermometer manufacturer indicated the digital infrared thermometer would not be the ideal instrument nor provide the best reading of running water. They recommended the use of a traditional probe thermometer. On 7/17/19 at 3:15 p.m., the Administrator provided a copy of current facility policy titled, Water Temperatures, Safety of dated, 12/2009. The policy indicated, .water heaters that service resident rooms, bathrooms, common areas, and tub/shower areas shall be set to temperatures of no more than 120 (degrees) F . or the maximum allowable temperature per state regulation . if at any time water temperatures feel excessive to the touch (i.e. hot enough to be painful or cause reddening of the skin after removal of the hand from the water), staff will report this finding to the immediate supervisor The immediate jeopardy began on 7/17/19 was removed on 7/19/19 when the Environmental Services Director (ESD) and staff were educated on safe water temperatures and to use a probe thermometer instead of the laser thermometer, and water temperatures were monitored to ensure water temperatures were less than 120 degrees F. The immediate jeopardy was removed on 7/19/19, but noncompliance remained at the lower scope and severity level of pattern, no actual harm with potential for more than minimal harm that is not Immediate Jeopardy, because not all staff had been educated on water temperatures and the facility needed to continue monitoring to ensure compliance. 3.1-45(a)

Based on observation, interview, and record review, the facility failed to prevent a male resident (Resident N) with known sexual behaviors, from sexually assaulting two female residents which resulted in psychosocial harm for Resident G when she stopped attending some of her favorite activities, and isolated herself in her room due to being afraid of Resident N for 1 of 3 residents reviewed for abuse, and 1 of 3 residents (Resident R) had a potential for harm when she was sexually abused by Resident G. Findings include: 1. During an interview on 7/17/19 at 12:48 p.m., Resident G indicated she was terrified of Resident N. About 7 months ago, sometime in January, Resident N had abused her. He used to walk up and down the hall, and stop at her door to wave. One day he didn't stop at her door, he came into her room. He walked up behind her and grabbed her breasts, she yelled and screamed for him to stop, but he didn't, he kept grabbing my breasts and slipped his hand down my back and groped my bottom. She kept screaming and was finally able to push him toward the door just as several staff members came in and took him out. All they said was, Resident N was confused and must have thought she was his wife. He must have had some problems before because they sent him out for two days, but then they let him come right back, and said she could move rooms to be farther away. Resident G indicated she was still scared of Resident N. Even though he did not do it as much, he still wandered up and down her hall, and if she went to activities he would be there staring at her. He would wave at her with a grin, and while everyone else thought he was just being sweet, the look in his eye scared her. She stayed in her room a lot now with her door closed, and does not go play cards much anymore, because if she did go to activity, Resident N was there, so she would leave. Resident G indicated she did not understand why Resident N was still at the facility, everyone knew he had a problem because before he grabbed her, he grabbed two CNAs (Certified Nursing Assistant), one right in the crotch. Resident G reported her complaint, but felt nothing had been done about it except she was told she could move rooms, and until he was locked up, she was not coming out. On 7/22/19 at 10:50 a.m., State Reportable records were reviewed. An incident report, dated 1/7/19, indicated, . (Resident N) wandering into other resident's rooms. Inappropriate sexual comments and gestures made towards staff/residents . Immediate Action: inpatient psych eval ((Resident N) sent out of psychiatric evaluation) . Follow Up: Resident remains at inpatient psych for eval and tx (treatment) ((Resident N) remains at inpatient psychiatric for evaluation and treatment) Affected resident interviewed and observed, no negative psychosocial effects noted or voiced, room move completed On 7/22/19 at 10:54 a.m., Resident G's record was reviewed. A quarterly MDS (Minimum Data Set) assessment, dated 7/16/19, indicated Resident G was cognitively intact and had no new or worsening behaviors. Resident G's had a current comprehensive care plan for activities, dated 4/9/19, indicated, . Resident is independently capable of pursuing her own activities of preference without intervention from the activity staff the goal for this care plan was for (Resident G) to express overall satisfaction with having enough that is interesting each day, and attend social groups at will (Resident G) had a second current care plan dated 9/24/18 related to depression which indicated .Resident is at risk for alterations in mood and depression symptoms related to recent placement in Long Term Care and the death of her husband Resident G's Nursing and Social Service Progress notes were reviewed. There was one note related to the incident. A Social Service note, dated 1/11/18 at 3:48 p.m., indicated, . visited with resident today related to follow up from resident altercation earlier in the week. Resident exhibits no signs/symptoms of psychosocial distress. Recently moved rooms to the (#) hall and stated she was very happy with her new room at the facility A psychology progress note, dated 5/10/19, indicated, . (Resident G) separated herself from most other residents, especially those with dementia A second psychology progress note dated 6/20/19 indicated, . (Resident G) continued to spend most of the time in her room, including eating meals in her room A third psychology progress note dated 7/16/19 indicated, . (Resident G) noted that she spent her days listening to the television and to religious tapes, and enjoyed visits from her family. She was in good spirits 'because I have to be' On 7/25/19 at 3:00 p.m., Resident N's record was reviewed. [DIAGNOSES REDACTED]. During an interview on 7/24/19 at 2:41 p.m., the Memory Care Director (MCD) indicated she had not been employed at the time Resident G was assaulted by Resident N. When she first started in (MONTH) as the Social Service Director, she was told Resident G's problem had been taken care of by the previous Director of Nursing (DON), and the Social Service Cooperate Consultant. At this time the Executive Director entered the office and indicated she had not been here at the time of the incident either. During an interview with Resident G, on 7/23/19 at 3:42 p.m., she was observed in her room, with a visitor, Resident M. Resident M indicated she visited Resident G a lot in her room, because Resident G did not want to come play games and cards anymore. Resident G indicated some of the activities were not fun for her, but she had liked to play cards, except she did not want to go down to activities anymore because Resident N was still there. During an interview on 7/24/19 at 2:53 p.m., the Activity Director (AD) indicated she was aware of the incident between Resident G and N, and since then it seemed that Resident G stopped coming to a lot of activities even though the activity staff tried to encourage her. If Resident G did come to activities and Resident N was there, Resident G would leave immediately, because she was still afraid of him. On 7/24/19 at 3:12 p.m., the Activity Assistant (AA) provided a copy of Resident G's activity participation logs and indicated, Resident G did a lot of independent activities, but a lot of the stuff she refused to come to, were activities that Resident N participated in, because Resident G did not like him. 2. On 7/25/19 at 3:00 p.m., Resident N's record was reviewed. [DIAGNOSES REDACTED]. A progress note, written by Registered Nurse (RN) 30, dated 7/4/19 at 1:58 p.m., indicated Resident N was sitting in the hallway and was found touching another resident (Resident R) outside of her shirt on the chest area. Resident N stated, I was just trying to talk to her. Will continue to monitor resident for inappropriate behaviors. On 7/25/19 at 3:07 p.m., Resident R's record was reviewed. A progress note, written by RN 30, dated 7/4/2019 at 1:49 p.m., indicated the Resident R was sitting in hallway, and Resident N was found touching the resident outside of her shirt on the chest area. One to one psychosocial support was provided. No skin issues were noted. No tearfulness nor crying noted. No complaints of pain noted nor negative psychosocial effects noted. Resident currently sitting at nurse's station with writer at this time. The Medical Doctor (MD) and family were notified. On 7/25/19 at 11:40 a.m., the facility provided Resident N's sexual abuse investigation. It consisted of a copy of the incident report. The report indicated Resident N reached out and felt Resident R's breast. A current policy, titled, Abuse Prevention Program, dated 2/22/18, was provided by the Vice President of Clinical Operations (VPCO), on 7/25/19 at 2:17 p.m. A review of the policy indicated, .Sexual abuse is non-consensual sexual contact of any type with a resident .A completed copy of the Incident Report and written statements from witnesses, if any must be provided to the Administrator .the Administrator, or his/her designee, will appoint a member of management to investigate the alleged incident. The individual conducting the investigation will, at a minimum: .Interview the person(s) reporting the incident; interview any witnesses to the incident; interview the resident (as medically appropriate); .interview staff members (on all shifts) who have had contact with the resident during the period of the alleged incident; .interview the resident's roommate, family members and visitors; review all events leading up to the alleged incident .interview should be conducted separately and in a private location; .employee witnesses will be required to sign and date any witness report they make This Federal tag relates to Complaint IN 844. 3.1-27(a)

Based on observation, interview, and record review, the facility failed to appropriately implement plans of corrective actions to prevent previously cited harm level deficiencies related to wounds from reoccurring. This was evidenced by the number and seriousness of citations at this survey, and the previous investigation of complaints with findings on 4/25/19. These deficient practices had the potential to affect all 3 of 3 residents reviewed for wounds. Findings include: During the survey entrance conference on 7/17/19 at 9:45 a.m., a copy of the facilities Quality Assurance Performance Improvement (QAPI) plan was requested, at 12:01 p.m., the ED provided a copy of a document titled, Guide for Developing a QAPI which served as the facility policy. The policy indicated, .the QAPI plan will guide your organization's performance improvement efforts . QAPI plan is intended to assist you i achieving what you have identified as the purpose, guiding principles and scope for QAPI . this plan should reflect input from caregivers representing all roles and disciplines within your organization . Guidelines for Governance and Leadership: QAPI is integrated into the responsibilities and accountabilities of top-level management and . how your caregivers will become and remain proficient with process improvement tools and techniques .Feedback, Data Systems, and Monitoring: the overall system that will be put in place to monitor care and services, drawing data from multiple sources (such as) i. input from caregivers, residents, families and others. ii. adverse events. iii. performance indicators. iv. survey findings. v. complaints During an interview on 7/25/19 at 2:51 p.m., the Vice Resident of Operations (VPO), Vice President of Clinical Operations (VPCO), the ED, the Senior Director of Nursing, (SDON), and current Director of Nursing (DON) were present. The ED indicated the purpose of the Quality Assurance and Performance Improvement plan/committee was to analyze how the facility was doing, and identify concerns that needed to be addressed. In regards to the wound management program, the VPCO indicated, it all boiled down to not having consistent staff, from direct caregivers like CNAs (Certified Nursing Assistants), all the way up to Nursing leadership like Unit Managers, DON, and ED leadership. Wounds have been a problem in the past, and we had a P[NAME] (Plan of Correction) in place from previous citations, but with a higher percentage of agency staff, and lots leadership turn over, the wound management program fell through the cracks. Wounds: 1. Resident B did not receive treatments and services to prevent her existing wounds from becoming worse, resulting in harm when she was sent from [MEDICAL TREATMENT] to the Emergency Department and be found septic with infection, and required amputation of her left leg. 2. Resident C developed a stasis ulcer, treatments and interventions were not observed in place, resulting in harm when, the wound worsened and caused the resident a great deal of pain, and fear that he may lose his leg. 3. Resident D, was observed at several times without pressure relieving boots as ordered, and during a wound treatment observation, a three day old bandage was removed from her wound which required daily dressings. Cross reference F684 and F686 This Federal tag relates to Complaint IN 929.

Based on interview, and record review, the facility failed to ensure wound assessment and treatments were completed for 2 of 2 residents reviewed for non-pressure wounds that resulted in 1 resident being hospitalized with an infection (Resident B) and 1 resident in having increased pain and worsening condition of the wound (Resident C). The facility failed to ensure a choking resident received continued treatment to clear her airway for 1 of 5 residents reviewed for accidents resulting in the resident becoming unresponsive and hospitalized (Resident Q). Findings include: 1a. On 7/22/19 at 10:37 a.m., a review of Resident B's medical record indicated the resident was admitted to the facility, from the (Name of Hospital) on 6/18/19. The [DIAGNOSES REDACTED]. Baseline, admission care plans, dated 6/18/19, indicated Resident has impaired skin integrity (SPECIFY location) The goal indicated Tissue injury would heal and be free of complications. The location, or type of the impaired skin integrity was not identified, and Resident B was at risk for skin breakdown. The goal was Resident B would be free from skin breakdown. An admission assessment, dated 6/18/19, indicated Resident B was admitted from the hospital. Skin conditions were identified as right lower leg front, and left lower leg front, vascular. No pressure ulcers were identified on the admission assessment. A review of the physician's orders [REDACTED]. Wound culture after antibiotic therapy. Hold [MEDICATION NAME] for 1 week. There were no orders for dressings or treatments. A review of the nursing progress notes did not reveal any documentation or treatments for pressure, or wound treatments. The nursing progress notes for this stay indicated: a. On 6/22/19 Patient was admitted (Name of Hospital) straight from the [MEDICAL TREATMENT]. Patient admitted for [MEDICAL CONDITION]. Left a message for the family. b. On 6/20/19 Lab notified Writer at this time of Critical value for [MEDICATION NAME] level 3.40. Writer notified (Name of Nurse Practitioner) on call. c. On 6/20/2019 at 9:33, Lab notified this writer of a Critical Glucose level 41, writer notified (Name of Nurse Practitioner). Awaiting return notification. d. On 6/19/2019 at 9:51, Skilled Nursing Late Entry: Note Text: Resident refused to go to her [MEDICAL TREATMENT] appointment because she said she was in too much pain to get into the W/C (wheelchair). She was approached 2 x (times) by staff and she still refused to go. Family notified. A facility admission physician note, dated 6/19/19, indicated per records, patient was under wound care management for [MEDICAL CONDITION] (infection) in LLE (left lower extremity) and was treated with IV (intravenous) [MEDICATION NAME] (antibiotic) and [MEDICATION NAME] (antibiotic). Patient reported pain in left leg from [MEDICAL CONDITION] (nerve) and infection. There were no wound care consults documented in the medical record. On 7/23/19 at 2:00 p.m., the Interim Assistant Director of Nursing provided copies of Resident B's physician orders, and admission assessment form. During an interview, at that time, the Vice President of Clinical Operations indicated Resident B had no other documentation of wounds, other than the admission assessment. The only order was for a wound consult. She did not believe the wound consult had been done, before the resident went to the hospital. On 7/23/19 at 2:30 p.m., the (Name of hospital) medical records department provided copies of Resident B's medical record, for the admitted [DATE]. Resident B was sent to the hospital on [DATE] from [MEDICAL TREATMENT], after experiencing a syncopal (dizzy) episode. The resident was seen in the emergency department, and admitted to the hospital. On 6/26/19, she underwent a debridement procedure to remove necrotic (dead) tissue from the bottom of her left foot, then on 7/1/19 she underwent surgery to amputate her left leg, above the knee. The admitting [DIAGNOSES REDACTED]. The Physician's note, dated 6/21/19, indicated Resident B was recently hospitalized , which included treatment for [REDACTED]. At the facility there was significant trouble with mobility. She had multiple skin tears on her arms and legs. She had worsening wounds on both of her legs, and some on her arms as well. There were .Innumerable areas of scabbing especially over her lower extremities, but some on her upper extremities as well. Some of these appear to be pressure ulcerations, some of them just appear to be skin tears and thin scab over. She has an area on the dorsum (bottom) of her left foot that is 4.5 cm (centimeters), has a foul odor, and appears to be an open wound that is at least Stage III (full thickness). She also has an area on her posterior left calf that was a deep tissue injury, present on her last hospital admission that is now an open wound. She has some swelling around the antecubital (bend) space of her left arm, likely from her previous IV (intravenous medication line) with a skin tear in the middle of it as well. All of these have some surrounding [DIAGNOSES REDACTED] (redness) and induration (raised) Doppler (ultrasound) studies showed impaired blood flow to both extremities (legs). Her [MEDICATION NAME] (heart medication) level was 3.0, toxic (too high), causing irregular heart rate and [MEDICAL CONDITION] (low blood pressure). There was significant leukocytosis (high white blood cells indicated infection in wounds) which resulted in a [DIAGNOSES REDACTED]. Photos provided in the hospital record showed Resident B's extremities (arms and legs), and buttocks. Photos taken on arrival at the hospital show bilateral lower extremities with tattered and torn gauze rolled dressing on both lower legs. The dressings were saturated in brown stains (wound drainage). The left foot was also wrapped in gauze roll. It had a saturation of brown stain, on the bottom aspect, up to the ankle area. The toes, of the left foot, were exposed and there was a thick dried black substance between them. Photos after the removal of the dressings show multiple scabbed areas on both legs, a large scabbed area on the bottom of the left foot, an open red and yellow wound to the right groin area, redness and excoriation on the buttocks, and sacrum, and multiple scabs on the arms. A physician's note, dated 6/22/19, indicated, .numerous ulcerations of bilateral (both) lower extremities and feet with surrounding [DIAGNOSES REDACTED] and purulent drainage .[MEDICATION NAME] toxicity presented with confusion, suspected ventricular arrhythmia and syncopal episode .Sepsis patient presented with leukocytosis, [MEDICAL CONDITION], altered mental status. Possible source includes skin and soft tissue infection as she has numerous severe ulcerations wit surrounding [DIAGNOSES REDACTED] and purulent drainage A physician's note, dated 6/30/19, indicated, .she was agreeable with proceeding with above the knee amputation for this coming Monday 1b. During an initial observation on 7/17/19 at 10:54 a.m., Resident C was observed lying in his bed, his sheets were disheveled and pulled up to his knees so that a bandage was observed on his right lower leg. The bandage was, dated 7/10/19, with a small, circular, diluted brown, discoloration noted on the bandage, and several spots of a brownish/red substances observed on the lower portion of the crumpled sheets. On 7/22/19 at 1:41 p.m., Resident C's medical record was reviewed. A nursing admission assessment, dated 7/11/19, indicated, Resident C admitted from the hospital, with no identified skin conditions A nursing progress note, dated 7/17/19 at 4:36 p.m., indicated, . Venous stasis ulcer noted to right lateral lower leg. Area with macerated wound edges (tissue softened due to moisture) wound bed with 95% granulation tissue (new healthy growth) and 5% slough (dead, unhealthy tissue). Moderate amount of serosanguinous drainage (fluid that contains both blood and the liquid part of blood, serum). Resident NP (Nurse Practitioner) and daughter notified of area. Treatment per order An initial wound observation tool, dated 7/17/19, indicated Resident C acquired a stasis ulcer which measured; 2.0 cm (centimeters) long, by 1.5 cm wide, by 0.1 cm deep, with macerated, irregular edges. An order was in place to: cleanse right lower leg with wound cleanser, pat dry, apply calcium alginate (a treatment used to maintain a physiologically moist environment to promote healing and the formation of granulation tissue) to wound bed, and cover with foam dressing. A current care plan, dated 7/11/19, indicated, Resident C had impaired skin integrity of a venous stasis ulcer on his right lower extremity. Interventions for the care plan included, but were not limited to: assess and document skin condition and notify the MD (Medical Doctor) of signs of infections (redness, drainage, pain, fever), check for incontinence and provide incontinent care as needed, and to provide wound treatment as ordered. On 7/22/19 at 9:16 a.m., Resident C was observed lying in bed. A new dressing was observed on his right lower leg, the dated was written in black ink on the edge of the bandage but had smeared and was illegible. On 7/24/19 at 8:54 a.m., Resident C was observed lying in his bed, and complained of pain in both his heels, and his right leg where the wound was located. Resident C groaned, and grimaced his face, he indicated he was scared he was going to lose his leg. He indicated he had asked for pain medicine early that morning before breakfast, but no one brought it yet. On 7/24/19 at 8:56 a.m., the Senior Director of Nursing (SDON) observed Resident C. She pulled the residents sheets back, and a large area under the resident was observed soiled, and stained with an expanding dark brown circular stain. She indicated she would get someone to clean him up immediately after she checked his feet and legs. She removed his left sock and inspected his heel. When she pressed on his heel and asked if it hurt, Resident C indicated yes, very much. The SDON then removed his right sock and inspected his right heel. When she pressed on his right heel, Resident C yelled out in pain, and indicated it hurt worse. The SDON indicated his heels were clean, dry, and in-tact, but she would call out getting skin prep as a preventative measure. The SDON indicated Resident C's bandage had come off of the wound on his right leg, and was observed rolled up and stuck the back of his left knee. She removed, and unrolled the bandage, which had an illegible date marked in black ink on the edge of the bandage (as observed on two days earlier). The SDON indicated she would send the Interim Director of Nursing (IDON) to come and dress the wound. On 7/24/19 at 9:02 a.m., CNA 29 entered the resident's room to assist with wound care. She indicated Resident C had been constipated and was given a suppository, so when he grunted to move in bed or try to move his bowels, there had some leakage, which soiled sheets, but the sheets were dry which meant it had probably been that way for hours. On 7/24/19 at 9:18 a.m., the IDON observed Resident C's open wound and soiled sheets. She indicated it did not look good, and there was a definite chance for infection from having the open wound exposed to the soiled sheets. She began to cleanse the wound with normal saline, but as she pressed the swab to the resident's leg, he yelled out in pain and jerked his leg away. The IDON apologized, but continued. She measured the wound and indicated it was: 2.5 cm long, by 3 cm wide, but could not measure depth due to the amount of slough, which was about 25%, with 75% granulation tissue. She continued to place the treatment as ordered. On 7/24/19 at 10:30 a.m., the IDON provided a copy of Resident C's MAR. The order to cleanse right lower leg with wound cleaner, pat dry, apply santyl (a medicated ointment to promote wound healing) to wound bed, cover with calcium alginate, and secure with foam dressing daily, had not been completed on 7/20/19, 7/21/19, or 7/23/19. On 7/24/19 at 11:35 a.m., the Executive Director (ED) provided a copy of current facility policy titled, Skin Management dated, 10/2018. The policy indicated, . Purpose: to ensure skin integrity with each resident . the licensed nurse is responsible for assessing any and all skin altercations as reported by the direct caregivers on the shift reported, residents identified at risk for skin breakdown will have appropriate prevention interventions put into place .treatment orders will be obtained On 7/23/19 at 2:00 p.m., the Vice President of Clinical Operations provided a current policy, dated (MONTH) (YEAR), titled Skin Management. This policy indicated .It is the policy of (Name of Facility) to assess each resident to determine the risk of potential skin integrity impairment, upon admission .A head to toe assessment will be completed by a licensed nurse upon admission/re-admission and weekly .Care plan interventions will be implemented based on resident risk factors .Any skin alterations noted by direct care givers during daily care and/ or shower days must be reported to the licensed nurse for further assessment, to include but not limited to bruises, open areas, redness, skin tears, blisters, and rashes. The licensed nurse is responsible for assessing any and all skin alterations as reported by the direct caregivers on the shift reported .Treatment order will be obtained .All alterations in skin integrity will be documented in the medical record 2. On 7/24/19 at 10:10 a.m., Resident Q's medical record was reviewed. A progress note, dated 7/24/19 at 10:07 a.m., created by Registered Nurse (RN) 5 indicated, Resident Q choked in the dining room during breakfast. The [MEDICATION NAME] maneuver was performed and suctioning done. 911 was called, related to oxygen (O2) saturations (sats) dropping. The resident went back to her room and oxygen was placed on her at 6 liters per minute, her O2 sats rose to 75%. Paramedics were able to dislodge the food from the resident's throat and O2 sats gradually improved. The resident was transferred to (name of) hospital. The family was notified. During an interview, on 7/24/19 at 10:35 a.m., the Senior Director of Nursing (SDON) indicated Registered Nurse (RN) 13 was in the dining room, and the SDON came in immediately after Resident Q began choking. The resident was on a regular diet. The [MEDICATION NAME] maneuver was done by RN 13. The SDON was getting the suction machine hooked up. After suctioning, we got a little bit out, Resident Q started moving a little bit of air. We took her to her room and called 911. Once the resident was in her room, Licensed Practice Nurse (LPN) 23 and RN 5 were in the resident's room until the fire department arrived. During an interview, on 7/24/19 at 10:46 a.m., RN 5 indicated she was not in the dining room when Resident Q started choking. She was standing just outside the dining room doorway. When the scheduling coordinator (SC) performed the [MEDICATION NAME] maneuver, a little bit of food came out of the resident's mouth. RN 13 did some suctioning, nothing came out with the suctioning. After the [MEDICATION NAME] maneuver was performed, Resident Q was looking pale and distressed, her breathing was a short, shallow, and labored. Her airway was still blocked. Resident Q was getting a little bit of air, and she needed O2. So, we took her to her room and put her on 6 liters (L) of O2 and her O2 saturation was 75%. During an interview, on 7/24/19 at 10:57 a.m., RN 13 indicated she was in the dining room when Resident Q started choking. The resident's lips started turning blue, she could not speak. While the resident was seated in a chair, RN 13 started the [MEDICATION NAME] maneuver. The resident was leaning forward, RN 13's indicated her arms were under Resident Q, with her hands at the costal angle (meeting point of the lower border of the false ribs with the axis of the sternum) and was thrusting in and up. A small piece of donut, about the size of a dime, but oblong, came out of the resident's mouth. The SC indicated the resident was able to stand. Then, the SC started the [MEDICATION NAME] maneuver while the resident was standing. The resident's lips were a dark blue, and the O2 saturation percentages were mid-to-low 80s and continued to go down. There was no improvement with the [MEDICATION NAME] maneuver, so RN 5 and the SC took Resident Q to her room in a wheelchair. RN 13 indicated to them Resident Q's O2 sats were continuing to drop. The resident's lips were dark blue. When the resident left the dining room, it was obvious not enough air was getting in, because her lips were still blue. Her breathing was not real breathing, just a small amount of breathing, it was not normal breathing. There was still an obstruction. RN 13 indicated the [MEDICATION NAME] maneuver should have been continued until the emergency services arrived. During an interview, on 7/24/19 at 1:31 p.m., the SC indicated she was in the dining room, when one of the aide indicated Resident Q was turning blue. She stood the resident up and did the [MEDICATION NAME] maneuver, then sat her back down, and called for the crash cart. RN 13 started suctioning the resident. After she was finished suctioning, the SC stood the resident up and started the [MEDICATION NAME] maneuver again. The SC indicated she grabbed a wheelchair and we took her to her room. In her room, her O2 saturation was 49%. O2 was put on the resident, and her O2 saturation went up to 60%. When emergency services arrived, the SC left the resident's room. She indicated when she learned the [MEDICATION NAME] maneuver, the resident should have been standing up. During an interview, on 7/24/19 at 1:54 p.m., LPN 23 indicated she was on her way to the dining room, when she heard a resident was choking. The resident's lips were blue and RN 13 grabbed the resident around the chest and was doing the [MEDICATION NAME] maneuver while the resident was sitting in the chair. The SC stood the resident up to do the [MEDICATION NAME] maneuver. LPN 23 indicated to the SC to raise her hands up, told her to put her hand at mid breast bone to do the [MEDICATION NAME] maneuver. We got an O2 saturation of 66%, and after blinking, it was 44%. We got a wheelchair to get her out of the dining room because the other resident's looked worried. We took her to her room and she was gurgling, like she had aspirated. The O2 was turned up to 6 L, we started her on a nasal cannula, but someone brought an oxygen mask. She was a do not resuscitate (DNR) resident, but something was still blocking her airway. Her lips turned a deeper blue. LPN 23 indicated she stayed in the room with the resident. She talked to her and rubbed her hand to try and keep her calm. The [MEDICATION NAME] maneuver was not done in the resident's room. The last O2 saturation was 71%, then the emergency services arrived and asked for the head of the bed to be put down. During an interview, on 7/24/19 at 2:06 p.m., Licensed Practical Nurse (LPN) 16 indicated she was in the Resident Q's room just before the emergency medical technicians (EMTs) arrived. The resident was already on O2, she was pale and gasping to breath. She had a donut in her throat, her breathing was still obstructed. She was pretty out of it, really lethargic, not responsive. During an interview, on 7/24/19 at 2:15 p.m., the Director of Human Resources indicated she called 911 about 5 minutes after Resident Q went into distress. They were taking her to her room when I called emergency medical services. They rolled her right past my office. During an interview, on 7/24/19 at 2:17 p.m., the Director of Nursing (DON) indicated once the staff realized a resident was choking, they should have done the [MEDICATION NAME] maneuver until the resident had an open airway. The most successful way would be was the resident standing up. Sitting in a chair would not be a very efficient way to do the [MEDICATION NAME] maneuver. It should be one hand over the fist, just below the breast bone, the thrusts should be in and up. Also, the staff could have tried hitting the resident on the back. Then, call 911. Suctioning should be done if needed, but to continue the [MEDICATION NAME] maneuver. The DON indicated she did not know if they should have moved Resident Q from the dining room, but it would have been a traumatic experience with the other residents watching. If Resident Q's lips were blue, her airway was still obstructed. The DON indicated she would not have moved Resident Q to her room, and would have done anything to get the object out of the resident's throat. In the resident's room, someone should have been either been suctioning or doing the [MEDICATION NAME] maneuver, and a different staff could have calmed the resident. The expectation for the staff, with a choking resident, was to do anything they could do it get the resident airway open. During an interview, on 7/24/19 at 2:41 p.m., LPN 16 indicated she called (name of) hospital for an update on Resident Q. The resident was admitted with a [DIAGNOSES REDACTED]. On 7/24/19 at 2:57 p.m., Resident Q's medical record was reviewed. Resident Q's [DIAGNOSES REDACTED]. Resident Q's hospital records, dated 7/24/19 at 8:51 a.m., indicated, .Chief Complaint: Patient presents with choking. (City name) EMS (Emergency Medical Services) from (name of) ECF (extended care facility). Pt (patient) got choked on a piece of donut, was agonal (abnormal pattern of breathing and brainstem reflex characterized by gasping, labored breathing), unresponsive (will not wake up with verbal or pain stimulus) and cyanotic (bluish or purplish discoloration due to deficient oxygenation of the blood) upon their arrival. EMS removed a large piece of donut from pt's (patient's) airway. Pt is now alert and oriented but is hypoxic (deprived of adequate oxygen supply) which is requiring 2 liters of oxygen, she is [MEDICAL CONDITION] and hypotensive on arrival .Pt said she feels horrible, doesn't remember eating donut, reports abdominal pain., unable to tell me exact locations .states, 'I just hurt all over.' Pt states yesterday she was feeling well .[DIAGNOSES REDACTED].RT (respiratory therapist) at bed side for [MEDICATION NAME] treatment (to treat and prevent symptoms of wheezing and shortness of breath), the medications included are [MEDICATION NAME] and [MEDICATION NAME] .Risk of Complications, Morbidity, and /or Mortality. Presenting problems: High .CT (reveals internal organs that cannot be seen by conventional x-rays) Abdomen Pelvis w (with) Contrast .Comparison is made to the previous study of 5/23/13. There is consolidation (becoming solid) posteriorly (in the back of) in the right lower lobe (part of the lung) is probably due to atelectasis (partial or complete collapsing of the lung). There is hazy opacity (lack of transparency) in the right middle lobe may be a developing infiltrate (introducing of something into the lung) .Impression: Questionable developing right middle lobe infiltrate .XR (x-ray) Chest .interstitial [MEDICAL CONDITIONS] (fluid found in the spaces around the cells) or pleural (the space between the lungs and the chest wall) abnormality is identified .Physical Exam .7/24/19 at 8:51 AM .Chronically ill appearing. BP (blood pressure) 87/54, HR (heart rate) 115, 94% on 2 liters (of oxygen) .Chest: Effort normal. No respiratory distress. She has decreased breath sounds. She has rales (abnormal rattling sound of the lung) .ED (emergency department) Vitals (vital signs) from 7/24/19 At 8:58 a.m., pulse was 116, respiration were 20, blood pressure (BP) 90/46, SpO2 (oxygen saturation) 89%. Resident started on 2 liters of oxygen per nasal cannula. At 9:12 a.m., pulse was 108, respiration were 22, BP 87/54, SpO2 94%. At 9:17 a.m., pulse was 106, respiration were 20, BP 82/49, SpO2 96 %. At 9:23 a.m., pulse was 108, respiration were 20, BP 75/47, SpO2 96 %. At 9:32 a.m., pulse was 101, respiration were 20, BP 81/48, SpO2 97 %. At 9:46 a.m., pulse was 96, respiration were 20, BP 100/62, SpO2 100%. A current policy, titled, Emergency Procedure - Choking, dated (MONTH) 2011, was provided by the Executive Director (ED) on 7/24/19 at 3:52 p.m. A review of the policy indicated, Policy Statement: Trained staff will assist the resident who is choking by attempting to expel the foreign body from the airway .Stand behind the resident. Wrap your arms around the resident's waist. Make a fist with one hand Place the thumb side of your fist against the resident's upper mid-abdomen, below the ribcage and above the navel. Grasp your clenched fist with your other hand. Press your fist into the resident's upper abdomen with a quick upward thrust. Do not squeeze the ribcage. Contain the force of the thrust to your hands Repeat the thrusts until the foreign body is expelled or the resident loses consciousness This Federal tag relates to Complaint IN 929. 3.1-37(a) 3.1-37(b)

Based on interview, observation, and record review, the facility failed to ensure treatment for [REDACTED]. The facility failed to ensure assessments were completed for a surgical wound, treatment orders were in place, and documentation of treatments completed for a resident with a right hip incision not resulting in harm but with a potential for harm for 1 of 3 residents reviewed for treatments (Resident C). Findings include: 1. During an interview, on 4/25/19 at 10:36 a.m., Resident D indicated he admitted to the facility in (MONTH) of 2019 from the hospital with [MEDICAL CONDITION] (a potentially serious bacterial skin infection) to his bilateral (left and right) lower extremities. He filed a grievance with the facility approximately 10 days after his admission because the facility failed to complete treatments to his bilateral lower legs for [MEDICAL CONDITION]. During this time, his legs became more swollen and painful, and the open areas to his bilateral lower legs became larger. He felt there had been a mix up with the discharge instructions from the hospital for the treatments to his lower legs and this had delayed him being discharged home. During an observation, on 4/25/19 at 2:08 p.m. Resident D's bilateral lower extremities were observed with Licensed Practical Nurse (LPN) 6. There was redness and open areas noted to the resident's bilateral lower extremities. The following measurements were obtained by LPN 6. Wound 1: Left outer lower leg; 5 centimeters (cm) length x 3 cm width x 0.1 cm depth. Wound 2: Left outer leg; 3 cm length x 1.4 cm width x 0.1 cm depth. Wound 3: Right lower leg; 2.3 cm length x 1.3 cm width x 0.1 cm depth. At the same time, LPN 6 indicated she had returned to work a couple of weeks ago,' and indicated the areas to the resident's bilateral lower extremities had been opened since she had returned. During this time, the Assistant Director of Nursing (ADON) entered the room and indicated she was unaware of the resident's open areas and had not been monitoring them weekly. She had not been notified by the nursing staff the areas had opened up. Resident D's record was reviewed on 4/25/19 at 11:00 a.m. The resident was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. A hospital document, titled, Preliminary Report, dated 3/8/19, indicated a discharge [DIAGNOSES REDACTED]. Hospital course: presented to the hospital with left lower extremity [MEDICAL CONDITION], superimposed on chronic [MEDICAL CONDITION], and underwent compression therapy and antibiotics, with improvement noted from the treatment. A hospital document, titled, Discharge Instructions, dated 3/8/19, indicated to continue the following medication, [MEDICATION NAME] (antibiotic) 875 milligrams (mg)-125 mg, take 1 tablet by mouth (PO) every 8 hours with a stop date of 3/15/19. Additional instructions indicated wound care instructions: 1. Left anterior (near the front) thigh and right posterior (further back in position) thigh wounds: cover with non-adherent dressing and secure with bordered foam dressing. Change every other day. 2. Bilateral lower legs: Cover wounds on left lateral calf with non-adherent dressing. Wrap both legs with cast padding and Coban (elastic, self-adherent gauze) and change Monday, Wednesday, and Friday. An admission nursing evaluation, dated 3/8/19, indicated the resident was admitted to the facility with [MEDICAL CONDITION] to the right rear thigh and measured 9 centimeters (cm) length x 6 cm width x 0.1 cm depth, and redness to the left front thigh. A Medication Administration Record [REDACTED]. The MAR indicated [REDACTED]. The MAR indicated [REDACTED]. A review of progress notes, dated 3/8/19 through 3/17/19, lacked documentation the physician was notified the medication was not administered as ordered. A weekly wound tracking form, dated 3/14/19, indicated the wound area to the right posterior thigh had been resolved. New areas were noted to the right lower extremity and left lower extremity with a vascular (relating to, affecting, or consisting of a vessel or vessels) etiology (the cause), and measurement indicated scattered. A progress note, dated 3/15/19, indicated the resident requested as needed (PRN) pain medication for leg pain rated a 5 out of 10. Repositioning and distraction with television and conversation was not effective, PRN pain medication administered. A grievance log, dated 3/18/19, indicated the resident had filed a grievance/concern for timeliness of care to legs. The resolution indicated a shower was provided, preferences reviewed and legs were dressed. A progress note, dated 3/18/19 at 3:24 p.m., indicated the residents legs were swollen, red, and weeping yellowish drainage. A criteria for initiating antibiotic therapy, dated 3/18/19, indicated skin and soft-tissue infection. The following criteria was noted: tenderness, warmth, and new or worsening swelling at affected site. A physician's orders [REDACTED]. A MAR, start date 3/18/19, indicated 4 flex (4 layer wrap) apply twice weekly on Monday and Thursday and as needed for soilage. The physician's orders [REDACTED]. A MAR, dated (MONTH) 2019 and start date of 3/19/19, indicated Keflex (antibiotic)1000 mg every 8 hours times 7 days for [MEDICAL CONDITION]. The MAR indicated [REDACTED] A MAR, dated (MONTH) 2019 and start date of 3/19/19, indicated [MEDICATION NAME] ([MEDICATION NAME] supplement) 250 mg daily times 14 days for [MEDICAL CONDITION]. The MAR indicated [REDACTED]. A review of progress notes, dated 3/18/19 through 3/30/19, lacked documentation the physician was notified the medications were not administered as ordered. A physician's progress note, dated 3/20/19, indicated nursing reported increased warmth and [DIAGNOSES REDACTED] and drainage to left lower extremity. The integumentary (skin) system had dry skin, open areas, and fragile skin noted. The assessment/treatment plan indicated [MEDICAL CONDITION] still not resolved, started Keflex 1000 mg by mouth every 8 hours times 7 days. A weekly wound tracking form, dated 3/21/19, indicated vascular areas to the right and left lower extremity with measurement as scattered. A signs and symptoms of skin/soft tissue infections form, dated 4/9/19, indicated the resident had [MEDICAL CONDITION] with a new or increasing presence of redness, swelling, tenderness or pain, and serous drainage at the affected site. A MAR, dated (MONTH) 2019, start date 4/9/19 and stop date 4/16/19, indicated Keflex 500 mg tablets, give 2 tablets PO (by mouth) every 8 hours times 7 days. The MAR indicated [REDACTED] A review of progress notes, dated 4/10/19 through 4/22/19, lacked documentation the physician was notified the medication was not administered as ordered. A social service progress note, dated 4/11/19 at 4:47 p.m., indicated the resident had stated he wanted to die, and made the statement due to the amount of pain he was feeling at the time. He currently had a lot of pain all over his body. A progress note, dated 4/15/19 at 12:55 a.m., indicated the resident received PRN pain medication at 12:30 a.m. for bilateral lower extremity pain. A progress note, dated 4/16/19 at 3:03 a.m., indicated the resident received PRN pain medication at 11:00 p.m. for pain. During an interview, on 4/25/19 at 12:12 p.m., the Senior Director of Nursing (DON) indicated she could not find an order prior to 3/18/19 for treatment to the resident's bilateral lower extremities. She was unsure how the discharge instructions from the hospital had been missed and indicated the resident should have had a physician's orders [REDACTED]. During an interview, on 4/25/19 at 1:30 p.m., the Assistant Director of Nursing (ADON) indicated the resident had developed scattered areas to his lower bilateral extremities in the facility. These areas were noted on a weekly skin round on 3/14/19 and lacked documentation of exact measurements. The residents MAR indicated [REDACTED]. The stop date for the medication was 4/16/19 and she was unsure why two additional doses had been administered on 4/20/19 at 8 a.m. and 4/22/19 at 4:00 p.m. On 4/24/19 at 1:30 p.m., the Senior DON provided a document titled, Medication Administration General Guidelines, and indicated it was the policy currently being used by the facility. The policy indicated, Policy: Preparation or administration of medications or biological's completed in accordance with physician's orders [REDACTED]. Documentation is completed on the MAR/eMAR immediately after medications ingested by resident and is completed by the licensed nurse/authorized personnel who administered the medications. i. initial paper MAR indicated [REDACTED]. After medication administration is completed, licensed nurse/authorized personnel review the MAR/eMAR to ensure all necessary doses were administered and documented On 4/25/19 at 1:31 p.m., the Administrator provided a document titled, Medication and Treatment Orders, and indicated it was the policy currently being used by the facility. The policy indicated, Policy Statement: Orders for medications and treatments will be consistent with principles of safe and effective order writing. Policy Interpretation and Implementations: .3. Drug and biological orders must be recorded on the physician's orders [REDACTED]. 2. Resident C's record was reviewed on 4/24/29 at 1:06 p.m. A comprehensive Minimum Data Set (MDS) assessment, dated 3/8/19, indicated the resident was cognitively intact and had a surgical wound. Census information on the resident's profile included, but was not limited to, admitted to the facility on [DATE], and discharged to home on 3/15/19. [DIAGNOSES REDACTED]. A report sheet, dated 3/1/19, indicated the resident was admitted to the facility related to a right total hip replacement. Hospital discharge instructions, dated 3/1/19, indicated, Incision Care: You will have a special waterproof dressing over your incision when you leave the hospital .This dressing will remain in place for 5 days after your surgery before being removed .After removal of your dressing, perform daily incision washes with soap and water; pat to dry well The resident's clinical record lacked documentation these orders were transcribed at the time of admission. A Nursing Evaluation Data Assessment, completed upon admission on 3/1/19, indicated the resident had a surgical incision to the right hip with 48 stitches. The same assessment also indicated the resident had a surgical incision to the right hip with 48 staples, and it was well approximated (edges together). The assessment lacked documentation of how the incision should have been treated. physician's orders [REDACTED]. A Medication Administration Record [REDACTED]. A care plan, initiated 3/4/19, indicated the resident had impaired skin integrity, right hip surgical wound. Interventions included, but were not limited to, assess and document skin condition, notify the physician of signs of infection, and notify the physician of worsening or no improvement in the wound. An untitled wound monitoring document, dated 3/7/19, indicated the resident had a surgical incision to the right hip with staples and an ABD pad (type of dry dressing). The physician's orders [REDACTED].>An untitled wound monitoring document, dated 3/14/19, indicated the resident had a surgical incision to the right hip with steri strips. The record lacked documentation of any treatment to the area. A discharge planning and evaluation form, dated 3/15/19, indicated the resident had not received wound care. A review of Skilled Charting documents indicated the resident had no new changes to skin integrity and the dressing was changed as per treatment orders and the record lacked documentation of any physician's orders [REDACTED]. The record lacked documentation of any further skilled charting documents. A review of nurse's notes indicated the following: On 3/2/19, indicated the resident's dressing from the right hip surgery was intact. The surgeon had written do not change until 3/3/19, on the dressing. On 3/12/19, indicated the resident went out to a scheduled orthopedic doctor's appointment to have staples removed, and 68 staples were removed. Steri strips (wound closure strips) were placed. The nurse's notes lacked documentation of any other assessments of the resident's right hip incision, and any dressing changes or treatments to the right hip incision being completed. During an interview, on 4/25/19 at 9:58 a.m., the Director of Nursing (DON) indicated she was not sure what should have been done for residents who admitted with a surgical incision or how they should have been cared for. She had to check and find out what should have been done. During an interview, on 4/25/19 at 10:40 a.m., the DON indicated assessments of Resident C's right hip incision should have been completed daily. The assessments should have been documented in the Daily Skilled Charting documents. She was unable to find Skilled Charting documents for 3/2/19, 3/3/19, 3/4/19, 3/5/19, 3/6/19, 3/7/19, 3/8/19, 3/9/19, and 3/13/19. She was unsure how the nurse assessed the resident's right hip incision on the admission assessment, dated 3/1/19, if the incision was covered with a dressing not to be removed until 3/3/19. She was not sure if the resident required a treatment to the right hip. During an interview, on 4/25/19 at 12:10 p.m., the Assistant Director of Nursing (ADON) indicated she was responsible for monitoring wounds in the facility and assessed them weekly. She thought the resident's dressing was supposed to be removed on 3/3/19, but was unable to provide documentation the dressing was removed or changed. She thought the resident was supposed to have an abdominal (ABD) pad to cover the incision. She was not sure if there should have been an order for [REDACTED]. During an interview, on 4/25/19 at 2:13 p.m., the Senior DON indicated there was no written facility policy for how to treat residents who admitted with surgical incisions. Incisions should have been assessed by the nurse upon admission, and daily thereafter. The assessments should have been documented in the Daily Skilled Charting documents. There should have been a physician's orders [REDACTED]. This Federal tag relates to Complaints IN 708 and IN 549. 3.1-37(a)

Based on record review and interview, the facility failed to ensure staff utilized precautions to avoid moving a body part with a suspected fracture when a mechanical lift was used to move a resident who fell resulting in a displaced [MEDICAL CONDITION] (long bone in the arm) for 1 of 3 residents reviewed for quality of care related to a suspected fracture (Resident B). Finding includes: The record for Resident B was reviewed on 3/2/16 at 10:00 a.m. Resident B's [DIAGNOSES REDACTED]. A Nursing Progress Note, dated 2/26/16 at 11:45 a.m., indicated the nurse heard a resident fall in the hallway and found the resident face down on the floor with a moderate amount of blood from a laceration on her chin, the DON (Director of Nursing) approached and instructed the nurse to call the physician and 911. The POA (Power of Attorney) was also notified. A Nursing Progress Note, 2//26/16 11:45 a.m., indicated Resident B was lying flat on her face with 2 staff members present. A small pool of blood was noted under the resident on the right side. The resident was alert and speaking. The nurse assessed the resident for pain, the resident indicated she had pain in her right arm. The nurse and staff then turned the resident over onto her back while supporting her joints and placed a pillow under her head to see where the blood originated. A small laceration was noted to her chin and there were no other visible injuries. Visual assessment of extremities showed symmetrical lower and upper extremities. The nurse then attempted to assess ROM (range of motion) of extremities. The assessment of lower extremities was without distress to the resident and the resident denied pain. The resident was asked to raise her arms, and was able to raise her left arm without difficulty, but her right arm only slightly and complained of shoulder pain. Pressure was applied to her chin. Resident was assisted up x's 2 (by 2 staff members) using hoyer lift (mechanical lift) ems (emergency medical services) had arrived resident was transferred to gurney via hoyer lift. The hospital emergency department examination report, 2/26/16, indicated Upper extremity exam included findings of inspection abnormal, deformity present . The hospital Radiology Report, 2/26/16, indicated There is a displaced [MEDICAL CONDITION] shaft of the right humerus. There is overriding with shortening. During an interview with the DON on 3/2/16 at 12:30 p.m., she indicated she had gone to the resident and when she (DON) was assessing Resident B's ROM, Resident B could barely lift her right arm and said her arm and shoulder hurt. The DON indicated she had asked the Unit Manager to get vital signs, and told her not to take the blood pressure in her right arm because Resident B said it hurt. Then we got her up on the hoyer (lift), the EMTs (emergency medical team) arrived and we lowered her onto their stretcher. During an interview with RN #1 on 3/2/16 at 9:20 a.m., she indicated the resident should not have been moved off the floor when staff was instructed to use the mechanical lift to move the resident and clean her up. During an interview with RN #2 on 3/2/16 at 11:20 a.m., she indicated she heard the resident fall and indicated the resident was crying in pain. She indicated the DON instructed the CNA to get the resident up with the mechanical lift. RN#2 indicated an injured resident should not have been moved. CNA #3 was interviewed on 3/2/16 at 11:45 a.m. She indicated she saw Resident B fall, but was too far away to reach her. She indicated Resident B kept crying I'm hurt, I'm hurt. She indicated the DON told her everyone who falls should be picked up off the floor by the (mechanical) lift. On 3/2/16 at 1:20 p.m., CNA #4 was interviewed. She indicated she did not think you were supposed to get someone hurt off the floor. She indicated Resident B was complaining of pain. The Falls Practice Guide Flowchart and Care Path Falls provided by the DON on 3/2/16 at 1:30 p.m. and identified as the current protocol for care of a resident who fell indicated an initial nursing evaluation for injury and/or mental status changes with a pathway of .DO NOT move off floor until complete exam has been performed and the next pathway was Suspected fracture or new bone deformity and indicated to notify MD (Medical Doctor or NP (Nurse Practioner) or PA (Physician Assistant). This federal tag relates to Complaint IN 540. 3.1-37(a)

Based on record review and interview, the facility failed to implement and evaluate efficacy of interventions to prevent a resident with an intellectual disability from falling, resulting in a fractured humerus (long bone in the arm). Additionally the facility failed to ensure adequate supervision to prevent the resident from removing the splint/immobilizer from the fractured arm, resulting in hospitalization and surgical repair of the fracture for 1 of 3 residents reviewed for accident supervision (Resident B). Finding includes: The record for Resident B was reviewed on 3/2/16 at 10:00 a.m. Resident B's [DIAGNOSES REDACTED]. The care plan, dated 12/15/15, for Resident B indicated she was at risk of falls. Interventions included, but were not limited to, encourage to transfer and change positions slowly, assist to transfer and ambulate as needed,and re-evaluate medications. A psychiatrist evaluation was added to interventions on 1//416 due to increased anxiety and flighty ideas and the plan was revised on 1/28/16 to provide non skid shoes. On 2/22/16 new interventions for frequent toileting, reminders for allowing staff to assist her, and reinforce using the call light were added. Interventions of storing the resident's walker outside her room when not in use, comforting the resident when she requested to see her mother, and non-slip socks were added to the plan on 2/26/16. The care plan did not address increased monitoring of every 30 minutes and the resident's noncompliance with using the call light and waiting for assistance. A Nursing Progress Note, dated 2/26/16 at 11:45 a.m., indicated the nurse heard a resident fall in the hallway and found the resident face down on the floor with a moderate amount of blood from a laceration on her chin, the DON (Director of Nursing) approached and instructed the nurse to call the physician and 911. The POA (Power of Attorney) was also notified. A Nursing Progress Note, 2//26/16 11:45 a.m., indicated Resident B was lying flat on her face with 2 staff members present. A small pool of blood was noted under the resident on the right side. The resident was alert and speaking. The nurse assessed the resident for pain, the resident indicated she had pain in her right arm. The nurse and staff then turned the resident over onto her back while supporting her joints and placed a pillow under her head to see where the blood originated. A small laceration was noted to her chin and there were no other visible injuries. Visual assessment of extremities showed symmetrical lower and upper extremities. The nurse then attempted to assess ROM (range of motion) of extremities. The assessment of lower extremities was without distress to the resident and the resident denied pain. The resident was asked to raise her arms, and was able to raise her left arm without difficulty, but her right arm only slightly and complained of shoulder pain. Pressure was applied to her chin. Resident was assisted up x's 2 (by 2 staff members) using hoyer lift (mechanical lift) ems (emergency medical services) had arrived resident was transferred to gurney via hoyer lift. The hospital emergency department examination report, 2/26/16, indicated Upper extremity exam included findings of inspection abnormal, deformity present . The hospital Radiology Report, 2/26/16, indicated There is a displaced fracture of the proximal shaft of the right humerus. There is overriding with shortening. A Nursing Progress Note, 2/26/16 at 10:20 p.m., indicated Resident B returned from the hospital with a cast and sling on her right arm. The note indicated the resident attempted to get up to go to the bathroom without assistance and was unsteady and off balance. The next entry, dated 2/27/16 at 7:53 a.m., indicated Resident was noted standing at bedside when noted by a CNA, nurse responded, noted resident standing with ace wrap bandage, open arm cast, & sling removed, previously resident had been to hospital and diagnosed with [REDACTED]. appliances replaced in proper position. The next entry at 3:01 p.m. on 2/27/16, indicated the resident had been very anxious, had been transferred with a gait belt and was a maximum assistance of 1 for basic care with cueing. She had kept trying to use her right arm to pull herself up. The ace wrap was reapplied after she had taken it off, the sling was adjusted several times. Her upper bicep was swollen and discolored and ice applied. The next nursing entry was at 11:34 p.m. 2/27/16. The entry indicated at 9:30 p.m. the resident had been found lying on her stomach on the floor at the foot of her bed. She was assessed, complained of pain, an ambulance was called and she was transported to the hospital at 10:30 p.m. The hospital radiology report, 2/27/16, indicated 2 views of the right humerus were obtained and compared to a previous examination of the right shoulder performed on 2/26/16. There is a spiral displaced fracture of the midshaft of the right humerus. The displacement and angulation has increased compared to the previous study suggesting the fracture is unstable. During an interview with the DON (Director of Nursing) on 3/3/16 at 3:00 p.m., she indicated staff were checking on the resident frequently, redirecting her, trying to get her involved in crafts. The DON indicated she expected frequent checking on a resident to be every 30 minutes. The record lacked documentation of the resident being monitored every 30 minutes. A current policy, dated 12/2011, titled Falls Practice Guide was provided by the DON on 3/2/16 at 3:45 p.m. The policy indicated .Initial Evaluation To determine if a patient has factors that may place them at risk for falls .Initial Plan of Care .an initial plan of care is developed and individualized interventions are initiated Interdisciplinary Care Planning .The interdisciplinary team designs the care plan to focus on all the patient's issues including those associated with fall prevention and fall risk management Change In Condition Or Fall Occurrence .The care plan is revised as clinically indicated to meet the patient's current needs This federal tag relates to Complaint IN 540. 3.1-45(a)(2)

Based on observation, interview, and record review, the facility failed to ensure pain medication was administered prior to a pressure ulcer dressing change resulting in symptoms of anxiety and severe pain that were unrelieved until the procedure was complete for 1 of 1 resident reviewed for pain (Resident #99) and failed to ensure communication of care and health status for 1 of 1 resident reviewed for [MEDICAL TREATMENT] (Resident #75). Findings include: 1. During an observation on 5/22/2015 from 10:35 a.m. through 10:56 a.m., RN (Registered Nurse) #5 changed a pressure ulcer dressing on Resident #99's right, outer ankle. Resident #99 was resting in bed with her eyes closed prior to the dressing change. During the dressing change Resident #99 bit down on her lip, grit her teeth, and squeezed her blanket tightly with her left hand. RN #5 was heard telling Resident #99 she was sorry, but continued with the dressing change without offering pain medication. Resident #99 lifted her head from the pillow, continued biting her lip and and squeezed her bed blankets with a tight grip. RN #5 indicated she could really see her grimace. RN #5 continued the dressing change. Resident #99 squeezed her blanket with a tight grip and lifted her head up off her pillow. RN #5 continued with the dressing change. Resident #99 lifted her head off the pillow again, grabbed her blanket and squeezed it tightly with her left hand. RN #5 indicated to Resident #99 she knew the dressing change was hurting her so much. When the procedure was done Resident #99 closed her eyes and rested without signs and symptoms of anxiety and pain. During an interview on 05/22/2015 at 10:54 a.m., RN #5 indicated Resident #99 indicated Resident #99 experienced a lot of pain during the dressing change and indicated she was not aware the resident had an order for [REDACTED]. During an interview on 5/26/15 at 11:42 a.m., Wound Care RN #4 indicated Resident #99's care plan included interventions for pain medication prior to dressing changes and indicated she didn't think it would have made a difference in the resident's tolerance of the procedure because Resident #99's pain was related to contractures and [DIAGNOSES REDACTED]. Resident #99's record was reviewed on 05/19/2015 at 12:07 P.M. The record indicated Resident #99 was non verbal due to [MEDICAL CONDITION] and having a [MEDICAL CONDITION]. A Minimum Data Set assessment tool, dated 4/1/15, indicated Resident #99 was severely cognitively impaired. An untimed physician's orders [REDACTED]. Care plans initiated on 3/9/15 and 3/14/15, and identified as current by the Director of Nursing on 5/26/15 at 10:30 a.m., indicated Resident #99 had a stage four pressure ulcer on her right outer ankle and had a potential for pain. Goals indicated pain would be relieved by a goal of zero. Interventions included administer [MEDICATION NAME] per physicians orders (offer prior to treatment/therapy). Nurse's notes dated: 3/9/15 at 11:34 a.m., 3/20/15 at 10:45 a.m., 3/23/15 at 12:33 p.m., 3/30/15 at 10:45 a.m., 4/6/15 at 5:55 a.m., 4/20/15 at 3:09 p.m., 5/4/15 at 5:13 p.m., and 5/13/15 at 1:44 p.m., indicated Resident #99 does experience some pain during dressing changes as exhibited by her facial grimacing. She does have pain medication that nursing will give before dressing changes are to be done. The March 2015, Medication Administration Record [REDACTED]. The April 2015 MAR indicated [REDACTED]. The record did not indicate prn pain medication was administered on any other dates. The May 2015 MAR indicated [REDACTED]. During an interview on 5/27/2015 at 2:10 p.m., the Director of Nursing (DON) indicated the facility did not have a policy regarding pain interventions for pain control. A Pain Practice Guide Flowchart, dated 2011 and provided by the DON on 5/27/2015 at 2:10 p.m., .ASSESS: Does the patient have pain or a condition that is likely to cause pain .IMPLEMENT: .Evaluate patients for pain daily and document .Ongoing management strategies .EVALUATE . 2. Resident #75's record was reviewed on 5/22/2015 at 10:30 a.m. The resident's [DIAGNOSES REDACTED]. A [MEDICAL TREATMENT] Communication Form indicated Resident #75 received [MEDICAL TREATMENT] on 5/8/2015 and did not indicate staff completed an assessment or checked vital signs prior to sending the resident to the [MEDICAL TREATMENT] center. A [MEDICAL TREATMENT] Communication Form indicated Resident #75 received [MEDICAL TREATMENT] on 5/18/2015 and did not indicate the [MEDICAL TREATMENT] center provided post-[MEDICAL TREATMENT] vital signs and health status. A [MEDICAL TREATMENT] Communication Form indicated Resident #75 had [MEDICAL TREATMENT] on 5/25/2015 and did not indicate the [MEDICAL TREATMENT] center provided post-[MEDICAL TREATMENT] vital signs. During an interview on 5/26/2015 at 10:32 a.m., Registered Nurse (RN) #2 indicated Resident #75 received [MEDICAL TREATMENT] three times a week. A binder that contained a [MEDICAL TREATMENT] Communication Form was sent to the [MEDICAL TREATMENT] center and had not been located upon the resident's return from the center on 5/25/2015. She indicated the binder was not always returned to the facility and indicated it would be retrieved the next time the resident went to the [MEDICAL TREATMENT] center. During an interview on 5/26/2015 at 11:11 a.m., the Administrator indicated the [MEDICAL TREATMENT] Communication Form was the policy and/or guidelines used to provide the [MEDICAL TREATMENT] center with the following: vital signs/weight, [MEDICAL TREATMENT] and patient status assessment, lab tests, diet order/fluid restrictions, and current medications. The form indicated the [MEDICAL TREATMENT] center should have provided the nursing facility with the following information upon resident's completion of daily [MEDICAL TREATMENT]: pre-[MEDICAL TREATMENT] vital signs and weight, post-[MEDICAL TREATMENT] vital signs and weight, patient complications during [MEDICAL TREATMENT], nutrition concerns, medications given during [MEDICAL TREATMENT], laboratory values, post [MEDICAL TREATMENT] instructions, new physician orders, and patient status. During an interview on 5/26/2015 at 12:29 p.m., the Administrator indicated the facility should have completed their portion of the communication form before sending the resident to [MEDICAL TREATMENT] and the facility staff was responsible for retrieval of the pre-[MEDICAL TREATMENT] and post-[MEDICAL TREATMENT] information when Resident #75 returned from [MEDICAL TREATMENT]. A document titled, Disease Management Guideline for [MEDICAL CONDITION], was provided by the Administrator on 5/26/2015 at 11:11 a.m. indicated, .NURSING .Communicate with the [MEDICAL TREATMENT] center. A document titled, SNF (Skilled Nursing Facility) Outpatient [MEDICAL TREATMENT] Services Agreement, was provided by the Administrator on 5/26/2015 at 11:11 a.m. indicated, .Resident Information: The Nursing Facility shall ensure that all appropriate medical and administrative information accompanies all residents at the time of transfer or referral to the [MEDICAL CONDITION] [MEDICAL TREATMENT] Unit. 3.1-37(a)

Based on record review and interview the facility failed to notify a physician of a significant change in condition to a resident which had the potential for requiring physician intervention when a resident had an abnormal blood pressure (Resident B) and when a resident needed pain management and had abnormal respirations (Resident C). The facility also failed to notify a family member when there was a significant change in condition (Resident C). This deficient practice affected 2 of 35 residents reviewed for physician/family notification. Findings: 1. Resident C's record was reviewed on [DATE] at 2:37 P.M. Resident C was admitted to the facility on [DATE], from an acute care hospital and had diagnoses, which included but were not limited to, urinary tract infection, muscle weakness, chronic [MEDICAL CONDITION], senile dementia, [MEDICAL CONDITIONS], uncontrolled diabetes type 2, [MEDICAL CONDITION], hypertension, urinary obstruction, [MEDICAL CONDITION], and gangrene symptoms. Resident C's son was the Power of Attorney and the primary contact. Review of a discharge summary (not dated) from the acute care hospital from which Resident C was admitted , indicated, Resident C's physicians had had conversations with Resident C's son regarding his end stage debility and possible [DIAGNOSES REDACTED]. (named) and the patient's son came up with a plan of putting in a PICC (peripheral inserted central catheter) line and trying TPN (total parental nutrition) for two weeks. If this does not succeed in increasing his functional status they will consider possible hospice versus other forms of alimentation at that point...." A document, dated [DATE] and titled, "State of Indiana, Out of Hospital Do Not Resuscitate Declaration and Order", indicated Resident C's son gave a verbal consent to change his fathers status to DNR (do not resuscitate). This form indicated, "... I direct that, if I experience cardiac or [MEDICAL CONDITION] failure in a location other than an acute care hospital or a health facility, cardiopulmonary resuscitation procedures be withheld or withdrawn and that I be permitted to die naturally. My medical care may include any medical procedure necessary to provide me with comfort care or to alleviate pain...." A social service note, dated [DATE], indicated, "Spoke with Resident's son (named) regarding hospice. (Nurse named), Nurse Weekend Manger had discussed hospice benefits with them over the weekend. I explained that hospice comes into the building to provide care on top of services that we already provide and is a good support for the family also. Resident has expressed to family that he wanted to die at home. The family is looking at all options right now. (Son named) had talked with hospice today but no decision have been currently...They would like to take him home but have things to get ready at home first. He stated that hospice may only be for a few days and then home but they haven't decided yet. I stated that I would follow up with him on Wednesday when I was back in the office." Orders were obtained to have the patient evaluated by hospice. A document, dated [DATE] and titled, "Manor Care Health Services Fax Cover Sheet", indicated, a hospice company was faxed with a request to contact Resident C's son on [DATE] to discuss hospice. An untrimmed nurse's note, dated [DATE], indicated, "Resident arrived at facility accompanied by 2 paramedics. Resident was transferred to bed in Rm (room).... Resident noted to be contracted into fetal position, moans and cries out in pain if attempts to straighten limbs are made. Resident has multiple open areas as detailed on skin assessment. Skin is warm and dry. Resident is lethargic alert to self. Vitals signs are stable. Respirations even, non labored..." The record including the MAR (Medication Administration Record) lacked documentation Resident C was administered pain medicine on this date. Resident C's admission physician's orders [REDACTED]. These physician's orders [REDACTED]. A care plan initiated on [DATE], indicated, Resident C had generalized pain as evidenced by verbal and non-verbal signs and symptoms related to contractures, arthritis, and pressure points/ulcers. The goal was for pain or [MEDICATION NAME] to not affect participation in activities of choice or daily care. Interventions listed to meet this goal included: 1) Report nonverbal expressions of pain such as moaning, striking out, grimacing, crying, thrashing, change in breathing, etc. 2) Administer pain medication per physician orders [REDACTED]. An untimed document, dated [DATE] and titled, "Pain Assessment in Advanced Dementia (PAINAD) Scale", indicated, "...the PAINAD scale was used for patients who could not verbally communicate about their pain. The PAINAD scale evaluates the realms of breathing, independent of vocalization; negative vocalizations; facial expression; body language; and consolability. The observations are converted to a numeric ,[DATE] scale. Observe the patient for five minutes before scoring the behaviors." A nurse's note, dated [DATE]-7:11 A.M., indicated Resident C had no signs of pain. The MAR, indicated at 8:00 A.M., his pain score was 8 out of 10. The next nurse's note, dated [DATE]-10:49 P.M., indicated, ..."pt (patient) moans with touch..." The record did not have documentation of a pain assessment or the physician being notified of the ineffectiveness of the ordered pain medication. A nurse's note, dated [DATE]-1:26 P.M., indicated, " Resident verbalized understanding of care being provided but would yell out and draw (sic) in with repositioning and care." An occupational therapy note, dated [DATE]-untimed, indicated, Resident C had an increase in expressions of pain. A nurse's note, dated [DATE]-3:21 P.M., indicated, "...Pt (patient) has several necrotic areas on feet and toes. Dressings and treatments completed on bilateral feet, toes and on buttocks. Pt says "ouch" anytime he is being moved or repositioned. Takes his meds crushed in apple sauce...." Resident C's record lacked documentation of a pain assessment, evaluation of the effectiveness of the ordered pain medication, or notification to the physician regarding Resident C's increased pain interfering with his daily care. A nurse's note, dated [DATE]-11:38 P.M., indicated, "Res. (resident) refused all oral meds(medications) this PM. Cursed at nursing staff when repositioned... Bed bath completed and lotions applied to skin. Res. continues to moan out in pain and curse when moved in bed...." The record lacked documentation a physician was notified of the his current pain status and the ineffectiveness of the ordered pain medication. A nurse's note, dated [DATE]-1:59 P.M., indicated, "...pt (patient) laying in bed in fetal position, staff attempted to reposition several times...any time pt is touched for care or repositioning pt yells out, becoming very combative, pt unable to make needs or wants clear to staff, pt currently laying in bed with call light in reach." The record lacked documentation of a pain assessment or documentation the physician was informed of the resident's current pain level and possible need to change or increase his pain medication. The December MAR indicated [REDACTED]. The record lacked documentation of a physician being notified of Resident C's inability to swallow medication or a request for pain medication to be delivered in a route other than oral. A physical therapy note, dated [DATE]-untimed, indicated, "...pt (patient) is non-responsive and been sleeping all time. Pt is completely dependent for bed mob. (mobility). Unable to perform functional transfers R (related to) L/E (lower extremity) contracture... Not alert or oriented at all. Pt also c/o (complains) generalized pain. Pt has dr's (doctors) for possible hospice eval. (evaluation). Not appropriate for skilled PT (physical therapy) at this date." The record lacked documentation of the physician being notified that Resident C could not complete therapy because of pain. An occupational therapy note, dated [DATE], indicated, "...movement of any sort appears uncomfortable as indicated by grimacing and moaning...." This note further indicated Resident C had expressions of pain with touch or movement. The record lacked documentation the physician was notified Resident C could not complete therapy because of pain. A nurse's note, dated [DATE]-11:18 A.M., indicated, "...staff state resident "yells out and moans" whenever care is provided. He has orders for scheduled pain med (medicine) however resident has been refusing all meds po (oral) meds at this time..." The record lacked documentation of a pain assessment, pain medication being administered, or the physician being notified of the patients increased pain. A physician's telephone order, dated [DATE]-untimed, indicated, Resident C may have the Tylenol given rectally instead of orally. The MAR indicated [REDACTED].M. (Eight hours after staff reported patients yelling and moaning.) A pain assessment or an evaluation of the effectiveness of the pain medication was not completed. A nurse's note, dated [DATE]-2:15 P.M., indicated, "Res. (resident) blood sugar was 534 at 11 am. Writer called and spoke with NP (Nurse Practitioner) and was told to give 18 units. Writer also spoke to NP about res pain, as he cries out when repositioned. Tylenol was D/C'd (discontinued) and a new order for [MEDICATION NAME] (a stronger pain medication) was given. Writer gave one does..." The MAR indicated [REDACTED].M. Resident C died on [DATE]. The record lacked documentation of care or assessments of Resident C after the above nurse's note, dated [DATE]- 2:15 P.M. During an interview, on [DATE] at 9:30 A.M., the Administrator indicated there was not further documentation on Resident C after [DATE] at 2:15 P.M. The Administrator was asked about the details surrounding the residents death and he indicated he was looking into it. The DON (Director of Nursing) obtained a statement on [DATE] at 9:50 A.M., from the nurse who cared for Resident C on [DATE]. LPN #17 indicated in this statement, "I went in after report around 6:,[DATE]:45 A.M. and checked him. He was having periods of apnea then. I went in to check on him between ,[DATE]:30 A.M. and he was already gone. Listened to his chest no heart beat or respirations. Went and got (nurse named). She listened to him and verified no heart rate or respirations. I called the son to notify him. Son just said thanks for letting me know. Then I notified the NP (named) in facility." During an interview, [DATE] at 5:10 P.M., the DON was asked to provide documentation Resident C's family and physician were notified when the nurse noted the change in his breathing, for any assessments of pain and/or follow up assessment on the elevated blood sugar reported in the last nurse's note. Policies were requested for: doctor notification, significant change, pain evaluation and management, and TPN/IV (Total parental nutrition/intra-venous) assessments. The DON indicated Resident C was not a hospice patient and indicated the physician should have been notified regarding Resident C's change in condition. The DON stated, "That's a good question," when queried regarding why the record lacked documentation of follow up regarding unrelieved pain and an elevated blood sugar. During the exit conference, [DATE] at 7:00 P.M., the Administrator and DON indicated no further documentation was available. 2. Resident B's record was reviewed on [DATE] at 2:08 P.M. Resident B was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Resident B was a DNR (do not resuscitate) but was not a hospice patient. A nurse's admission note, dated [DATE]-10:24 P.M., indicated, Resident B was brought to the facility late in the evening. She was very scared and called out please help me repeatedly. The family indicated to the staff the resident had eaten poorly in the few days prior to admission to the facility. Her vitals were taken. This note indicated, "...Her blood pressure was very low on admission ,[DATE]." The record lacked documentation a physician was notified of this low blood pressure. A nurse's note, dated [DATE]-7:04 A.M., indicated Resident B refused to have her vitals taken. A nurse's note, dated [DATE]-13:14, indicated, she continued to refuse to have her vitals taken. The record lacked documentation which indicated the physician was notified of the resident's refusals to allow monitoring of vital signs following the low blood pressure on admission. A nurse's note, dated [DATE]-5:39 P.M., indicated, the physician was called regarding the resident's behaviors of yelling and calling out all night. An anti-anxiety medication was ordered for three days until the physician could evaluate her. A nurse's note, dated [DATE]-9:40 P.M., indicated, Resident B was yelling out and hitting the staff. The record indicated Resident B's family was called and indicated the family informed facility staff that the resident had not eaten and barely drank anything during the four days prior to admission to the facility. The nurse's note indicted the resident continued the nutrition and hydration routine. The record lacked documentation which indicated the physician was notified of the resident's nutrition/hydration status. A nurse's note, dated [DATE]-4:20 A.M., indicated, "Aide came to nurse to report pt (patient) did not seem "right". On arriving in pt room, noticed labored respirations and groaning coming from pt. Vital signs obtained -02 (oxygen level)-80%, HR (heart rate) 54, RR (respirations)-24, BP (blood pressure)-unable to obtain. Applied supplemental oxygen 4L(liters) ,[DATE]%, RR-16, HR-68 still unable to obtain BP. Pt only responded to sternal rub by groaning. Lung sounds clear...Dr office notified of pt. status. Family notified." A nurse's note, dated [DATE]-5:55 A.M., indicated, "Pt (patient) family member came to get nurse to discuss further care options for pt. Pt husband wanted to see wife before discussing further options with family. Nurse escorted family to pt room. Upon going to pt side of room pt did not have visible respiration. On assessing pt no audible heart sounds. Went to get another nurse to verify no audible heart sounds..." During an interview, on [DATE] at 3:00 P.M., the Administrator was asked if a physician had been notified of Resident B's admission blood pressure "being very low". He indicated he would check into it. During an interview ,on [DATE] at 9:30 A.M., the Administrator indicated, the nurse could not remember if she notified the physician of the blood pressure and the record did not have documentation the physician was notified. This federal tag is related to Complaint IN 582. 3XXX,[DATE](a)(2) 3XXX,[DATE](a)(3)

Based on record review and interview the facility failed to provide the necessary services to ensure a resident with pain was evaluated and provided proper pain management interventions (Resident C). This deficient practice affected 1 of 3 residents reviewed for death/dying. Findings: Resident C's record was reviewed on [DATE] at 2:37 P.M. Resident C was admitted to the facility on [DATE], from an acute care hospital, and had [DIAGNOSES REDACTED]. Resident C's son was his Power of Attorney and the primary contact. Review of an undated discharge summary, from the acute care hospital from which Resident C was admitted , indicated, Resident C's hospital physicians had had conversations with his son regarding his end stage debility and possible [DIAGNOSES REDACTED]. (named) and the patient's son came up with a plan of putting in a PICC (peripherally inserted central catheter) line and trying TPN (total parental nutrition) for two weeks. If this does not succeed in increasing his functional status they will consider possible hospice versus other form of alimentation at that point...." A document dated, [DATE] and titled, "State of Indiana, Out of Hospital Do Not Resuscitate Declaration and Order", indicated Resident C's son gave a verbal consent to change his fathers status to DNR (do not resuscitate). This form indicated, "I declare: My attending physician has certified that I am a qualified person, meaning that I have a terminal condition a medical condition such that, if I suffer cardiac or [MEDICAL CONDITION] failure, resuscitation would be unsuccessful or within a short period I would experience repeated cardiac or [MEDICAL CONDITION] failure resulting in death. I direct that, if I experience cardiac or [MEDICAL CONDITION] failure in a location other than an acute care hospital or a health facility, cardiopulmonary resuscitation procedures be withheld or withdrawn and that I be permitted to die naturally. My medical care may include any medical procedure necessary to provide me with comfort care or to alleviate pain...." A social service note, dated [DATE], indicated, "Spoke with Resident's son (named) regarding hospice. (Nurse named), Nurse Weekend Manger had discussed hospice benefits with them over the weekend. I explained that hospice comes into the building to provide care on top of services that we already provide and is a good support for the family also. Resident has expressed to family that he wanted to die at home. The family is looking at all options right now. (Son named) had talked with hospice today but no decision have been currently...They would like to take him home but have things to get ready at home first. He stated that hospice may only be for a few days and then home but they haven't decided yet. I stated that I would follow up with him on Wednesday when I was back in the office." Orders were obtained to have the patient evaluated by hospice. A document, dated [DATE], and titled, "Manor Care Health Services Fax Cover Sheet", indicated, a hospice company was faxed with a request to contact Resident C's son on [DATE] to discuss hospice. An untrimmed nurse's note, dated [DATE] indicated, "Resident arrived at facility accompanied by 2 paramedics. Resident was transferred to bed in Rm (room).... Resident noted to be contracted into fetal position, moans and cries out in pain if attempts to straighten limbs are made. Resident has multiple open areas as detailed on skin assessment. Skin is warm and dry. Resident is lethargic alert to self. Vitals signs are stable. Respirations even, non labored..." The record including the MAR (Medication Administration Record) lacked documentation Resident C was administered pain medicine on this date. Resident C's admission physician's orders [REDACTED]. These physician's orders [REDACTED]. A care plan initiated on [DATE], indicated, Resident C had generalized pain as evidenced by verbal and non-verbal signs and symptoms related to contractures, arthritis, and pressure points/ulcers. The goal was for pain or [MEDICATION NAME] to not affect participation in activities of choice or daily care. Interventions listed to meet this goal included: 1) Report nonverbal expressions of pain such as moaning, striking out, grimacing, crying, thrashing, change in breathing, etc. 2) Administer pain medication per physician orders [REDACTED]. A untimed document, dated [DATE], and titled, "Pain Assessment in Advanced Dementia (PAINAD) Scale", indicated, "...the PAINAD scale was used for patients who could not verbally communicate about their pain. The PAINAD scale evaluates the realms of breathing, independent of vocalization; negative vocalizations; facial expression; body language; and consolability. The observations are converted to a numeric ,[DATE] scale. Observe the patient for five minutes before scoring the behaviors." A nurse's note, dated [DATE]-7:11 A.M., indicated, Resident C had no signs of pain. The MAR (Medication Administration Record) indicated, at 8:00 A.M., his pain score was 8 out of 10. He was not given pain medication at this time. The next nurse's note, dated [DATE]-10:49 P.M., indicated, ..."pt (patient) moans with touch..." The record did not have documentation of a pain assessment being completed or pain medication being administered. A nurse's note, dated [DATE]-1:26 P.M., indicated, Resident C verbalized understanding of care being provided but would yell out and drawl in with repositioning and care. An occupational therapy note, dated [DATE]-untimed, indicated Resident C had an increase in expressions of pain. The December MAR indicated [REDACTED].M., Resident C was assessed to have a pain score of 2 out of 10. The record lacked documentation pain medication was administered at that time. A nurse's noted, dated [DATE]-3:21 P.M., indicated, "...Pt (patient) has several necrotic areas on feet and toes. Dressings and treatments completed on Bilateral feet, toes and on buttocks. Pt says "ouch" anytime he is being moved or repositioned. Takes his meds crushed in apple sauce...." Resident #18's record lacked documentation of a pain assessment. The MAR (medication administration record) indicated Tylenol was given at 8 P.M. The record lacked documentation of the effectiveness of the pain medication. The December MAR indicated [REDACTED].M. for pain of 4 out of 10. The record lacked documentation of the effectiveness of the pain medication. A nurse's note, dated [DATE]-11:38 P.M., indicated, "Res. (resident) refused all oral meds (medications) this PM. Cursed at nursing staff when repositioned....Bed bath completed and lotions applied to skin. Res. continues to moan out in pain and curse when moved in bed..." The record lacked documentation of a pain assessment, the administration of ordered pain medications, or the physician being notified of the his pain interfering with care. A nurse's note, dated [DATE]-1:59 P.M., indicated, "...pt (patient) laying in bed in fetal position, staff attempted to reposition several times...any time pt is touched for care or repositioning pt yells out, becoming very combative, pt unable to make needs or wants clear to staff, pt currently laying in bed with call light in reach." The record lacked documentation of a pain assessment at this time or the administration of ordered pain medications. The December MAR indicated [REDACTED]. The record lacked documentation of a physician being notified of Resident C's inability to swallow medication or a request for pain medication to be delivered in a route other than oral. The MAR for [DATE], indicated Resident #18's daily pain score was zero. A physical therapy note, dated [DATE], indicated, "...Pt is non-responsive and been sleeping all time. Pt (patient) is completely dependent for bed mob. (mobility). Unable to perform functional transfers R (related to) L/E (lower extremity) contracture... Not alert or oriented at all. Pt also c/o (complains) generalized pain. Pt has dr's (doctors) for possible hospice eval. (evaluation). Not appropriate for skilled PT (physical therapy) at this date." An occupational therapy note, dated [DATE], indicated, "...movement of any sort appears uncomfortable as indicated by grimacing and moaning...." This note further indicated Resident #18 had expressions of pain with touch or movement. A nurse's note, dated [DATE]-11:18, indicated, "...staff state resident "yells out and moans" whenever care is provided. He has orders for scheduled pain med (medicine) however resident has been refusing all meds po (oral) meds at this time..." The record lacked documentation of a pain assessment at this time or of pain medication being administered on this date. A physician's telephone order, dated [DATE]-untimed, indicated, Resident C may have the Tylenol given rectally instead of orally. The MAR indicated [REDACTED].M. The record lacked documentation of a pain assessment or the effectiveness of the pain medication. The MAR indicated [REDACTED].M., Resident C was administered the Tylenol suppository for pain as ordered. The record lacked documentation of a pain assessment or the effectiveness of the pain medication given. The next nursing note, dated [DATE]-2:15 P.M., indicated, "Res. (resident) blood sugar was 534 at 11 am. Writer called and spoke with NP (nurse practitioner) and was told to give 18 units. Writer also spoke to NP about res pain, as he cries out when repositioned. Tylenol was D/C'd (discontinued) and a new order for [MEDICATION NAME] (a stronger pain medication) was given. Writer gave one does. Writer called and spoke with son, updating him on the condition of his father and informing him of the new orders for pain meds. Son stated that even though we have been unable to give meds due to res inability to swallow, he would like for us to continue to try to give him his meds." The MAR indicated [REDACTED].M. The record lacked documentation of the effectiveness of the pain medication that was administered. Resident C died on [DATE]. The record lacked documentation of care and assessments for Resident C after the above nurse's note, dated [DATE] at 2:15 P.M. During an interview, on [DATE] at 9:30 A.M., the Administrator indicated there was not any further documentation on Resident C after [DATE] at 2:15 P.M. The Administrator was asked about the details surrounding the residents death and he indicated he was looking into it. The DON (Director of Nursing) called the nurse's who cared for Resident C his last day in the facility. The gave statements regarding the care provided. A statement from LPN #15, obtained on [DATE] at 4:50 P.M., indicated she worked on [DATE] from 2 PM to 10 PM. LPN (Licensed Practical Nurse) #15 indicated, "I only had him that one time. I know that he wasn't swallowing his meds, but I know that wasn't new, he wasn't taking his meds. (nurse named), got new orders for [MEDICATION NAME] on her shift. He had TPN running. Nothing changed on my shift. I started [MEDICATION NAME] on my shift. No apnea or mottling noted. He was asleep the whole shift. I sent (staff named) to give him mouth care. Basically what I did for him that night was comfort care. Kept him clean, gave him mouth care, turned him, he wasn't eating or drinking, comfort meds, TPN was running." A statement, obtained from LPN #16 on [DATE] at 3:50 P.M., indicated, she was asked how the resident was during the night shift. She replied, "Fine." She was asked if she took his 6 A.M. Blood sugar. She replied, "Yes." She was asked to tell her assessment of him when she was in the room taking his blood sugar. She replied, "He was laying on his right side, 02 was on, TPN was running. I said his name. He opened his eyes. I checked his blood sugar. I think it was like 132 or in the 130s. It was normal. I didn't have to give him insulin. After I got done checking his blood sugar the CNA's (certified nursing assistants) stated he seemed more comfortable and they were going in there to check him. She was asked if she noticed any apnea or mottling and she replied, "no apnea, no mottling, he seemed normal." She was asked if she remembered anything else. She replied, "No not right now." A statement, obtained from LPN #17 on [DATE]-9:50 A.M., indicated, she worked [DATE]-,[DATE] P.M.. LPN #17 indicated, "I went in after report around 6:,[DATE]:45 A.M. and checked him. He was having periods of apnea then. I went in to check on him between ,[DATE]:30 A.M. and he was already gone. Listened to his chest no heart beat or respirations. Went and got (nurse named). She listened to him and verified no heart rate or respirations. I called the son to notify him. Son just said thanks for letting me know. Then I notified the NP (named) in facility." During the interview, on [DATE] at 5:10 P.M., the DON was asked to provide information which included, but not limited to, pain assessments, assessments of the effectiveness of the ordered pain medication, and physician notification of Resident C's inability to have care due to his pain. Policies for pain management and assessment were requested. I asked her why there wasn't any documentation regarding a follow-up on Resident #18's pain and she replied, "That's a good question." Review of Resident C's controlled substance record, indicated, LPN #17 administered one dose of [MEDICATION NAME] on [DATE] at 1:30 P.M. The rest of the medication was destroyed when Resident C died . During the exit conference, on [DATE] at 7:00 P.M., the Administrator and the DON indicated they did not have any further information to provided at that time. This federal tag relates to Complaint(s) IN 582 and IN 854 3XXX,[DATE](a)

Based on record review,interview, and observation, the facility failed to implement appropriate fall interventions to prevent injury of a cognitively impaired resident who was identified as a high fall risk on admission. This deficient practice affected 1 of 3 residents reviewed for accidents out of 35 sampled residents (Resident F). Findings include: On 2/13/13 at 3:10 P.M., Resident F's record was reviewed. [DIAGNOSES REDACTED]. A "Patient Admission/Re-Admission" assessment, dated 10/15/12 at 11:03 P.M., included but was not limited to, "Fall Risk: (marked) Unsteady gait, Appliances/device in use (wheelchair), Underlying health conditions that may predispose patient to falls (dementia, cellulitis of leg, heart disease with diuretic use)..." A fall care plan, dated 10/15/12, included, but was not limited to, "At risk for falls due to impaired balance/poor coordination, unsteady gait/noncompliant with asking for assistance... Minimize risk of injury related to falls... Administer medication per physician's orders [REDACTED]. An admission MDS (Minimum Data Screening) assessment, dated 10/22/12, indicated Resident F had cognitive impairment with a BIMS (Brief Interview Mental Status) score of 7, required extensive assistance of 1 staff member for transfers, required limited assistance of 1 staff member to walk in his room, and required limited assistance of 1 staff member for toileting. In addition, Resident F was assessed as occasionally incontinent of his bladder. A fall assessment (after a fall), dated 10/27/12 at 2:04 P.M., included, but was not limited to, "Resident (F) was found laying on floor between bed, wheelchair brakes were locked, call light was not on, resident was barefooted... states that his wheelchair slid out from underneath him... root cause poor safety awareness related to lack of footwear... (Interventions) Non-skid socks were immediately applied, educated on using call light..." A "Nurse's Progress Notes" dated 10/29/12 at 1:35 P.M., included, but was not limited to, "Resident (F) still exhibiting poor safety awareness... not utilizing call light for staff assistance... resident (Resident F) is still ambulating in room using wheelchair as assistive device and furniture walking... Resident (F) and wife acknowledged education... they both require reinforcement and encouragement for compliance..." A "Nurse's Progress Notes" dated 11/24/12 at 7:24 A.M., included, but was not limited to, "At 5:00 A.M., resident (Resident F) was found by staff sitting on bottom (buttocks) on floor in front of wheelchair... immediate intervention initiated to maintain an environment free of hazard and debris..." A "Nurse's Progress Notes" dated 12/13/12 at 7:07 A.M., included, but was not limited to, "Wife of resident (Resident F) came to door and stated her husband needed help... was laying on floor between the two beds attempting to get up... skin tear on left elbow 6 centimeters in length... family notified and requested an alarm... new intervention is to report development of pain, bruises, or change in mental status..." There was no documentation in the care plan of an alarm being implemented for Resident F. A "Nurse's Progress Notes" dated 12/13/12 at 4:33 P.M., included, but was not limited to, "Resident (F) fell in bathroom this was witnessed by head of housekeeping... resident (Resident F) has always been non-compliant with transfers refuses to ask for help... New intervention anti roll back brakes... educated on need to wait for assistance..." A "Nurse's Progress Notes" dated 12/13/12 at 9:54 P.M., included, but was not limited to, "Resident (F) has transferred self in and out of wheel chair several times this shift..." There was no documentation in the care plan of new fall interventions implemented related to Resident F's continued non-compliance with using call light for assistance with transfers. A "Nurse's Progress Notes" dated 12/14/12 at 5:37 P.M., included, but was not limited to, "Resident (F) was found on the floor by an aide on his left side and wife was trying to help him up... has a laceration on his forehead and left arm... sent to (Local Hospital) emergency room ..." An Acute Care Transfer assessment, dated 12/14/12 at 2:00 P.M., included, but was not limited to, "Unplanned transfer... Reason for transfer: Patient fell in his room and has a large puncture laceration on his forehead and a small laceration on his left wrist..." A "(Local Hospital) Discharge Instructions" dated 12/14/12 at 6:28 P.M., included, but was not limited to, "Final Diagnosis: [REDACTED]. On 2/14/13 at 2:00 P.M., Resident F was observed in his room sitting in his wheelchair with his call light on the floor. At that time, in an interview (Resident F was alert and oriented to person and place), Resident F indicated he could reach his call light if needed. On 2/18/13 at 2:44 P.M., in an interview, the Director of Nursing (DoN) indicated Resident F required a lot of supervision from admission in October, 2012 through December, 2012. She indicated staff needed to keep close watch of him because he would transfer without assistance. She indicated the main cause of his falls was related to unassisted transfers in the bathroom or related to his need to toilet. The DoN indicated the facility was an alarm free facility, therefore, the use of alarms was not implemented as requested by Resident F's family. The DoN indicated his falls have decreased as a result of the implementing every 2 hour toileting (added to care plan on 1/25/13). This federal tag is related to Complaints IN 582 and IN 854. 3.1-45(a)(2)

Based on record review and interview, the facility failed to ensure care was planned and/or implemented to prevent falls. The deficient practice affected 2 of 9 residents reviewed for falls in a sample of 23. (Resident #25, Resident #80) Resident #25 fell , the plan of care was not revised with interventions to prevent further falls, and Resident #25 subsequently fell and sustained a neck fracture. Findings include: 1.Record review for Resident #25 was completed on 12/1/11 at 1:45 P.M. [DIAGNOSES REDACTED]. The care plan for Resident #25, dated 11/21/08 ,with revision date of 9/12/11 indicated, "...At risk for falls due to Disease process of dementia, antidepression medication diabetes medication. Res (resident) puts self on floor and coantinues (sic) to be non compliant with call light for transfer assistance and attempts to self transfer...." Interventions were as follows: "...11/25/08: Notify physician and family/responsible party of any falls, provide adequate lighting, Have commonly used articles within easy reach, reinforce need to call for assistance. 5/10/11: Administer medication per physician's order [REDACTED]. 6/6/11: Observe and report changes in gait/balance 9/12/11: Ensure that sensor alarm is in place when in w/c (wheelchair) and bed,. Ensure wheelchair is out in hallway when res. (resident) in bed. Implement use of preventative device sensor alarm to bed and wc, encourage to have wife call for assistance if res needs help with transfer. Encourage wife to get staff when re needs to be toileted or get out of bed ..." Nursing notes indicated the resident had a fall on 8/25/11 at 2:30 A.M. The nursing notes at this time indicated, " ...Res. Was found by writer sitting on floor in his room in upright position by his w/c...." There was no update of care plan done at this time regarding interventions for this fall. Nursing notes for Resident #25 on 9/6/11 at 11 P.M. indicated, "...While writer was receiving report from prior shift CNA ' s (certified nursing aid) alerted that Res. Had fallen from his w/c onto floor face down, D/t (due to) possible head trauma Res was not removed from floor, v/s (vital signs) taken, Res. Was conscious et (and) alert et talking, 911 notified, family notified another nurse spoke with son ... stated he will meet Res. At hospital, MD office notified, attempted to call DCD (Direct Care Director) no reply. Notified DON ..., papers sent with ambulance , Hospital ER called with report will wait for reply from Hospital ....9/7/11 2:20 A.M. Received call from HOSp. ER spoke with ..., Res is being admitted with Fx (fractured) neck, stated Res. Remains alert Will pass on to management & next shift ...." Resident #25 fell , the plan of care was not revised with iterventions to prevent further falls, and the resident fell again and sustained a neck fracture. A document titled HCR ManorCare Investigation Report indicated on 9/7/11 under summary of alleged incident: "...Resident on floor next to BR (bathroom) in room with hematoma to head ...Conclusion: Resident attempted to take self to BR s with line over it (without assist). Resident is one assist for transfers. Resident lost his balance and fell according to wife. Hematoma to head-Resident sent to ER for evaluation & tx (treatment). Since resident is not asking for help, sensor alarms or tab aloarms will be used upon return to remind resident he needs assistance...." A MDS (Minimum Data Set) assessment (a tool used to assess different care areas for residents), dated 9/16/11, indicated the resident was unable to make decisions for himself. In an interview with the DON (Director of Nursing) on 12/2/11 at 3:35 P.M. regarding Resident #25, she indicated when the resident was found on floor on 8/25/11, this was considered a fall and should be on care plan. She indicated she did not know why there was no updated interventions at that time. The DON indicated at the exit confrence on 12/2/11 at 5:00 P.M., they did labs and a psychiatric referral on 8/26/11 and this was their intervention for the resident's fall on 8/25/11. 2. In an interview during the initial orientation tour on 11/28/11 at 10:40 A.M., R.N. #2 indicated Resident #80 had experienced a recent fall, sustaining a laceration to his forehead. She indicated he had been in the facility for a few months, but had been moved recently to his current room and wing. The nurse indicated the resident had bed and wheelchair alarms, a low bed with floor mats, and bed bolsters because he continued to try to climb out of bed or transfer himself out of the wheelchair without assistance. The clinical record for Resident #80 was reviewed on 12/1/11 at 10:45 A.M. [DIAGNOSES REDACTED]. The quarterly M.D.S. (Minimum Data Set) assessment, dated 11/7/11, indicated the resident had clear speech, was able to express ideas and wants and understood verbal content, and had a "Brief Interview for Mental Status (BIMS)" score of "03" (severe impairment for cognitive patterns). The assessment also indicated the resident required extensive physical assistance of 1 staff person for all daily care, including transfers. Electronic record information indicated the resident had falls on 8/25/11 at 4:15 P.M., 9/6/11 at 8:15 P.M., and 9/9/11 at 1:15 P.M. The assessment on 9/6/11 indicated, "... Patient wanting to lay down soon after meals...." A Care Plan addressing falls was originally initiated on 8/10/11, and included an intervention of "bed in low position." On 8/25/11, the following interventions were added: "Ensure that tab alarm with shortened string is in place when in wheelchair/bed; Provide assist to transfer and ambulate as needed; reinforce need to call for assistance." On 9/6/11, the following Care Plan intervention was added: "Nursing to put resident to bed immediately following meals." An "Investigation Report," submitted to ISDH on 11/15/11 reporting a fall on that date, indicated the following: "6:45 P.M. (Resident's name) was wheeled from North dining room to the North nurse station. He was just adjacent to the station, close to the pass-through for staff to enter and exit the station. He was within arms reach of the station. The intention of this position was for the Nurse (name) to be close to the resident until the nurse's aid could finish moving people out of the dining room and assist (resident) to prepare to lay down in his room...." 7:00 P.M. (Resident's name) began to lean forward, his chair alarm sounded. (Nurse's name) was seated behind the North Nurse station and responded to prevent the fall. She was approximately 3 steps away from (resident). She placed her hands on his shoulder, instructed him to sit up and repositioned him with proper posture in his wheelchair... and returned to the nurse station. 7:01 P.M. (Resident's name) leaned forward again. (Nurse) had her back turned while sending a fax, and did turn to respond to the alarm. At that same instant, (another nurse) was working about halfway down 800 hall and saw (resident) start to lean forward again. He responded, but could not reach the patient in time. (Resident's name) hit the floor head first from a sitting position...." 7:02 P.M. ... found a laceration to forehead. Pressure was applied.... Ambulance was called...." In an interview on 12/2/11 at 10:30 A.M., the Administrator indicated he re-visited the investigation and determined the timeline needed to be revised. He provided the new timeline which indicated the resident was brought to the Nurse's Station at 6:15 P.M., and first leaned forward, setting off his alarm, at 6:30 P.M. Although the timeline was revised, both reports indicated the nurse did not take the resident to his room and place him in bed immediately following his meal. The resident remained at the nurse's station for 15 minutes. After the resident set off his personal alarm by leaning forward, he still was not taken to his room and placed in bed. 3.1-45(a)(2)

Based on observation, record review and interview, the facility failed to monitor and provide supervision to ensure the safety of a resident with a history of exiting the facility, resulting in Immediate Jeopardy because of the risk of serious harm, injury, or death to 1 of 3 residents reviewed for exit seeking behaviors in the sample of 3. (Resident X) The Immediate Jeopardy began on 2/19/2011 when a resident was returned to the facility after an elopement and without the implementation of a plan to prevent further elopements. The Administrator and Director of Nursing were notified of the immediate jeopardy at 4:45 p.m. on 3/11/2011. The immediate jeopardy was removed on 3/07/2011 when, based on record review and interview, the resident was placed on continuous 1:1 monitoring, but the noncompliance remained at the lower scope and severity level of isolated with no actual harm with potential for more than minimal harm that is not immediate jeopardy because the facility failed to fully implement a plan to prevent the resident from exiting the facility in the future. Findings include: Resident X was identified by LPN (Licensed Practical Nurse) #1, during the orientation tour 3/11/2011 at 9:45 a.m., as having exit seeking and wandering behaviors. In addition, she reported he had eloped twice. One witnessed and the other unwitnessed. He was observed at the time ambulating rapidly through the facility with a stern facial expression. He was observed in the 600 hall, the 800 hall and the front lobby. Resident X's clinical record was reviewed on 3/11/2011 at 3 p.m. It indicated he was admitted to this facility on 12/2/2009. His [DIAGNOSES REDACTED]. It indicated Resident X had exhibited exit seeking behavior and wandering consistently since admission and that he periodically expressed delusions that his wife was leaving him and he needed to be home. He also experienced dreams of a similar nature which he found difficult to separate from reality. At these times, his anxiety levels rose and he became agitated and intensely exit seeking. He was wearing a WanderGuard device which electronically locks the doors when the device comes close to the exit. The nursing notes indicated on Saturday, 2/19/2011, Resident X stayed in the front lounge near the main exit. When a visitor exited the main door around 2 p.m., Resident X "bolted" from a chair in the lounge where he'd been sitting and exited the door while it was still open, pushing past the visitor on his way to the outside. The visitor alerted staff who then found the resident in the yard of adjacent condominiums, equivalent to a half block from the door. He fell as he attempted to elude the staff and was brought back inside. A documented and signed interview of LPN #2 on 2/19/2011 indicated Resident X was" upset about his wife." In response to the 2/19/2011 elopement, the facility initiated 1:1 staff monitoring of Resident X. His wife took him on a leave of absence from the facility and he appeared calm upon his return, so the 1:1 monitoring was discontinued. The facility checked all WanderGuard doors and bracelets and window stops and inserviced staff on facility elopement procedures. However, the fact that resident X had demonstrated he could plan an elopement and carry it out was not addressed. Review of his care plan indicated there was an entry addressing elopement risk initiated on 6/21/2010, but it was not updated after the 2/19/2011 elopement. The interventions remained as: "check wanderguard placement and function q (every) shift " (initiated 6/21/2010) "ensure that (wife's name) signs resident out and makes staff aware when leaving and escort back into the building" (initiated 9/2/2010) "encourage socialization with others and provide recreational programming, woodworking, read magazine" (initiated 9/2/2010) Nursing notes on Monday, 3/7/2011 indicated facility staff became aware Resident X was missing at about 12 noon. He had last been seen at approximately 11:55 a.m. A "code green" was announced, which the Administrator indicated during interview 3/11/2011 at 10:50 a.m., was the facility's protocol for announcing to staff a resident was missing, at which time staff systematically searched the building and grounds. When Resident X was not located, the Administrator called 9-1-1. He indicated that while talking with the dispatcher, she told him the police had located the resident. Passers-by had spotted the resident lying in a ditch at the intersection of U.S. highway 36 and County Road 400 and notified the police. The Administrator indicated he'd sent the Maintenance Supervisor to check on the resident, but EMTs already had the resident in the ambulance and told him the resident was being sent to the emergency room . Weather information obtained from the "History for KIND, Indiana" website 3/13/11 at 9 p.m. indicated on 3/7/2011 in the Indianapolis area, the temperature at 12:30 p.m. was 35.6 degrees Fahrenheit with a wind speed of 9.2 miles per hour. At 2:54 p.m. the temperature was 39.9 degrees with a wind speed of 9.2 miles per hour. The Administrator indicated during interview 3/11/2011 at 10:50 a.m., Resident X was dressed in a long sleeved T-shirt with another shirt pulled over that, slacks and moccasins. He was not wearing a jacket, coat, sweater, etc. Review of the emergency room documentation for Resident X was done on 3/11/2011 at 1:30 p.m. It indicated the resident was received in the emergency room at 14:40 (2:40 p.m.) on 3/7/2011, which was 2.5 hours after the resident was noted missing from the facility. He had fallen in a ditch along highway 36. He was discharged from the emergency room at 18:42 (6:42 p.m.) with [DIAGNOSES REDACTED]." The clinical record indicated Resident X was again placed on 1:1 monitoring which was still in effect on 3/11/11. The elopement risk care plan had been updated 3/11/2011. The new interventions were: "place picture in Center Watch Book and on bulletin board, allow to vent feelings and/or frustration prn (as needed) and assist with calling wife, kids, or brother to assist with calming." There was no evidence a psychological evaluation had been sought for Resident X since this elopement. The Administrator made an entry in the Social Service progress notes dated 3/11/2011. In this entry he documented a conversation with Resident X's family and indicated other placement was being sought for Resident X for his safety. "...Explained we strongly recommend a secured unit for him...Family wants to consider other options. Explained that we would like to move (Resident's name) asap (as soon as possible) but within 30 days if possible. Family expressed desire for continued basis w (with) (resident's name). I cautioned that his desire to elope is erratic and unpredictable and that he should be within eyesight at all times...Family agreed to review all discharge options and cooperate." During interview 3/11/2011 at 10:50 a.m., the Administrator indicated they had not been able to determine how Resident X eloped on 3/7/11. He indicated all staff had been interviewed and Resident X wasn't telling. An immediate jeopardy was identified on 3/11/2011 at 4:45 p.m. The immediate jeopardy began on 2/19/2011 when Resident X first eloped from the facility. The Administrator and the Director of Nursing were notified of the immediate jeopardy related to lack of supervision to prevent an elopement on 3/11/2011 at 4:45 p.m. The immediate jeopardy was removed on 3/7/2011 when records and interviews confirmed that the resident was on continuous 1:1 monitoring since return to the facility. The facility ' s noncompliance remained at the level of no actual harm with a potential for more than minimal harm that is not immediate jeopardy because the facility needed to fully implement its plan to make the site for supply deliveries more secure; to install a key pad lock; to update its Center Watch Book; to install surveillance cameras on the main entrance area; and to inservice all staff. This federal tag relates to complaint IN 451. 3.1-45(a)(2)

Based on record review and interview, the facility failed to notify the physician of changes in Resident conditions that required physician interventions for a Resident with a decline in mental status and respiratory function, a Resident with lower extremity [MEDICAL CONDITION] that did not improve with treatment, and a Resident with a respiratory infection assessed with [REDACTED]. this resulted in hospitalization s for 3 residents reviewed for physician notification in a sample of 6. (Residents C, B and G) Findings include: 1. The clinical record of Resident G was reviewed on [DATE] at 1:00 P.M. [DIAGNOSES REDACTED]. A plan of care for "At risk for respiratory impairment related to [MEDICAL CONDITION] , asthma," dated [DATE], indicated "Goal : will experience symptom management." Interventions included, but were not limited to, assess lung sounds and VS (vital signs) as needed. Report abnormalities to physician, observe for and report adverse changes in respiratory rate, cough, respiratory effort, and sputum color/consistency. A plan of care for "Infection of respiratory tract," dated [DATE], indicated "Goals : Will be resolved without requiring hospitalization ." Interventions included, but were not limited to, observe for and report signs of worsening of condition such as respiratory distress, sudden change in mental status, increased fever, increased sputum, diarrhea. A Nursing note, dated [DATE] at 10:30 P.M., indicated "Res (resident) in company of family, returned to facility. Pt (patient) is lethargic (sleepy), barely awake, transported into bed...." Nursing notes, date [DATE] through [DATE], did not indicated Resident G was lethargic. A physician's orders [REDACTED].M., indicated "Hold [MEDICATION NAME] (an antidepressant)20 mg (milligrams) x 2 days. Hold [MEDICATION NAME] (an antipsychotic) 0,5 mg x 2 days. A Physician's progress note, dated [DATE] (no time noted), indicated increased somnolence (prolonged drowsiness) and increased incontinence. A physician's orders [REDACTED].M., indicated "D/C [MEDICATION NAME]. D/C [MEDICATION NAME]. CT brain (with) & (without) contrast. Altered mental state." A Nursing note, dated [DATE] at 2:00 P.M., indicated "Resident has slept this shift, [MEDICATION NAME] and Resperdal (sic) are being D/C'd (discontinued). CT scan being ordered, UA (urinalysis) C&S (culture and sensitivity), Pt (patient) was fed lunch and needed reminding to chew and swallow. Will cont. (continue) monitoring." A Medication Administration Record, [REDACTED].M. to 2:00 P.M. shift, Resident G had an oxygen saturation (O2Sat) of 86%. A Lab urinalysis report, date [DATE] at 9:47 A.M., indicated Resident G's urine was yellow, cloudy and had a large amount of bacteria. A hand written notation indicated the results had been called to the physician's office, no time was noted. A nursing note, dated [DATE] at 2:30 P.M., indicated "Pt very lethargic and hard to get a response out of, Writer obtained a urine specimen via I/O (in and out) cath....NP (nurse practioner) notified, Received N.O. (new order) to place a PICC line. Sister of pt. stated that her veins are terrible and they would rather just go ahead & do a PICC. (Name of company) called to come out. They stated it would be approx. 4 hrs before they can get here. Once PICC is placed we are to start DS,[DATE] NS @ 50 cc (cubic centimeters)/hr x 72 (hours)....Sensitivity is pending. Will notify MD when receive results. Spoke to sister and she is okay (with) orders. Will continue to monitor pt. VS (vital signs) ,[DATE] (blood pressure), 54 (pulse), 22 (respirations), 97.3 (temperature) as a nursing measure, Writer put pt on 3 liters of O2 (oxygen), couldn't get a reading. In the meantime, the pt's sister came in to see her. Pt was unresponsive. She wouldn't drink anything or open eyes for the family. Sister stated she wasn't going to wait for PICC line to be placed, that she wanted her sent to (name of hospital) ER (emergency room ) now. MD called & approved transfer. Ambulance called to transport. Family followed. When pt left, she was still having difficulty breathing & O2 sats would not register." A physician's orders [REDACTED].M., indicated "1. PICC line placement...." A physician's orders [REDACTED]. sent to (name of hospital) for eval (evaluation) & tx (treatment)...D/C PICC line placement..." An Ambulance transfer form, dated [DATE], indicated arrival time at the facility was 3:15 P.M. Resident G was unresponsive, had cyanotic nail beds and had respiratory wheezes. VS: pulse 115, respirations 38, blood pressure (B/P) 110/P. The Resident was placed on 15 liters via non-rebreather mask. VS at 3:45 P.M. were: pulse 128, respirations 42, B/P 90/P. A Cardiac monitor indicated Resident G was in sinus [MEDICAL CONDITION] She had wheezes both inspiratory and expiratory. The SPO2 was unobtainable due to cyanotic fingers and cold extremities. At approximately 3:40 P.M. Resident G started having periods of apnea (stopping of respirations). The ambulance pulled over and treated Resident G for apnea and then decided to continue the transfer to (name of hospital). "SPO2 finally obtained @ 41%...( no time noted)" Resident G arrived at the hospital at 4:30 P.M. A hospital emergency room form, dated [DATE] at 4:37 P.M., indicated Resident G was unable to speak and had spontaneous ineffective respirations. VS at 4:40 P.M.: temperature 97.9, pulse 122, respirations 24, Sat 93% and B/P ,[DATE]. Resident G was treated for [REDACTED]. A hospital death summary, dated [DATE], indicated "...originally came in to the hospital with [MEDICAL CONDITION] on the 11th of this month. It appeared to be a pneumonia....A CT of the head was performed that showed that she indeed did have an infarct...." Resident G died on [DATE]. During an interview with the Director of Nursing, on [DATE] at 2:300 P.M., she indicated the Resident was sent out for PICC line placement and the Resident's sister wanted her to go to (name of hospital) because in was close to where the sister lived. They would have sent her to a hospital much closer if the Resident was in distress. During an interview with RN #2, on [DATE] at 3:20 P.M., she indicted she had not taken care of Resident G before and was told in report that the Resident had been lethargic the past few days but was stable. When RN #2 went into the resident's room, "probably around 7:00 A.M.," she found the resident laying with her hands hanging over the sides of the bed. The Resident's hands were purple in color, cold and had no capillary refill. RN #2 indicated she elevated the Resident's hands, tried to warm them and started the Resident on O2 at 2 liters. "The hands got better but not back to normal." When RN #2 tried to give the Resident her morning medications, the Resident clamped her mouth shut and refused to drink. RN #2 indicated the physician was notified "around 12:00 P.M. or 1:00 P.M. regarding not being able to get an O2SAT. The Physician's office ordered the O2 increased to 3 liters, and would call back with more orders. When the Physician's office called back it was for a PICC line to be started, for hydration. It was going to take four hours for the PICC team to arrive and the sister didn't want to wait that long she wanted the Resident sent to (name of hospital) to get the PICC placed. She indicated she only heard the Resident cough once, it sounded "junky", she was hunched over with shallow breathing. I could not get her to take a deep breath and couldn't get good lung sounds. She was never gasping for air. 2. The clinical record of Resident B was reviewed on [DATE] at 11:15 AM. [DIAGNOSES REDACTED]. A Nursing note, dated [DATE] at 1:50 P.M., indicated Resident B was requesting to go to the hospital because "...she knew she had pneumonia." Resident B's lungs were assessed and were found to be 'wheezy." There was no indication the physician had been notified. A Chest x-ray completed, on [DATE], indicated early pneumonia in lower left lung. A Physician order, dated [DATE] at 11:00 A.M., indicated to begin resident on [MEDICATION NAME] (antibiotic) 875 mg (milligrams) twice a day for ten days and to start [MEDICATION NAME] (decongestant) 1200 mg twice a day for five days. A Physician order, dated [DATE] at 10:00 A.M., indicated resident on [MEDICATION NAME] (steroid) 10 mg twice a day for seven days. A review of Nursing notes, [DATE] - [DATE], indicated that Resident B had abnormal lung sounds with each nursing assessment with "audible wheezes". There was no indication the physician had been notified. Last dosage of [MEDICATION NAME] given on [DATE]. No nursing notes noted from [DATE]-[DATE]. A nursing note, dated [DATE] at 10:30 A.M., indicated resident was not feeling well, "...she felt like she still had pneumonia." Resident B's lungs sounds were described as "coarse with rhonchi and wheezing". A Physician order, dated [DATE] at 10:50 A.M., indicated Resident was on [MEDICATION NAME] 875 mg twice a day for ten days and [MEDICATION NAME] 20 mg twice a day for ten days for an upper respiratory infection. This was the same antibiotic that was ordered on [DATE]. A review of Nursing notes, dated [DATE] - [DATE], indicated that Resident B had abnormal lung sounds with "coarse...scattered wheezes" There was no indication the physician was notified. There were no Nursing notes from [DATE] - [DATE]. A Nursing note, dated [DATE] at 10:00 A.M., indicated resident had "scattered wheezes" noted in lungs. The last [MEDICATION NAME] dose was administered on [DATE] and there was no indication the physician was notified the Resident was still having symptoms of an upper respiratory infection. A Nursing note, dated [DATE] at 11:00 A.M., indicated the Resident was complaining of hemorrhoids. "MD contacted for hemorrhoid treatment". The physician was not informed of the "scattered wheezes" assessed on [DATE]. A Nursing note, dated [DATE] at 11:00 A.M., indicated "c/o (complaining of) mouth and sides of tongue sore (sic)." The note also indicated an order, from the physician, for MMP (Mary's Magic Potion) 10 cc four times per day swish and spit. A Nursing note, dated [DATE] at 10:00 A.M., indicated Resident B was complaining of "shortness of breath and chest congestion." Her lungs sounds were noted to be "wheezy." The Resident requested a chest Xray be done. A Chest Xray, date [DATE], indicated right lower lobe pneumonia. A Physician order, dated [DATE] at 9:10 P.M., indicated [MEDICATION NAME] 875 mg twice a day for ten days. This was the third round of [MEDICATION NAME] to be ordered for Resident B to treat a respiratory infection. A Nursing note, dated [DATE] at 6:00 A.M., indicated the Resident was experiencing "increased shortness of breath." Resident B was given a nebulizer treatment with some relief. The Resident also experienced "loose to soft stools" A Nursing note, dated [DATE] at 7:30 A.M., indicated the Resident was found on the floor after falling. She sustained a laceration over right eye and was transported to (name of hospital). A hospital history and physical, dated [DATE], indicated Resident B was admitted with a [DIAGNOSES REDACTED]." A hospital discharge summary, dated [DATE], indicated Resident B's pneumonia was improving on [MEDICATION NAME] (antibiotic) 500 mg daily. A Physicians order, dated [DATE] at 9:45 P.M., indicated to discontinue the [MEDICATION NAME] and start the Resident on [MEDICATION NAME] ,[DATE] mg twice daily for seven days. This was the fourth 10 day round of [MEDICATION NAME] for the resident in 44 days. A Physicians order, dated [DATE] at 10:30 A.M., indicated [MEDICATION NAME] (steroid) 0.5 mg via nebulizer twice daily. A review of Nursing notes, [DATE] - [DATE], indicated Resident B had abnormal lung sounds including "wheezes and crackles with course cough". There was no indication physician was notified. A Nursing note, dated [DATE] at 1:03 A.M., indicated the Resident experienced shortness of breath with exertion and rib pain. The Resident had "course crackles and audible wheezes". A Nursing note, dated [DATE] at 2:00 P.M., indicated the Resident requested the nurse to inform the physician that she "...was released from hospital too soon and the antibiotic was not helping." A fax to the physician, dated [DATE] at 1:47 P.M., indicated "Res request MD be informed that she feels that she was released from hospital too soon. And the pneumonia is not getting any better. Res doesn't believe ATB (antibiotic) is helping. There is 2 more days left on current ATB order. Lung sounds remain course (sic) (with) scattered wheezing. Lower lobes diminished. No temp. SOB (shortness of breath) upon exertion. O2 (oxygen) 2L (liters) - 3L NC (nasal cannula). Has productive cough." A physicians order, dated [DATE], indicated the Resident was to have a chest x-ray. A chest x-ray report, dated [DATE], indicated right lower lobe pneumonia. This was the same results as the chest x-ray done on [DATE]. A Physicians order, dated [DATE] at 11:45 A.M., indicated the Resident was to discontinue the [MEDICATION NAME] and start on Bactrim (antibiotic) DS twice daily for ten days and [MEDICATION NAME] (decongestant) 100 mg three times daily for ten days for an upper respiratory infection. This was the fifth round of antibiotic treatment for [REDACTED]. During an interview with the DoN, on [DATE] at 3:00 P.M., she indicated the staff had been in communication by fax with physician regarding this resident. The only fax submitted for review regarding residents respiratory status was the one dated [DATE]. No other information was submitted prior to exit. 3. The clinical record for Resident #C was reviewed on [DATE] at 1:00 P.M. [DIAGNOSES REDACTED]. A Care Plan for Resident #C, dated [DATE], indicated, "[MEDICAL CONDITION], need for monitoring related to [MEDICAL CONDITION], Hypertension (high blood pressure), CAD [MEDICAL CONDITION]." Goal: "Will experience effective symptom management." Interventions included but were not limited to, "Administer medication as per MD orders & monitor effectiveness... Observe for and report adverse changes in respiratory effort, pulse rate, dizziness, SOB (shortness of breath), chest pain, [MEDICAL CONDITION], vital signs, general condition. Review weights. Report any significant change." A Nurses Note, dated 11/ 29/ 2010 at 11:45 P.M., indicated Resident #C "...feels as if he can not breath and thinks his pulse & Heart is beating to fast. Res (resident) states he was on Anxiety pills Three times a day and [MEDICATION NAME] two times a day before he came here. Res feet & legs are 3+ (plus) [MEDICAL CONDITION]. -Notified MD, received 1x (time) order for [MEDICATION NAME] (an antianxiety medication) 0.25 mg (milligram) Now. Res given [MEDICATION NAME]. Res Also put on list to see MD about his [MEDICATION NAME] et (and) Anxiety meds (medications). Will Cont. (continue) to Assess." A Nurses note, dated 11/ ,[DATE] at 2:30 P.M., indicated the nurse practitioner was in to evaluate Resident #C...."+2 [MEDICAL CONDITION], elevated R & LLE (right and left lower extremities), apply ted hose (compression stockings) [MEDICAL CONDITION] improved cont (continue) [MEDICAL CONDITION] +1...." A Nurses note, dated 11/ 30/ 2010 at 10:00 P.M., indicated that Resident #C had +3 [MEDICAL CONDITION] in lower extremities. There was no indication the physician was notified regarding the increase in the [MEDICAL CONDITION]. A Nurses Note, dated [DATE] at 2:30 P.M., indicated "...Dr office in to Eval (evaluate)-NO (no orders) received...+3 [MEDICAL CONDITION]." A Nurses Note, dated [DATE] at 11:00 P.M., indicated "...+3 [MEDICAL CONDITION] in lower extremity's (sic)...." A physician's orders [REDACTED].M., indicated "1. make pt (patient) F/U (follow up) (with) [MEDICAL CONDITION]...3. [MEDICATION NAME] (a diuretic) 20 mg po ( by mouth) bid (twice a day) [MEDICAL CONDITION]. 4. (change) checks wt (weight) to qd (every day) call MD if (increase) wt (greater or less than) 2 lb in 24 h (hours)." A Medication Administration Record, [REDACTED].M., indicated [MEDICATION NAME] 20 mg by mouth was initiated. A Nurses Note, dated [DATE] at 3:00 P.M., indicated "... +3 [MEDICAL CONDITION] to right and left lower extremities present." A Nurses Note, dated [DATE] at 11:00 P.M., indicated, "... Patient still has +3 [MEDICAL CONDITION]." A Nurses Note, dated [DATE] at 1:45 A.M., indicated, "... [MEDICAL CONDITION] in lower extremities...." There was no indication the physician was notified regarding the continued [MEDICAL CONDITION] to the lower extremities after two days of diuretics. A Nurses Note, dated [DATE] at 12:50 P.M., indicated "...cont to have 3+ [MEDICAL CONDITION] in (lower) extremities...." There was no indication the physician was notified regarding the continued [MEDICAL CONDITION]. A Nurses Note, dated [DATE] at 10:00 P.M., indicated,..."Patient still has +3 [MEDICAL CONDITION].." There was no indication the physician was notified regarding the [MEDICAL CONDITION]. A Nurses Note, dated [DATE] at 10:00 A.M., indicated,..."[MEDICAL CONDITION] improving encouraged to elevate feet et legs...." A Nurses Note, dated [DATE] at 10:00 P.M., indicated Resident #C had been admitted to the hospital. The resident was sent to the hospital from the Pulmonology office when Resident B was there for the F/U appointment. A hospital history and physical, dated [DATE], indicated "...EXTREMITIES: Reveal 4+ [MEDICAL CONDITION] to the knees...PLAN: ...It is hoped that we can aggressively [MEDICATION NAME] this individual,...and compensate his congestive cardiac dysfunction and his [MEDICAL CONDITION]." On [DATE] at 3:30 P.M., the DoN indicated the facility follows state regulations concerning physician notification and that there was no specific facility policy related to physician notification. The DoN also indicated the physician should have been notified regarding the [MEDICAL CONDITION]. This federal tag relates to complaint #IN 617. 3XXX,[DATE](a)(2) 3XXX,[DATE](a)(3)

Based on record review and interview, the facility failed to follow physician orders [REDACTED]. This impacted 1 of 6 residents reviewed for the following of physician's orders [REDACTED]. (Resident #C) Findings include: The clinical record for Resident #C was reviewed on 12/28/2010 at 1:00 P.M. [DIAGNOSES REDACTED]. A Care Plan for Resident #C, dated 12/3/10, indicated, "[MEDICAL CONDITION], need for monitoring related to [MEDICAL CONDITION], Hypertension (high blood pressure), CAD [MEDICAL CONDITION]." Goal: "Will experience effective symptom management." Interventions: included, but were not limited to, "Administer medication as per MD orders & monitor effectiveness... Observe for and report adverse changes in respiratory effort, pulse rate, dizziness, SOB (shortness of breath), chest pain, [MEDICAL CONDITION], vital signs, general condition. Review weights. Report any significant change." A physician's orders [REDACTED].M., indicated "1. make pt (patient) F/U (follow up) (with) [MEDICAL CONDITION]...3. [MEDICATION NAME] 20 mg po (by mouth) bid (twice a day) [MEDICAL CONDITION]...4 (change) checks wt (weight) to qd (every day) call MD if (increase) wt (greater or less than) 2 lb in 24 h (hours)." The Medication Administration Record, [REDACTED].M., indicated [MEDICATION NAME] 20 mg by mouth. The Medication Administration Record, [REDACTED]. A Nurses Note, dated 12/04/2010 at 3:00 P.M., indicated +3 [MEDICAL CONDITION] to right and left lower extremities present. A Nurses Note, dated 12/04/2010 at 11:00 P.M., indicated, "... Patient still has +3 [MEDICAL CONDITION]." The Resident was not weighted. A Nurses Note, dated 12/05/2010 at 1:45 A.M., indicated, "... [MEDICAL CONDITION] in lower extremities...." A Nurses Note, dated 12/05/2012 at 12:50 P.M., indicated,..."cont (continue)to have 3+ [MEDICAL CONDITION](sic) in (lower) extremities...." A Nurses Note, dated 12/05/2010 at 10:00 P.M., indicated,..."Patient still has +3 [MEDICAL CONDITION].." The Resident was not weighted. A Weights and Vitals Summary, dated 12/6/10, indicated Resident #C weighed 157.4 pounds. This was a decrease of 2.8 pounds and the Physician was not called. A Nurses Note, dated 12/07/2010 at 10:00 A.M., indicated,..."[MEDICAL CONDITION] improving encouraged to elevate feet et legs...." A Nurses Note, dated 12/07/2010 at 10:00 P.M., indicated Resident #C had been admitted to the hospital from the Pulmonology office. A hospital history and physical, dated 12/07/2010, indicated,...EXTREMITIES: Reveal 4+ [MEDICAL CONDITION] to the knees...PLAN: ...It is hoped that we can aggressively [MEDICATION NAME] this individual,...and compensate his congestive cardiac dysfunction and his [MEDICAL CONDITION]." On 12/20/2010 at 9:30 A.M., the DoN indicated only two weights were done during the 5 days prior to the Resident's hospitalization for diuresing. 3.1-35(g)(2)

Based on record review and interview, the facility failed to follow the plan of care for Residents regarding the monitoring of daily weights, reporting increased lower leg [MEDICAL CONDITION], reporting of changes in mental status and reporting of respiratory changes. This resulted in hospitalization s for diuresing and [MEDICAL CONDITION]. This impacted 2 of 6 Residents reviewed for following the plan of care in a sample of 6. (Residents C and G) Findings include: 1. The clinical record of Resident G was reviewed on 12/29/10 at 1:00 P.M. [DIAGNOSES REDACTED]. A plan of care for "At risk for respiratory impairment related to [MEDICAL CONDITION] , asthma," dated 11/29/10, "Goal : will experience symptom management." Interventions included, but were not limited to, assess lung sounds and VS (vital signs) as needed. Report abnormalities to physician, observe for and report adverse changes in respiratory rate, cough, respiratory effort, and sputum color/consistency. A plan of care for "Infection of respiratory tract," dated 11/29/10, indicated "Goals : Will be resolved without requiring hospitalization ." Interventions included, but were not limited to, observe for and report signs of worsening of condition such as respiratory distress, sudden change in mental status, increased fever, increased sputum, diarrhea. A Medication Administration Record, [REDACTED].M. to 2:00 P.M. shift, Resident G had an oxygen saturation (O2Sat) of 86%. A nursing note, dated 12/11/10 at 2:30 P.M., indicated "Pt very lethargic and hard to get a response out of, Writer obtained a urine specimen via I/O (in and out) cath....NP (nurse practioner) notified, Received N.O. (new order) to place a PICC line. Sister of pt. stated that her veins are terrible and they would rather just go ahead & do a PICC. (Name of company) called to come out. They stated it would be approx. 4 hrs before they can get here. Once PICC is placed we are to start DS1/2 NS @ 50 cc (cubic centimeters)/hr x 72 (hours)....Sensitivity is pending. Will notify MD when receive results. Spoke to sister and she is okay (with) orders. Will continue to monitor pt. VS (vital signs) 90/63 (blood pressure), 54 (pulse), 22 (respirations), 97.3 (temperature) as a nursing measure, Writer put pt on 3 liters of O2 (oxygen), couldn't get a reading. In the meantime, the pt's sister came in to see her. Pt was unresponsive. She wouldn't drink anything or open eyes for the family. Sister stated she wasn't going to wait for PICC line to be placed, that she wanted her sent to (name of hospital) ER (emergency room ) now. MD called & approved transfer. Ambulance called to transport. Family followed. When pt left, she was still having difficulty breathing & O2 sats would not register." An Ambulance transfer form, dated 12/11/10, indicated arrival time at the facility was 3:15 P.M. Resident G was unresponsive, had cyanotic nail beds and had respiratory wheezes. VS: pulse 115, respirations 38, blood pressure (B/P) 110/P. The Resident was placed on 15 liters via non-rebreather mask. VS at 3:45 P.M. were: pulse 128, respirations 42, B/P 90/P. A Cardiac monitor indicated Resident G was in sinus [MEDICAL CONDITION] She had wheezes both inspiratory and expiratory. The SPO2 was unobtainable due to cyanotic fingers and cold extremities. At approximately 3:40 P.M. Resident G started having periods of apnea (stopping of respirations). The ambulance pulled over and treated Resident G for apnea and then decided to continue the transfer to (name of hospital). "SPO2 finally obtained @ 41%...( no time noted)" Resident G arrived at the hospital at 4:30 P.M. A hospital emergency room form, dated 12/11/10 at 4:37 P.M., indicated Resident G was unable to speak and had spontaneous ineffective respirations. The VS at 4:40 P.M.: temperature 97.9, pulse 122, respirations 24, Sat 93% and B/P 115/101. The Resident was treated for [REDACTED]. During an interview with RN #2, on 12/30/10 at 3:20 P.M., she indicted she had not taken care of Resident G before and was told in report that the Resident had been lethargic the past few days but was stable. When RN #2 went into the resident's room, "probably around 7:00 A.M.," she found the resident laying with her hands hanging over the sides of the bed. The Resident's hands were purple in color, cold and had no capillary refill. RN #2 indicated she elevated the Resident's hands, tried to warm them and started the Resident on O2 at 2 liters. "The hands got better but not back to normal." When RN #2 tried to give the Resident her morning medications, the Resident clamped her mouth shut and refused to drink. RN #2 indicated the physician was notified "around 12:00 P.M. or 1:00 P.M. regarding not being able to get an O2SAT. The Physician's office ordered the O2 increased to 3 liters, and would call back with more orders. When the Physician's office called back it was for a PICC line to be started, for hydration. It was going to take four hours for the PICC team to arrive and the sister didn't want to wait that long she wanted the Resident sent to (name of hospital) to get the PICC placed. She indicated she only heard the Resident cough once, it sounded "junky", she was hunched over with shallow breathing. I could not get her to take a deep breath and couldn't get good lung sounds. She was never gasping for air. 2. The clinical record for Resident #C was reviewed on 12/28/2010 at 1:00 P.M. [DIAGNOSES REDACTED]. A Care Plan for Resident #C, dated 12/3/10, indicated, "[MEDICAL CONDITION], need for monitoring related to [MEDICAL CONDITION], Hypertension (high blood pressure), CAD [MEDICAL CONDITION]." Goal: "Will experience effective symptom management." Interventions included but were not limited to, "Administer medication as per MD orders & monitor effectiveness... Observe for and report adverse changes in respiratory effort, pulse rate, dizziness, SOB (shortness of breath), chest pain, [MEDICAL CONDITION], vital signs, general condition. Review weights. Report any significant change." A physician's orders [REDACTED].M., indicated "1. make pt (patient) F/U (follow up) (with) [MEDICAL CONDITION]...3. [MEDICATION NAME] (a diuretic) 20 mg po ( by mouth) bid (twice a day) [MEDICAL CONDITION]. 4. (change) checks wt (weight) to qd (every day) call MD if (increase) wt (greater or less than) 2 lb in 24 h (hours)." The Medication Administration Record, [REDACTED].M., indicated [MEDICATION NAME] 20 mg by mouth. A Nurses Note, dated 12/04/2010 at 3:00 P.M., indicated +3 [MEDICAL CONDITION] to right and left lower extremities present. A Nurses Note, dated 12/04/2010 at 11:00 P.M., indicated, "... Patient still has +3 [MEDICAL CONDITION]." A Nurses Note, dated 12/05/2010 at 1:45 A.M., indicated, "... [MEDICAL CONDITION] in lower extremities...." No indication the physician was notified regarding the continued [MEDICAL CONDITION] to the lower extremities after two days of diuretics. A Nurses Note, dated 12/05/2012 at 12:50 P.M., indicated,..."cont to have 3+ [MEDICAL CONDITION] in (lower) extremities...." No indication the physician was notified regarding the continued [MEDICAL CONDITION] and the ineffectiveness of the treatment. A Nurses Note, dated 12/05/2010 at 10:00 P.M., indicated,..."Patient still has +3 [MEDICAL CONDITION].." No indication the physician was notified related to the [MEDICAL CONDITION]. A Nurses Note, dated 12/07/2010 at 10:00 A.M., indicated,..."[MEDICAL CONDITION] improving encouraged to elevate feet et legs...." A Nurses Note, dated 12/07/2010 at 10:00 P.M., indicated Resident #C had been admitted to the hospital. The resident was sent to the hospital from the Pulmonology office when Resident B was there for the F/U appointment. The continued lower extremity [MEDICAL CONDITION] was not reported the the physician as stated in the plan of care. A hospital history and physical, dated 12/07/2010, indicated,...EXTREMITIES: Reveal 4+ [MEDICAL CONDITION] to the knees...PLAN: ...It is hoped that we can aggressively [MEDICATION NAME] this individual,...and compensate his congestive cardiac dysfunction and his [MEDICAL CONDITION]." On 12/30/2010 at 3:30 P.M., the DoN indicated the facility follows state regulations concerning physician notification. The DoN also indicated the physician should have been notified regarding the [MEDICAL CONDITION]. This federal tag relates to complaint #IN 617. 3.1-37(a)