Every finding on record at Majestic Care of Sheridan

Based on observation, interview and record review, the facility failed to ensure incontinence care was provided to a resident with urinary incontinence and more than one incontinence brief was not utilized for 1 of 2 residents reviewed for Activities of Daily Living (ADL) care. (Resident 7)Findings include:1. During an observation, on 4/6/26 at 12:10 p.m., Resident 7 was lying in his bed, and the side of his pants was visibly wet with urine. His room had a urine smell.During an observation, on 4/6/26 at 2:13 p.m., Resident 7 was still wet and the wet color on his pants was fading.During an interview, on 4/6/26 at 2:16 p.m., Certified Nurse Aide (CNA) 6 indicated he checked on residents every two (2) hours. He had checked Resident 7 last before lunch.During an interview, on 4/6/26 at 2:30 p.m., CNA 6 indicated he had just gone and changed Resident 7 and he was wet.2. During an observation, on 4/8/26 at 10:14 a.m., Resident 7 was lying in bed with at least two (2) incontinent pads under him. His bed was visibly wet with ring of urinary incontinence around him.During an observation, on 4/8/26 at 12:20 p.m., there was now an even darker ring under the resident of urine along with a lighter ring of urine which was drying.During an observation, on 4/8/26 at 1:44 p.m., Resident 7 was in the same position, and his bed was still wet with urine.During an observation, on 4/8/26 at 1:49 p.m., CNA 4 indicated he last changed Resident 7 at 10:00 a.m. The CNA indicated the resident had not refused any care with him today. The resident slept a lot during the day. The CNA again indicated Resident 7 had not refused any care with him today.During an ADL care observation, on 4/8/26 at 1:50 p.m., CNA 4 was observed to check if Resident 7 needed incontinence care. CNA 4 stopped at the door, saw Resident 7 sleeping, and indicated see, he's sleeping. The CNA was asked if he could check to see if Resident 7 needed care. The CNA asked Resident 7 if he could get him up, and Resident 7 did not respond. Then the CNA asked Resident 7 if he could get him up to be changed, and Resident 7 did not respond. The CNA was then asked if he could educate Resident 7 that he needed care and if CNA 4 could please change him. Resident 7 then got up and allowed the CNA to change him. Resident 7 had two (2) incontinence pads which were soaked with urine. Resident 7's red shirt was soaked at the bottom of his shirt, his incontinent brief was soaked, and the bed sheets were soaked underneath the resident. Resident 7's clothes and bed sheets were changed, and the CNA placed two (2) incontinence briefs on the resident.During an interview, on 4/8/26 at 2:18 p.m., CNA 4 indicated the resident was soaked with urine. He did wet himself heavily and staff were to check him every two (2) hours. He had not refused any care with him today. He typically placed two (2) briefs on Resident 7.The clinical record for Resident 7 was reviewed on 4/8/26 at 10:12 a.m. The diagnoses included, but were not limited to, benign prostatic hyperplasia without lower urinary tract symptoms, vascular dementia, and intellectual disability.The facility point of care response history for bladder elimination, personal hygiene, and behaviors did not indicate the resident had refused care for 4/6/26 or 4/8/26.The clinical record did not indicate any documented refusals, on 4/6/26, in the progress notes.A current care plan, dated 3/9/26, indicated Resident 7 had episodes of incontinence. Staff were to assist with routine toileting and as needed, to check routinely for incontinence and provide incontinence care as needed, to encourage Resident 7 to allow staff to assist him when he was incontinent, and to explain the risks to the resident if he did not allow staff to assist him.The care plan did not indicate the staff were to place two (2) incontinent briefs on Resident 7.During an interview, on 4/9/26 at 3:49 p.m., the Executive Director indicated staff should not place two (2) briefs on a resident unless the resident's care plan indicated.During an interview, on 4/10/26 at 11:28 a.m., CNA 5 indicated if someone refused care, CNAs were to tell the nurse and chart it in the tasks in the record. A current facility policy, titled Resident-Patient Rights, dated effective 4/1/26 and received from the Executive Director on 4/9/26, indicated .Care Team Members will treat each resident/patient with kindness, respect and dignity and provide care that enhances and promotes quality of life and resident/patient preferences and individuality.A current facility policy, titled ACTIVITIES OF DAILY LIVING, dated as last revised on 1/2/24 and received from the Executive Director on 4/9/26 at 3:00 p.m., 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.Toileting.A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene.410 IAC (Indiana Administrative Code) 16.2-3.1-38(a)(2)(c)

Based on observation, interview and record review, the facility failed to ensure enhanced barrier precautions (EBP) were followed for 1 of 1 resident reviewed infection control. (Resident 7)Findings include:The clinical record for Resident 7 was reviewed on 4/8/26 at 10:12 a.m. The diagnoses included, but were not limited to, benign prostatic hyperplasia without lower urinary tract symptoms, vascular dementia, and intellectual disability.A physician's order, dated 3/8/26, indicated to utilize Enhanced Barrier Precautions when engaging in high contact resident care activities every shift related to a gastrostomy tube.A current care plan, dated 3/9/26, indicated Resident 7 required enhanced barrier precautions.During an observation, on 4/8/26 at 1:50 p.m., CNA 4 provided incontinence care to Resident 7. The CNA put on gloves to change the resident's incontinence brief but did not put on a gown. The CNA changed Resident 7's urine-soaked brief, wet shirt, wet bed sheets, and wet pants. The wet urine-soaked bed sheet had come into contact with the CNA's uniform. When the CNA was done changing some of the linens, the CNA walked out of the room with a dirty bag of linens and the same pair of gloves and then walked back into the room with the same pair of gloves and continued to provide care.The CNA did not wear a gown during any part of care or change gloves.An enhanced barrier precautions sign located on Resident 7's door indicated ENHANCED BARRIER PRECAUTIONS EVERYONE MUST: Cleanse their hands, including before entering and when leaving the room. PROVIDERS AND STAFF MUST ALSO: Wear gloves and a gown for the Following High-Contact Resident Care Activities. Dressing. Bathing/showering. Transferring. Changing linens. Providing Hygiene. Changing briefs or assisting with toileting. Device care or use: central line, urinary catheter, feeding tube.During an interview, on 4/8/26 at 2:18 p.m., CNA 4 indicated he did usually put on a gown for care, but he forgot and he should have worn a gown.During an interview, on 4/10/26 at 11:28 a.m., CNA 5 indicated when completing ADL care for a resident, staff should wear a gown and gloves if the resident was in enhanced barrier precautions.A current facility policy, titled Contact Precautions, dated 3/1/25 and received from the Executive Director on 4/10/26 at 11:35 a.m., indicated .Enhanced Barrier Precautions (EBP) is an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and gloves use during high contact resident/patient care activities.an order for enhanced barrier precautions will be obtained for residents/patients with any of the following.indwelling medical devices.High-contact resident/patient care activities include, but not limited to.Dressing.Providing hygiene. Changing linens. Changing briefs or assisting with toileting.410 IAC (Indiana Administrative Code) 16.2-3.1-18(b)(2)

Based on interview and record review, the facility failed to ensure the physician was notified of abnormal blood sugar readings as ordered for 1 of 5 residents reviewed for notification of change. (Resident 65)Findings include:The clinical record for Resident 65 was reviewed on 4/7/26 at 2:00 p.m. The diagnoses included, but were not limited to, type two diabetes mellitus, hypertension, and dementia.A care plan, dated 4/2/25, indicated Resident 65 was at risk for complications and symptoms of hypoglycemia (low blood sugar) or hyperglycemia (high blood sugar) with an intervention to obtain blood sugars as ordered and to document and notify the physician of abnormal findings.A physician's order, dated 4/3/25 and discontinued 4/2/26, indicated to obtain an Accu Check (blood sugar reading) four (4) times a day and to notify the provider if the blood sugar reading was less than 90 or greater than 350.The Medication Administration Record (MAR) indicated the following abnormal blood sugar readings were documented with N (no) for physician notification:On 12/26/25, with a blood sugar of 85.On 12/28/25, with a blood sugar of 74.On 12/31/25, with a blood sugar of 368.On 1/18/26, with a blood sugar of 367.On 2/19/26, with a blood sugar of 80.On 3/16/26, with a blood sugar of 83.On 3/18/26, with a blood sugar of 82.On 3/19/26, with a blood sugar of 84.During an interview, on 4/9/26 at 2:56 p.m., the Executive Director (ED) indicated if the physician was in the building at the time the abnormal blood sugar reading was taken, the nurse would have notified the physician and documented the finding in a progress note.During an interview, on 4/9/26 at 3:00 p.m., Licensed Practical Nurse 2 indicated when a N was documented on the MAR, the physician would not have been notified.During an interview, on 4/9/26 at 3:49 p.m., the ED indicated she was unable to find documentation for the physician notification of Resident 65's low blood sugar readings.During an interview, on 4/10/26 at 11:52 a.m., the ED indicated the facility did not have a policy regarding call orders and physician notification.410 IAC (Indiana Administrative Code) 3.1-5(a)(2)410 IAC (Indiana Administrative Code) 3.1-5(a)(3)

Based on observation, interview and record review, the facility failed to ensure quarterly smoking assessments were completed for 2 of 2 residents reviewed for accident hazards related to smoking. (Resident 4 and 67) Findings include: During an observation, on 3/30/25 at 10:38 a.m., Resident 4 and Resident 67 were observed to be smoking in the assigned smoking area. 1. The clinical record for Resident 4 was reviewed on 4/1/25 at 9:25 a.m. The diagnoses included, but were not limited to, chronic obstructive pulmonary disease, malignant neoplasm of the laryngeal cartilage, and encounter for attention to tracheostomy. A care plan, dated 2/14/20, indicated Resident 4 was at risk for injury related to smoking and to complete the smoking assessment quarterly and as needed. A smoking assessment was completed on 11/20/24. There were no current smoking assessments found in the record at the time of the record review. A current smoking assessment was requested on 4/1/24 at 1:02 p.m. The facility was unable to provide a current smoking assessment which had been completed after 11/20/24 and prior to 4/1/25. 2. The clinical record for Resident 67 was reviewed on 4/1/25 at 11:01 a.m. The diagnoses included, but were not limited to, lack of coordination, tobacco use, and alcohol dependence with alcohol induced persisting dementia. A care plan, dated 4/22/24, indicated Resident 67 was at risk for injury related to smoking and to complete the smoking assessment quarterly and as needed. A smoking assessment was completed on 11/1/24. There were no current smoking assessments found in the record at the time of the record review. A current smoking assessment was requested on 4/1/25 at 1:02 p.m. The facility was unable to provide a current smoking assessment which had been completed after 11/1/24 and prior to 4/1/25. During an interview, on 4/2/25 at 10:17 a.m., the Executive Director indicated smoking assessments were to be completed quarterly. A current facility policy, titled Smoking, dated as effective 2/19/25 and received from LPN 5 on 4/2/25 at 10:37 a.m., indicated .Each resident/patient who smokes must have a smoking assessment completed .quarterly 3.1-45(a)(1)

Based on interview and record review, the facility failed to ensure the ombudsman was notified of a resident's transfer and discharge to the hospital for 1 of 2 residents reviewed for transfer and discharge. (Resident 55) Findings include: The clinical record for Resident 55 was reviewed on 4/2/25 at 10:16 a.m. The diagnoses included, but were not limited to, displaced fracture of the base of the neck of the right femur, muscle weakness, and osteoporosis. The clinical record, dated 8/2/24, indicated Resident 55 fell while attempting to self-transfer. The clinical record, dated 8/3/24, indicated Resident 55 complained of right hip pain. An X-ray was ordered which indicated Resident 55 had a right hip fracture and was transferred to an area hospital by emergency services. Hospital discharge documents indicated Resident 55 was admitted to the hospital on [DATE] and discharged back to the facility on 8/8/24. An email from the area ombudsman, dated 4/2/25 at 11:11 a.m., included the discharge information the facility submitted to the ombudsman program for August of 2024. Resident 55 was not included in the documents provided by the ombudsman. During an interview, on 4/2/25 at 10:13 a.m., the Social Service indicated the facility did not have anything further to provide. A document, titled Family of Social Service Administration, last updated October 2024, indicated .Dear Nursing Home Administrator: As you know, CMS requires nursing facilities to notify the Long-Term Care (LTC) Ombudsman of the majority of residents' transfers and discharges .When a resident is transferred on an emergency basis to an acute care facility and expected to return, the SLTCO must be notified. Information from facilities regarding emergency transfers should be provided in a monthly list to the SLTCO, which should include residents' names, dates of transfer, facilities to which residents were transferred, and reasons for the transfers. Please make sure your facility's name is included on the monthly list A current facility policy, titled TRANSFERS & DISCHARGES, dated 1/2/2024 and received from the Clinical Support Nurse on 4/3/25 at 11:42 a.m., indicated .It is the policy of this facility to permit each resident to remain in the facility, and not initiate transfer or discharge for the resident from the facility, except in limited circumstances .Exceptions to the 30-day requirement apply when the transfer or discharge is effected because .An immediate transfer or discharge is required by the resident's urgent medical needs .In these exceptional cases, the notice must be provided to the resident, resident's representative if appropriate, and LTC ombudsman as soon as practicable before the transfer or discharge .Emergency Transfers/Discharges-initiated by the facility for medical reasons to an acute care setting such as a hospital .The Social Services Director, or designee, will provide copies of notices for emergency transfers to the Ombudsman, but they may be sent when practicable, such as in a list of residents on a monthly basis 3.1-12(a)(6)(A)(iv)

Based on interview and record review, the facility failed to ensure physician's orders were followed, medications were held, and the physician was notified when vital signs were below the ordered parameters for 1 of 5 residents reviewed for quality of care. (Resident 42) Findings include: The clinical record for Resident 42 was reviewed on 3/31/25 at 2:00 p.m. The diagnoses included, but were not limited to, hypertension, hypotension, and atrial fibrillation. A physician's order, dated 11/4/24, indicated to administer diltiazem (a medication used to treat high blood pressure) 30 mg (milligram), three (3) times a day with instructions to hold the medication if the systolic blood pressure was below 90 or the heart rate was below 60 and to notify the physician if the systolic blood pressure was below 80. The Medication Administration Record (MAR), dated February 2025, indicated the diltiazem was administered three (3) times with the systolic blood pressure below the physician's ordered hold parameter. The MAR, dated March 2025, indicated the diltiazem was administered three (3) times with the systolic blood pressure below the physician's ordered hold parameter. A physician's order, with a discontinued date of 3/27/25, indicated to administer midodrine (a medication used to treat low blood pressure) 5 mg, three (3) times a day with instructions to hold the medication if the systolic blood pressure was above 120. The MAR, dated February 2025, indicated the midodrine was administered one (1) time with the systolic blood pressure above the physician's ordered hold parameter. The MAR, dated February 2025, indicated Resident 42's systolic blood pressure was below 80 on 2/1/25. The nurse documented n for physician notification which indicated the physician was not notified. The MAR, dated March 2025, indicated Resident 42's systolic blood pressure was below 80 for two (2) of the three (3) medication administrations on 3/25/25. The nurse's documented n/a for physician notification which indicated the physician was not notified. During an interview, on 4/1/25 at 1:19 p.m., Licensed Practical Nurse (LPN) 4 indicated the check marks documented on the MAR meant the medication had been administered and both medications had been administered with systolic blood pressure below and above the physician's ordered hold parameters. During an interview, on 4/1/25 at 2:50 p.m., the Clinical Support Nurse indicated a check mark on the MAR indicated the medications were administered. During an interview, on 4/1/25 at 1:56 p.m., the Administrator indicated the diltiazem and midodrine were both administered with the systolic blood pressure below and above the physician's ordered hold parameters and the physician was not notified of the systolic blood pressures below 80. A current facility policy, titled MEDICATION ADMINISTRATION, dated 1/2/2024 and received from the Administrator on 4/1/25 at 2:21 p.m., indicated .Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice .Obtain and record vital signs, when applicable or per physician orders. When applicable, hold medications for those vital signs outside the physician's prescribed parameters .Report and document any adverse side effects, omittances, or refusals 3.1-37(a)

Based on observation, interview, and record review the facility failed to ensure only one medication administration was set up at a time for 2 of 2 residents reviewed. (Residents 34 and 282) Finding includes: During a random observation on 03/20/24 at 2:59 p.m., RN 4 was observed to have two cups of medication set up for administration for Residents 34 and 282. The nurse picked up both medication cups and indicated he was going to administer them. He indicated the resident's were right there. The medication administration was interrupted. During an interview on 03/20/24 at 2:59 p.m., RN 4 indicated he should probably not set up more than one medication administration at a time and the medications were for Residents 34 and 282. During an interview on 03/21/24 at 09:36 a.m., the Executive Director indicated presetting more that one medication was not good practice. A facility policy titled, General Guidelines for Medication Administration, dated as last revised in 08/2020 and received from the Executive Director on 03/22/24 at 9:43 a.m., indicated, .medications are administered at the time they are prepared .Medications are not pre-poured .for more than one resident at a time 3.1-25(b)(5)

Based on observation, interview, and record review, the facility failed to store chemicals in a safe manner and failed to ensure only medications were stored in the refrigerator/freezer unit for 1 of 2 medication storage rooms. Finding includes: During an observation of medication storage on 03/20/24 at 2:36 p.m., seven (7) bottles of [chemical used to destroy medications] were found stored on the floor. One bottle was noted to have a black/brown substance down the side of the bottle, the cap was taped on the bottle and the tape was coming off. There was also a bottle labeled hazardous waste with a broken cap stored on the floor. There was frozen dinner, unlabeled, and a tall medication bottle with keys found in the freezer of the medication refrigerator unit. During an interview on 03/20/24 at 2:36 p.m., RN 3 indicated there was destroyed medications in the bottle labeled hazardous waste. During an interivew on 03/20/24 at 03:14 p.m., the Director of Nursing indicated nothing was to be stored on the floor of the medication storage rooms. During an interview on 03/21/24 at 9:28 a.m., the Executive Director indicated the keys belonged to the old medication carts and food should not be stored in that freezer. A facility policy titled, Storage of Medications dated as last revised 08/2020 and received from the Executive Director on 03/22/24 at 9:43 a.m., indicated, .Potentially harmful substances .are clearly identified and stored in a locked area separately from medications or in accordance with facility policy 3.1-25(m)

Based on observation, interview and record review, the facility failed to label, date and store refrigerated and freezer foods, failed to prevent freezer burn, failed to date canned items when received, failed to date frozen meats when placed in the refrigerator to thaw, and failed to serve food in a sanitary manor. This deficient practice had the potential to effect 78 of 78 residents who received food from the kitchen. Findings include: During a kitchen observation, on 01/04/23 at 9:23 a.m., with the Kitchen Manager present the following was observed: 1. In the dairy refrigerator: a. A large bag of shredded cheese was open, unsealed without an open date. b. 15 hot dogs were open, unsealed without an open date. 2. In the meat freezer: a. 20 frozen hamburgers were in a plastic bag unsealed. b. 20 pieces of fish were in a plastic bag unsealed. 3. Vegetable freezer: a. Two bags of frozen broccoli were frozen solid and were crunchy when touched. b. Two pork loin packages were defrosting in a pan on the bottom shelf without a date to indicate when they were placed in the refrigerator to thaw. 4. Dry storage area: a. Several food cans were not labeled with a receive date. During an interview, at that time, the Kitchen Manager indicated items in both the refrigerator and freezer should be labeled and dated when opened and placed in a sealable container. Freezer burnt items should be thrown away. All foods moved from the freezer to the refrigerator to defrost should be dated when moved over, and all canned food goods should be dated when they were received. 5. During a dining observation, on 1/4/23 at 12:19 p.m., Dietary Aide (DA) 1 touched his facemask twice then grabbed a dinner roll and a carton a milk without gloves and without sanitizing his hands. At 12:36 p.m., DA 1 touched the hood of his sweatshirt without sanitizing his hands. Again, at 12:38 p.m., DA 1 reached up and pulled his mask away from his face and did not sanitize his hands. 6. During an observation, on 1/4/23 at 12:39 p.m., the Dietary Manager touched the back of his head and walked over to a resident drink cup filled with a red liquid and placed a plastic cover on the cup. The Dietary Manager was not observed to sanitize his hands before placing the cover on the cup. During an interview, on 1/6/23 at 9:46 a.m., the Infection Preventionist indicated she expected staff to wash or sanitize their hands after touching their face mask, hat, or hair. A current policy, titled Food Storage dated October 2018 and provided by the Executive Director on 01/09/23 at 11:52 a.m., indicated .Open containers will be resealed in a manner that protects the remaining food product and will be dated with open date and a discard date on or before 30 days following opening Items .will be dated with date of delivery and will be rotated/used following FIFO [first in first out]. A current policy, titled Handwashing, undated, indicated staff should wash their hands as frequently as needed throughout the day following proper hand washing. 3.1-21(i)(1) 3.1-21(i)(3)

Based on observation, record review and interview, the facility failed to ensure a resident's physician recommendations and comprehensive care plan were followed to reduce the risk of aspiration for 1 of 1 resident reviewed for quality of care. (Resident 53) Finding includes: During an observation, on 1/5/23 at 10:23 a.m., Resident 53 was observed lying in bed in a flat position. A sign on the wall indicated elevate the head of bed. During an observation and interview, on 1/5/23 at 10:40 a.m., Licensed Practical Nurse (LPN) 3 indicated Resident 53's bed was in the flat position and should be elevated to reduce the risk of aspiration. The record for Resident 53 was reviewed on 1/5/22 at 3:50 p.m. Diagnoses included, but were not limited to, Alzheimer's disease, displaced fracture right femur, and neuralgia. A Kardex, dated 1/11/22, indicated staff were to ensure the head of the bed was elevated 30 degrees or higher due to the risk of aspiration. A care area assessment (CAA), dated 6/2/22, indicated Resident 53 had a functional limitation in range of motion, inability to perform activities of daily living without significant physical assistance, and a decrease ability to make self-understood or understanding others. His CAA lacked indication Resident 53 had a swallowing problem. A quarterly Minimum Data Set (MDS) assessment, dated 11/3/22, indicated Resident 53 had exhibited no rejection of care. He required extensive physical assistance for personal hygiene. A care plan, with a revision date of 11/9/22, indicated Resident 53 had an alteration in nutritional status. Interventions included, but were not limited to, ensure the head of the bed was elevated at a 30-degree angle. A physician's assessment summary, dated 11/1/22, indicated it was recommended for the resident to be elevated at 90 degrees during oral intake and 45 minutes after meals, and he should always have the head of the bed no lower than 45 degrees at all times. A nutrition assessment, dated 11/3/22, indicated the resident had diet changes made due to dysphagia related to coughing and choking with meals and liquids. Resident 53 had a history of dysphagia. A Treatment Administration Record (TAR), dated 1/23, indicated Resident 53 was to have the head of the bed elevated to alleviate shortness of breath while lying flat in bed due to the diagnoses of dysphagia and the risk of aspiration. During an interview, on 1/6/23 at 2:30 p.m., the MDS nurse indicated she was responsible for updating the care plan when new recommendations from the physician came in. Resident 53's care plan did not reflect his head of bed was to be elevated to a 45-degree angle when he was not eating. During an interview, on 1/6/23 at 4:37 p.m., the Speech Therapist indicated Resident 53's head of bed should be elevated to a 30-to-45-degree angle at all times because of the risk of aspiration. He had been throat clearing a lot and even seemed to choke on saliva. A current policy, titled Activities of Daily Living (ADL's) Supporting, indicated residents who are unable to carry out ADL's independently will receive the services necessary to maintain good nutrition. Staff were to provide assistance in care which included mobility and dining. 3.1-37(a)

Based on observation, interview and record review, the facility failed to ensure a medication cart was secured for 1 of 4 medication carts reviewed for medication storage. (100 Hall cart) Finding includes: During an observation, on 1/4/23 at 9:00 a.m., an unidentified nurse walked away from her medication cart facing the lounge. The medication cart was unlocked and had medication cards, a medication cup with pills inside, and an inhaler left on top of the medication cart. The medication cart was unlocked, and residents were seated in the lounge and walking around the area of the nurse's station. During an observation, on 1/04/23 at 10:30 a.m., Resident 76 was observed to wander up and down the 100 hallway. He walked up to the medication cart, at 10:31 a.m., and shook the top medication drawer. No staff were observed at the medication cart or in the nurse's station. Additionally, 12 other residents were observed seated in the lounge. During an observation, on 1/04/23 at 1:38 p.m., Registered Nurse (RN) 1 stood at the medication cart as she prepared medications for a resident. She grabbed the plastic medication cup and walked away with her back to both medication carts roughly 15 feet away where an unidentified resident was seated in a wheelchair. The medication cart was observed to be unlocked with the keys still in the medication cart. No staff were observed in the nurse's station or at the medication carts. 10 residents were observed seated in the lounge. During an observation, on 01/10/23 at 4:50 p.m., Licensed Practical Nurse (LPN) 2 was observed with her back to the medication cart more than 25 feet away near the dining room. A medication cart across from the lounge was observed unlocked. Nursing Assistant (NA) 4 was seated at the nurse station in front of the computer. Residents were observed in the lounge across from the unsecured medication cart. The record for Resident 76 was reviewed on 9/30/22 at 9:56 a.m. Diagnoses included, but were not limited to, dementia, mood disorder, psychotic disorder, and major depression. A care area assessment (CAA), dated 11/11/22, indicated he had behaviors of wandering and disorganized thinking. A care plan, dated 9/19/22, indicated Resident 76 exhibited signs of cognitive impairment due to diagnosis of dementia and directed staff to intervene as indicated. During an interview, on 1/10/23 at 4:45 p.m., the Executive Director indicated nursing staff should lock the medication carts and monitor to ensure the residents did not get into the carts. A current policy, titled Storage of Medication, dated of 11/20, indicated drugs were stored in locked compartments. Compartments including but not limited to drawers, cabinets, and carts are locked when not in use. Nursing staff are responsible for maintaining medication storage. 3.1-25(m)

Based on observation, record review and interview, the facility failed to maintain a sanitary environment related to an accumulation of a black substance on the floors of the shower rooms and failed to maintain a clean, sanitary, and homelike environment for 1 of 1 resident and 2 shower rooms reviewed for environment. (North Shower, South Shower and Resident 53) Findings include: 1. During the Environmental Tour of the North Shower room, on 1/4/23 at 11:21 a.m., with Nursing Assistant (NA) 1 the following was observed: a. The wall of the shower room had multiple missing tiles on the wall near the toilet and exposed the sheet rock. b. The grout of the entire shower room floor was stained with a buildup of a black colored substance. During an interview, on 1/4/23 at 11:23 a.m., NA 1 indicated the grout was stained with a black substance. She indicated all residents in the North Hall used the shower room to bathe. After a resident gets a shower, the staff spray the shower walls down with a disinfectant solution. The housekeeping staff were responsible to clean the floors. 2. During the Environmental Tour of the South Shower room, on 1/4/23 at 2:40 p.m., with NA 5 the following was observed: a. The grout of the entire shower room floor was stained with a buildup of a black colored substance. b. A blue colored glove was found on the floor near the garbage can. c. A tan colored blanket was found on the floor near two gray colored garbage cans. During an interview, on 01/06/23 at 3:08 p.m., the Executive Director indicated there was a cleaning schedule for the showers and they should be cleaned when scheduled. During an interview, on 1/6/23 at 3:22 p.m., the Director of Environmental Service indicated the floors were deep cleaned on Monday and Friday. The problem related to the grout was they need a deep scrub because the mop just pushed the dirt back and forth. He was aware of the missing tile on the wall of the shower room. 3. During an observation, on 1/4/23 at 10:30 a.m., Resident 53 was observed lying in bed with the fall mat next to the bed. The fall mat had a 10-inch dry clear stain on the left lower corner and multiple other stained areas throughout the area. During an observation, on 1/5/23 at 9:19 a.m., Resident 53 was seated, in his Broda chair, near the nurse's station. His Broda chair had dried food stains on the arms and sides of the chair. During an observation, on 1/6/23 at 9:12 a.m., Resident 53's Broda chair was visibly soiled with dry, yellow-colored stains on the left side. His blue colored fall matt positioned next to the bed had multiple areas of dirty dry shiny areas. The Hoyer sling found on the seat of the Broda chair had a large amount of food crumbs scattered across the fabric. During an interview, on 1/10/23 at 10:07 a.m., the Executive Director indicated her expectation for staff if they see something, they should clean it. Everyone was responsible for ensuring the resident rooms and equipment was clean. A current policy, titled Cleaning and Disinfection of Resident Care Items and Equipment, dated 10/18, indicated resident care equipment would be cleaned and disinfected according to current CDC recommendations for disinfection. 3.1-19(f)(5)

Based on observation, record review and interview, the facility failed to prevent an avoidable accident when 2 staff members did not use a mechanical lift to transfer a resident from a wheelchair to a bed and failed to have a Physical Therapy (PT) evaluation completed before determining the resident was safe to transfer with the assistance of 2 staff members and a gait belt for 1 of 3 residents reviewed for accident hazards. (Resident B) This resulted in harm when Resident B had a fall which resulted in a lower extremity fracture requiring hospitalization and surgery. Finding include: During an observation of the facility, on 01/27/2021 at 3:30 p.m., Resident B was observed in her bed. During an interview, at this time, she indicated she recently had a fall and broke her leg because 2 CNAs put her to bed from her wheelchair. She told them they were supposed to use the Hoyer lift (a mechanical lift used to transfer residents). They didn't and instead grabbed her under her arms and tried to move her. Her knees buckled and she fell . She told them they couldn't lift a resident like me, the others use the Hoyer lift. An incident report, provided by the Executive Director (ED), on 01/27/2021 at 10:20 a.m., indicated Resident B was transferred from her wheelchair to her bed by 2 CNAs when the resident's foot slipped which caused her to be lowered to the ground. The record for Resident B was reviewed on 01/27/2021 at 10:16 a.m. [DIAGNOSES REDACTED]. A progress note, dated 1/18/2021 at 10:53 p.m., indicated LPN 1 was called to Resident B's room for a fall. During a transfer from the wheelchair and the bed, the resident's knees gave out and two staff assisted her to the floor. The resident complained of some right knee pain after the fall but was given pain medication and was better not long after. A progress note, dated 01/19/2021 at 6:41 a.m., indicated the resident complained of right knee pain, the physician was notified and an x-ray was ordered. A progress note, dated 01/19/2021 at 11:57 a.m., indicated the x-ray results showed a right femur (long bone of the lower extremity) fracture and the resident was transported to the hospital. A radiology report, dated 01/19/2021 at 11:29 a.m., indicated the resident had a moderately displaced supracondylar and intercondylar [MEDICAL CONDITION] femur (a fracture at the knee). A hospital document, dated 01/19/2021 at 8:42 p.m., provided by the ED on 01/27/2021 at 10:20 a.m., indicated the resident was transferred by two CNAs when they accidentally dropped her on her right knee. The patient reported her knee flexed awkwardly. On physical exam, there was swelling noted at the area of the right knee consistent with a closed fracture (a broken bone not protruding through the skin). The patient was referred to (name of hospital) a trauma center. A Morse fall assessment, dated 11/19/2020, indicated the resident was a moderate risk for falls. A quarterly Minimum Data Set (MDS) assessment, dated 12/16/2020, indicated the resident required 2+ person physical assist with transferring between bed and chair. A care plan, provided by the Director of Nursing (DON) on 01/27/2021 at 5:42 p.m., indicated the resident was at risk for falls and injuries. The resident required 2 person assistance as tolerated due to resident frequent refusals to use Hoyer and/or sit to stand lift. The care plan was initiated on 12/21/2020. The resident fell on [DATE]. The care plan was resolved on 01/26/2021. A care plan, provided by the DON on 01/27/2021 at 5:42 p.m., indicated the resident required assistance with activities of daily living. The resident required the use of a Hoyer lift for transfers. The care plan was initiated on 01/22/2021 after the resident had a fall resulting in a fracture and was revised on 01/27/2021. A document, titled Order Recap Report, dated 06/01/2020 - 01/31/2021, provided by the DON on 01/27/2021 at 5:42 p.m., indicated Physical Therapy (PT) was ordered for Resident B from 08/11/2020 through 11/19/2020 for muscle wasting of right thigh and right knee pain. The resident did not receive PT from 11/19/2020 until 01/22/2021. Occupational Therapy (OT) was ordered for Resident B from 12/08/2020 through 12/10/2020 when the resident became positive for Covid-19 and therapy was discontinued and restarted on 01/06/2021 through 01/19/2021. PT and OT documents were provided by the DON, on 01/27/2021 at 5:45 p.m., and indicated the following: 1. Physical Therapy Evaluation and Plan of Treatment from 08/10/20 - 09/08/20. Fall risk assessment indicated the patient had fallen 3 times in the past year. She felt unsteady when standing and when walking. She worried about falling. The patient was unable to stand and needed a Hoyer for transfers and functional mobility. Certification period from 09/09/20 - 10/08/20 indicated on 09/09/20 the resident was unable to stand for a few seconds using the stand-up lift. The resident's lower extremities were not strong enough to support her weight as she was moderately obese. Certification period from 10/07/20 - 11/05/20 indicated on 10/07/20 the resident was able to stand in the stand-up lift consistently with brief breaks. Certification period from 11/03/20 - 12/02/20 indicated on 11/03/20 the resident was able to stand with minimal assist of 2 for 30 seconds in parallel bars. There was not any notes related to using the stand up lift during this period. PT discharge summary, for service date 8/10/20-11/17/20, indicated on 11/17/20 the resident was able to stand in the stand-up lift for 30 seconds. The resident was discharged from PT services on 11/17/20 because the resident was scheduled for surgery on the left side of her face on 11/18/20. 2. The OT Clinical Impressions, dated 01/6/21 - 02/05/21, indicated Nursing caregivers are utilizing Hoyer lift at this time for safe transfers given the patient's weakness. In a written statement, dated 01/19/2021, LPN 1 indicated she was called to the Resident B's room and saw the resident lying on the floor with both legs under her bed and her wheelchair was to the left side of her. The resident complained of knee pain. She was assessed and could move her extremities within normal limits and was assisted back to bed. During an interview, on 01/27/2021 at 11:57 a.m., LPN 1 indicated she was called to Resident B's room by the CNA and found the resident lying on her back with her feet under the bed. The resident was in a weird position and the resident indicated her right knee was hurting. She assessed the resident and left the room to get her some pain medication. At this point, the CNAs put the resident in bed using the Hoyer lift. She also indicated the staff would attempt to use the Hoyer lift for transfers but she often refused and part of the resident's plan of care indicated the resident could be transferred with the assistance of 2 CNAs. In a written statement, dated 01/19/2021, CNA 2 indicated she was transferring Resident B with CNA 3. They started to pivot the resident and her foot slipped which caused her knees to buckle. They lowered her to her knees first then to her bottom and one of them got the nurse. After the nurse assessed the resident, we were all able to Hoyer her back to bed. The resident did initially say her knee hurt when all her weight was on it. During an interview, on 01/27/2021 at 1:13 p.m., CNA 2 indicated the resident had a shower that evening and the CNA who gave her the shower did not place the Hoyer pad in her wheelchair. She was going to use the Hoyer lift to put her in bed but the resident refused so she looked it up and it said the resident could be moved with two staff and a gait belt. She and CNA 3 stood the resident up fine but then her foot slipped and she was lowered to her knees and then to her bottom. She called for the nurse and the nurse assessed the resident and then she was put into bed using the Hoyer lift. She had transferred the resident one time before using the Hoyer lift and at that time the resident had not refused or complained. During an interview, on 01/27/2021 at 3:52 p.m., CNA 4 indicated she gave Resident B a shower on 01/18/2021 in the evening. She used the stand-up lift to transfer her from her bed to her wheelchair and from her wheelchair to the shower chair. After her shower was done, she used the lift to transfer her back to her wheelchair from the shower chair. She had taken care of Resident B frequently and had always used the stand-up lift or the Hoyer lift for transfers. The resident preferred the Stand-up lift over the Hoyer but she had always been able to convince her to use the Hoyer if she needed to. During an interview, on 01/27/2021 at 5:50 p.m., the DON indicated she had provided all Resident's B Therapy notes from 06/2020 through 01/27/2021. The resident's last physical therapy treatment prior to her fall on 01/18/2021 was on 11/17/2020 and she could not provide a policy for therapy evaluations or a policy for transferring residents. During an interview, on 01/27/2021 at 6:17 p.m., the Director of Therapy indicated the last PT recertification and evaluation Resident B had was from 11/03/20 through 12/02/20. She was not picked back up by PT until 01/22/2021 after her fall on 01/18/2021. A current policy, titled Fall Management, dated 10/2019 and provided by the Executive Director, on 01/27/2021 at 2:30 p.m., indicated .Purpose: to prevent injuries related to falls The resident specific care requirements will be communicated to the assigned care team members This Federal Tag relates to Complaint IN 709. 3.1-45(a)(1) 3.1-45(a)(2)

Based on observation, interview and record review, the facility failed to use standard infection control practices during the care of a urinary catheter for 1 of 1 resident observed for urinary catheter care. (Resident B) Finding includes: During an observation of urinary catheter care, on 08/05/2020 at 10:00 a.m., with LPN 1, the following was observed. LPN 1 placed her supplies on a clean surface on the resident's over bed table, washed her hands and put on gloves. She then put soap and water on a cloth and began to clean the resident's perineal (genital) area and urinary catheter. When she cleansed the urinary catheter she made swipes with the cloth in both directions, going away from the meatus (opening in the penis where the catheter was inserted) and then towards the meatus. She did this several times. Without changing her gloves or washing her hands she then took a clean wet cloth and began to rinse the resident's perineum and catheter in the same manor. During an interview, at this time, LPN 1 indicated she should have cleansed the catheter wiping only away from the meatus and she should have also removed her contaminated gloves and washed her hands before reaching for a clean cloth to rinse the resident's catheter and perineal area. The record for Resident B was reviewed on 08/04/2020 at 1:00 p.m. [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. An undated facility document, titled Procedure 34: PERINEAL CARE, provided by the Director of Nursing on 08/05/2020 at 12:45 p.m., indicated .10 .Gently wipe four inches of catheter away from meatus out A facility policy, titled Standard Precautions dated 02/2018 and provided by the Director of Nursing on 08/05/2020 at 12:50 p.m., indicated .Remove gloves promptly after use, before touching non-contaminated items and wash hands immediately to avoid transfer of microorganisms A facility policy, titled Handwashing/Hand Hygiene dated 02/2018 and provided by the Director of Nursing on 08/05/2020 at 12:50 p.m., indicated .when to use Alcohol-Based Hand Rub .f. Before moving from a contaminated body site to a clean body site during resident care This Federal tag relates to Complaint IN 292. 3.1-18(a) 3.1-18(l)

Based on interview and record review, the facility failed to notify the physician timely of elevated blood sugar levels for 1 of 5 residents reviewed for unnecessary medications (Resident 67). Finding includes: The record for Resident 67 was reviewed on 03/04/20 at 10:50 a.m. [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. A care plan, provided by the Director of Nursing on 03/11/20 at 3:00 p.m., indicated Resident 67 was at risk for complications and symptoms of [DIAGNOSES REDACTED] (low blood sugar) and [MEDICAL CONDITION] (high blood sugar) and to check the blood sugars as ordered by the physician as well as document abnormal findings and notify the physician. A blood sugar result, on 02/22/20 at 9:45 p.m., was 381. There was no documentation of the notification to the physician on this day. A blood sugar result, on 03/01/20 at 1:45 p.m., was 364. There was no documentation of the notification to the physician on this day. A blood sugar result, on 03/03/20 at 5:29 p.m., was 383. There was no documentation of the notification to the physician on this day. A blood sugar result, on 03/07/20 at 8:21 p.m., was 404. There was no documentation of the notification to the physician on this day. During an interview, on 03/11/20 at 3:00 p.m., the Director of Nursing indicated she would find documentation to show the physician was notified of the elevated blood sugars. On 03/11/20 at 5:10 p.m, the Medical Records Clerk presented documentation indicating the physician was not notified of the elevated blood sugar for 02/22/20 until an appointment on 02/25/20. The physician was not informed of the elevated blood sugar on 03/01/20 until an office visit on 03/02/20. The physician was not informed of the elevated blood sugar result on 03/07/20 until an office visit on 03/09/20. A current facility policy, titled Change in a Resident's Condition or Status, dated as revised 5/17, provided by the Corporate Support Nurse on 03/11/20 at 3:25 p.m., indicated .Our facility shall promptly notify the .Attending Physician .of changes in the resident's medical .condition 3.1-5(a)(2)

Based on observation, interview and record review, the facility failed to provide privacy during a procedure for 1 of 3 residents observed for privacy (Resident 68). Finding includes: The record for Resident 68 was reviewed on 03/09/20 at 12:48 p.m. [DIAGNOSES REDACTED]. During a dressing change, on 03/06/20 at 9:38 a.m., Resident 68 was positioned with his brief removed, exposing his buttocks, for a dressing change to his coccyx. The window blinds were missing a section of slats, leaving a gap on the right side of the window, leaving the resident exposed to the parking lot. After the dressing change was completed, at 9:45 a.m., the Assistant Director of Nursing indicated he should have closed the blinds. During an interview, on 03/06/20 at 11:43 a.m., the Director of Nursing indicated even though the blinds were missing slats, all the windows were tinted so no one was able to see anything in the residents rooms from the parking lot. During an observation, on 03/06/20 at 12:44 p.m., through a window from the same parking lot, privacy curtains in the rooms, a fan in the window of rooms which did not have the blinds closed were observed. During an observation of the windows from the outside, on 03/06/20 at 2:56 p.m., Maintenance Employee 1 indicated the windows did not appear to be tinted. During an observation from the same parking lot, on 03/10/20 at 1:33 p.m., another resident (Resident 56) could be clearly observed, through her window, sitting in her room. During an observation from the same parking lot, on 03/11/20 at 08:15 a.m., another resident (Resident 12) could be clearly observed, through her window. The resident was sitting on her bed, wearing a hospital gown, holding an article of clothing in her hands. On 03/09/11 at 11:13 a.m., Maintenance Employee 2 provided a copy of a sticker which he indicated had come from a facility window. The sticker did not indicated who the manufacturer of the windows was, nor did it indicate whether the window had been tinted. A facility document, titled Work Order #58, was provided by the Director of Nursing on 03/06/20 at 3:23 p.m. The document indicated a work order to fix the blind was initiated on 03/06/20 at 10:22 a.m. A current facility policy, titled Resident Rights, provided by the Director of Nursing on 03/11/20 at 10:30 a.m., indicated .rights include the resident's right to .privacy and confidentiality 3.1-3(p)(4)

Based on record review and interview, the facility failed to complete an assessment for a self-release seat belt for 1 of 3 resident's reviewed for physical restraints. (Resident 78) Finding includes: The record for Resident 78 was reviewed on 03/05/2020 at 10:11 a.m. [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. An undated care plan indicated the resident was at risk for falls related to dementia with confusion. Interventions included, but were not limited to, self-release belt alarm to wheelchair. An Admission Minimum Data Set (MDS) assessment, dated 12/03/2019, indicated the resident was severely cognitively impaired. An Adaptive Device Review- V3 document, dated 12/17/2019, provided by the Director of Nursing on 03/06/2020 at 11:00 a.m., indicated there were not answers documented for the following questions; if the resident could easily and on command release the seat belt, whether the device restricted or prevented the resident's freedom of movement and if the device restricted the resident's normal access to their body. An undated Adaptive Device Review- V2 document, provided at the same time, indicated the answers to the same questions as not applicable. During an interview, on 03/06/2020 at 11:12 a.m., the Director of Nursing indicated the documentation should have been fully completed. A current facility policy, titled Use of Restraints, dated 04/2017, provided by the Director of Nursing on 03/06/2020 at 4:11 p.m., indicated .evaluation for the need of restraints will be documented 3.1-26(s)

Based on interview and record review, the facility failed to develop a care plan for [MEDICAL CONDITION] and to develop an accurate cardiac care plan for 1 of 3 residents reviewed for care plans (Resident 70). Finding includes: On 03/04/20 at 8:53 a.m., Resident 70 was observed up in his wheel chair with his feet elevated. The resident had [MEDICAL CONDITION] to both lower extremities. On 03/05/20 at 12:04 p.m., the resident was observed sitting in his wheel chair. The resident had [MEDICAL CONDITION] to both lower extremities and was wearing Ted hose (Elastic stockings which compress the superficial veins in the lower limbs). On 03/06/20 at 3:14 p.m., the resident was observed with [MEDICAL CONDITION] to both lower extremities. On 03/09/20 at 10:11 a.m., the resident was observed with both feet elevated and wearing his Ted hose. On 03/10/20 at 09:35 a.m., the resident was in his room up in a wheel chair and wearing Ted hose. On 03/11/20 at 11:04 a.m., the resident was sitting in a wheel chair in his room. He was wearing his Ted hose and his feet were not elevated. At this time, he indicated he was educated on elevating his feet and wearing Ted hose to help with the [MEDICAL CONDITION]. The record for Resident 70 was reviewed on 03/05/20 at 11:02 a.m. [DIAGNOSES REDACTED]. There was no care plan for [MEDICAL CONDITION] in the record. A care plan, revised on 12/03/19, indicated Resident 70 was at risk for impaired cardiac output. An intervention initiated 12/03/19 indicated the resident was taking a diuretic and a potassium replacement. A review of Resident 70's physician's orders [REDACTED]. A physician's orders [REDACTED]. During an interview, on 03/11/20 at 11:42 a.m., the Minimum Data Set (MDS) Coordinator indicated a care plan addressing [MEDICAL CONDITION] should have been completed. She also completed the cardiac care plan and indicated the [MEDICATION NAME] and potassium were incorrect and she must have hit the wrong button. A current facility policy, titled Care Plans, Comprehensive Person-Centered, revised on 12/16, provided by the Director of Nursing on 03/11/20 at 10:10 a.m., indicated .The comprehensive, person-centered care plan will .Incorporate identified problem areas .Reflect treatment goals, timetables and objectives in measurable outcomes A current facility policy, titled Documentation Guidelines For The Medical Record, provided by the Director of Nursing on 03/10/20 at 12:56 p.m., indicated .Document the correct information 3.1-35(a)

Based on observation, interview and record review, the facility failed to assess, document and notify the physician of bruises for 1 of 1 resident reviewed for non-pressure related skin conditions. (Resident B) Finding includes: During an observation, on 03/04/2020, Resident B had a large bruise on the back of both her hands. During an observation, on 03/06/2020 at 10:00 a.m., with the Director of Nursing, the bruising to the back of the resident's hands was present. The record for Resident B was reviewed on 03/05/2020 at 2:21 p.m. [DIAGNOSES REDACTED]. A care plan, dated as revised 01/25/2019, indicated Resident B was at risk for skin breakdown. Interventions included, but were not limited to, a skin inspection weekly and as needed, document and notify the physician of abnormal findings. A physician's orders [REDACTED]. A Weekly Nursing Summary, dated 03/02/2020, provided by the Director of Nursing on 03/05/2020 at 10:00 a.m., indicated the resident did not have any open areas, skin tears or bruises. A Weekly Nursing Summary, dated 03/06/2020, provided by LPN 3 on 03/06/2020 at 11:00 a.m., indicated the resident had a 2 cm (centimeter) x 3 cm bruise on the back of her right hand and a 7 cm x 3 cm bruise on the back of her left hand. There was no indication the physician was notified. During an interview, on 03/06/2020 at 10:00 a.m., the Director of Nursing indicated the bruises should have been documented on the weekly skin assessment sheet. A current policy, titled Skin Management, dated October 2019, provided by the Director of Nursing on 03/06/2020 at 12:25 p.m., indicated .5. a) Care plan interventions will be implemented .8. a) The licensed nurse is responsible for assessing any and all skin alterations This Federal tag relates to Complaint IN 790. 3.1-37(a)

Based on observation, interview and record review, the facility failed to implement measures to prevent a facility acquired pressure ulcer (a shallow open area or blister on the skin) for 1 of 2 resident's reviewed for pressure ulcers. (Resident 39) Finding includes: On 03/05/2020 at 9:59 a.m., Resident 39 was observed to have a pressure ulcer to her left outer ankle. The record for Resident 39 was reviewed on 03/09/2020 at 2:01 p.m. [DIAGNOSES REDACTED]. An admission Minimum Data Set (MDS) assessment, dated 07/30/2019, indicated the resident did not have a pressure ulcer upon admission but was at risk for developing one. A Pressure Ulcer-Weekly Observation document, dated 01/21/2020, indicated the resident acquired a stage 2 pressure ulcer on 01/21/2020. A physician's orders [REDACTED]. A review of the resident's treatment administration record, dated 01/01/2020 thru 01/31/2020, did not indicate any pressure relieving interventions in place prior to 01/21/2020. A comprehensive care plan related to the resident being at risk for alterations in skin integrity was requested from the Director of Nursing, on 03/10/2020 at 4:04 p.m. The care plan could not be provided and at this time, the Director of Nursing indicated the care plan had been deleted. During an interview, on 03/11/2020 at 4:58 p.m., the Corporate Support Nurse indicated she could not find documentation where preventative interventions to maintain skin integrity were in place prior to 01/21/2020. A current policy, titled Care Plans, Comprehensive Person-Centered, dated 12/2016, provided by the Director of Nursing, on 03/11/2020 at 10:10 a.m., indicated .12. The comprehensive, person-centered care plan is developed within 7 days of the completion of the required comprehensive assessment (MDS) 3.1-40(a)(1)

Based on observation, interview and record review, the facility failed to provide adequate supervision, for a resident wearing a wanderguard bracelet, which resulted in the resident being able to elope from the facility for 1 of 3 residents reviewed for accidents. He had a wanderguard bracelet intact to his ankle and he exited the facility, without any staff members' knowledge he was missing from the facility until the (Name of City) Fire Department called to inform the facility they had the resident and was returning him to the facility. (Resident B) The Immediate Jeopardy began on (MONTH) 15, 2019, when the facility failed to ensure Resident B with a [DIAGNOSES REDACTED]. The facility staff was unaware the resident was missing until Receptionist 1 received a phone call from the (Name of City) Fire Department informing her one of their residents was found at the intersection of (Name of Street) and a busy two lane highway (Name of Highway). The Fire Chief indicated the call was dispatched as a person had a fall and was at the intersection of a street and a busy two lane highway, which was one street East from the facility approximately 0.2 miles (1056 feet). The direction the resident ambulated after exiting the facility door was unclear. He was found by a concerned citizen who observed him fall in a field and he placed him in his car and parked at the intersection until the ambulance could arrive to pick up the resident. The resident was dressed in a pair of sweatpants, a sweatshirt and a pair of shoes. He did not have a [NAME]et on. The temperature for 11/15/19 at 12:00 p.m., according to accuweather was 40 F. The Executive Director (ED) and Director of Nursing (DON) were notified of the Immediate Jeopardy on 12/4/19 at 5:16 p.m. The Immediate Jeopardy was removed on 12/5/19, but noncompliance remained at the lower scope and severity level of no actual harm with the potential for more than minimal harm that was not immediate jeopardy. Finding includes: During an interview, on 12/3/19 at 12:40 p.m., the ED (Executive Director) and the DON (Director of Nursing) were in attendance. The DON indicated she was not at the facility when the resident eloped, so she was told about the incident. The ED indicated they received a phone call from the fire department indicating the fire department had received a call from someone saying they found Resident B walking in the field next to the facility. The fire department brought him back to the facility. He had his wanderguard on when he arrived back to the facility. During their investigation, they discovered a visitor let the resident out of the facility. The ED indicated they had increased the footage of the covered area for the door alarm in part due to Resident B knew the required amount of feet it took to keep the door from opening with his wanderguard on, he would stand back and then he would dart for the door to try to run out the door to leave the facility. The ED demonstrated the way the resident darted out the door by putting his head down and forward and thrusted his body forward. He indicated Resident B would ran full force towards the sliding door, in an effort to clear the door, before it closed if he observed someone exiting the door. The resident stood at the South nurses station frequently watching for someone to open the sliding doors to leave. The ED indicated the staff usually got him before he got out of the sliding doors or the outside door, but this particular day on 11/15/19, he did not know what happened. The only thing he could explain was he must have waited until the visitor opened the door then darted out the door behind him, then out the next door, which was also coded. The alarm system the facility had installed presently told them what wanderguard bracelet was setting off the alarm by showing the number on the keypad, but they did not know this information at the time of the resident's elopement. The ED and Maintenance Director found out the meaning of the codes on the alarm screen after Resident B eloped. At that time, the ED went to the sliding South entrance door to demonstrate the wanderguard alarm keypad and to show how it logged the residents with wanderguard bracelets which were sitting around the door. There were residents presently sitting around the door and their wanderguard bracelet numbers were on the keypad. He indicated when the resident went out the sliding glass door, the wanderguard alarm must have sounded, since he had his wanderguard bracelet on when he returned and as far as he knew they had not had any problems with their system not functioning properly. A staff member probably came down to shut the alarm off, but because he was already out both doors with the visitor, the staff member did not see him in between the sliding glass door and the door leading outside the facility. There were residents sitting around the entrance door or walking past the entrance door as there usually were, so the staff member did not think anything about the alarm sounding and reset the alarm, not thinking a resident went out the doors. When asked if the staff member went outside to check for the resident, the ED indicated he did not ask that question, but he did not know why they would have because it was not part of the facility's elopement policy and there would have been no reason for them to because when they got to the alarm keypad to reset it, there were probably residents sitting here by the door like there were today, so the person thought those residents set the alarm off. The staff were more aware now the resident stood by the sliding door and watched for it to open, so they were monitoring the door and the resident closely to observe for him exiting the facility. During an interview, on 12/3/19 at 4:46 p.m., the Maintenance Director and the DON was in attendance. The DON was not standing at the sliding glass door during the Maintenance Director interview, she was standing approximately 12 feet away from the door. During the observation and interview, the DON was moving residents away from the sliding glass door and the TV lounge next to the door because the door would not open due to residents with wanderguard bracelets sitting by the door. The Maintenance Director demonstrated how the wanderguard system on the South end sliding glass door alarmed when Resident B walked through it to test the function of his wanderguard bracelet and to show how he may have exited the facility through the doors with his functioning wanderguard bracelet intact. An unidentified activity assistant was observed ambulating Resident B down to the nurses station from the main dining room to at least 10 feet away from the sliding glass door while the Maintenance Director placed the code into the keypad to unlock the door. The Activities Assistant, while holding Resident B's hand, assisted him through the sliding glass door and the wanderguard alarm was observed to alarm. The DON indicated typically Resident B would run for the sliding glass door when it opened, but the Activities Assistant had ahold of his hand, so he was walking slowly through the door. The Maintenance Director indicated the door lock down mechanism range was changed from five feet to ten feet to increase the security of the residents not being able to exit with visitors. He did not know how the resident exited the facility. He was told a visitor let him out. As far as he knew, the wanderguard alarm system should have been working that day. He checked the system every Monday and Friday and had not had a problem with it working. He checked the doors using a resident who could ambulate through the doors to check the wanderguard alarm system and he frequently used Resident B when he checked the sliding glass door to ensure his wanderguard bracelet was also functioning. During an interview, on 12/4/19 at 1:02 p.m., the Captain of the (Name of City) Fire Department indicated the ambulance was called out to assist a person at the intersection of (Name of Street) and (Name of Street) (Also known as name of busy two lane highway). He indicated when they arrived on scene there was a car parked on the previously named streets and Resident B was getting out of a car. An unknown passerby had picked up Resident B and waited for the ambulance to come get him. The Captain indicated the resident was unable to answer questions appropriately to find out where he lived, but when the ambulance crew observed his wanderguard bracelet on his ankle, they knew he was a resident at the facility. He only remembered him wearing the tan colored pants because his bilateral knees were wet, so he knew he had fallen down somewhere, but he was not sure exactly. By the time he was taking his vital signs, two representatives (he was not sure of the male and female staff members' names) from the facility had came to the location on those two streets to pick the resident up to take him back to the facility, but since he was already in the ambulance, they returned him to the facility. During an interview, on 12/4/19 at 1:20 p.m., the DON, the ED and the Nursing Consultant were in attendance. The DON indicated she was not at the facility when Resident B eloped. She was upset because she was not aware two staff members went to the scene of where the resident was picked up by the ambulance and she was not informed by these staff members prior to this interview. The ED told the DON who the staff members were and she indicated Receptionist 1 did not document in her interview she went somewhere to pick him up. At that time, the ED indicated he did not call and speak to anyone at the fire department following the elopement as part of his investigation. During an interview, on 12/4/19 at 1:30 p.m., Receptionist 1, the DON, the ED and the Nursing Consultant were in attendance. Receptionist 1 indicated the (Name of City) Fire Department called on 11/15/19 at 11:47 a.m., telling her there was a man (Name of resident) at (Name of Street) and (Name of Street) who was found in a field and the ambulance crew had him on the ambulance. She and the ADON (Assistant Director of Nursing) went to the location where the fire department said the ambulance had him to pick him up, which was on the next street over on (Name of street) and (Name of Street), but it was not at the intersection of those two streets. The DON indicated she knew the fire department called right at 11:47 a.m., on 11/15/19, because she took the time and date right off the caller identification screen on the facility phone. The ED and the DON indicated neither of them talked to the fire department after the elopement to interview the ambulance crew to investigate where the resident was during the time he was missing from the facility. During an interview, on 12/4/19 at 1:50 p.m., the (Name of City) Fire Chief indicated the ambulance was dispatched to the intersection of (Name of Street) and (Name of Street) for a man who fell in a field and the unknown caller had the resident at the listed intersection. They were not able to determine which field the unknown caller seen Resident B fall in because there were three fields by the facility. He indicated he had a basic report the ambulance crew filled out when they went out on a public assistance call and he would provide the report in an email. During an interview, on 12/4/19 at 5:00 p.m., the ED indicated he had not asked the facility staff who were working on 11/15/19, if the wanderguard alarm was sounding on the date and time the resident exited the facility. He was more worried about if a visitor was in the building, to determine how the resident got out of the building to keep his other residents safe, than to determine if the wanderguard alarm was sounding that day. The facility elopement policy did not have in it for the staff to go outside to look and see if a resident was outside after the wanderguard alarm went off because their wanderguard alarm system will tell the staff, which wanderguard bracelet left the building. During an interview, on 12/5/19 at 1:20 p.m., the Maintenance Director and DON was in attendance. The Maintenance Director indicated there were only two ways the resident could have exited the facility on 11/15/19, one way was the door had to have been opened already and the resident went through the door, the wanderguard alarm sounded as he went through the door and someone reset the alarm assuming a resident was close to the door or the only other way was a staff member would have had to put in an override code to allow a resident with a wanderguard bracelet to exit the facility without the alarm sounding. He called the manufacturer of the alarm company to verify if the alarm had sounded on 11/15/19, when the resident exited the facility. There was no way to know which one happened, but he did know the alarm system was working on 11/15/19, the day the resident exited the building. If the wanderguard system was not functioning when he exited the facility the Maintenance Director would have known it was malfunctioning because there were different checks and balances to let him know when the system was offline and non-functional. The record review for Resident B was completed on 12/4/19 at 11:00 a.m. [DIAGNOSES REDACTED]. A care plan, dated 10/9/19 and revised on 10/14/19, addressed the problem the resident was an elopement risk due to he had an impaired safety awareness. The interventions included, but were not limited to, 10/9/19--assess for unmet needs when wandering/exit seeking, such as needing to toilet, pain, hunger thirst, intervene as indicated . A psychiatry progress note, dated 10/18/19, indicated as of the conclusion of the (MONTH) 2019 neuropsychological evaluation, Resident B was a safety risk and would benefit from having someone assist in handling his affairs. In (MONTH) 2019, APS (Adult Protective Services) removed him from his home due to increased paranoia and confusion and he was placed in a facility memory care unit for his safety. His level of function indicated he was independent with transfers and mobility and he had severe deficits with cognition and he required assistance with IADL's (Independent Activities of Daily Living). His BIMS (Brief Interview Mental Status) at his previous facility was 0 (cognitively impaired). A psychiatry progress note, dated 10/21/19, indicated the staff reported Resident B attempted to elope from the facility by climbing the fence on 10/18/19. During the session he was assessed to be confused, have a slow thought process and mumbled and soft speech. He was oriented to himself, but he had difficulty recalling his last name. A psychiatry progress note, dated 11/6/19, indicated Resident B presented with exit seeking symptoms. The summary of session indicated he told the clinician he was looking for a way to go outside and that they lock all the doors so he can't go out. A psychiatry progress note, dated 11/8/19, indicated the chief complaint or reason for the visit was the Pt (patient) was seen wandering again today . The subjective information indicated on 11/8/19, the Social Service Director and the staff reported the resident continued to wander trying to find a way out of the facility. A presenting symptom included, but was not limited to, exit seeking. He was screened for safety concerns including dangers to him and others as well as environmental risks and the safety screen was positive. A progress note, dated 11/15/19 at 2:40 p.m., indicated Building received a phone call from the (Name of City) Fire Department informing us that they might have a resident of ours. They received a phone call from someone stating they had observed a white male walking in the field next to the (Name of Facility) building. When Fire Department arrived to scene they noticed a wanderguard on this person's ankle. At this time the Fire Department drove him back to the facility. ADON verified identity to Fire Department then assisted resident back into the building. At this time ADON had nursing staff assess resident for any injuries. No injuries were noted. Resident has a long history of exit seeking. Immediate interventions: Nursing assessed resident for injuries, no injuries noted. Maintenance director tested locking mechanism, alarms, and wanderguard functionality on every exit door in the building. IDT team check placement of every wanderguard currently being used. A untitled document, provided by email from the (Name of City) Fire Department Chief and dated 11/15/19, indicated an incident type occurred, which was a Public service assistance and the Ambulance was dispatched on 11/15/19 at 11:38 a.m. The ambulance arrived at the location they were dispatched to at 11:42 a.m., which was the intersection of (Name of Street) and (Name of Avenue) (Also known as a busy two lane highway). The action taken was they provided first aide and checked the person. The report indicated the location was at a divided highway location (marked on the report). The ambulance was completely finished with the resident, delivered him back to the facility and went back into service on 11/15/19 at 11:59 a.m. The report indicated Dispatched to above on a fall. Upon arrival found male sitting in a passerby's care. Patient was confused and did not know where he was and stated he lived in Evansville. Upon further examination patient had bracelet on right leg. It appeared to be a tracing device. Called (Name of Facility) care to see if patient was a resident. Spoke with employee (Name of Employee) and she sated (sic) he was a patient and they would be down to pick him up immediately. They arrive and patient was checked by M361 crew. ECF (Extended Care Facility) STAFF STATED THAT WAS HIS NORMAL STATE OF CONFUSION. M361 transported patient back to facility and assisted with getting patient inside. ECF staff stated they had no clue how he got out and would be conducting test immediately . An Elopement policy and procedure was requested for the policy the staff would follow when the wanderguard alarm sounded, but as of the exit conference there was not policy and procedure provided to indicate the procedure the staff was to do when the wanderguard alarm sounded. The staff was able to verbally indicate they were educated to go outside and check to see if a resident exited the building. The Administration staff did not provide a policy and procedure prior to exit out of the facility on the elopement procedure other than if the resident was already missing. The immediate jeopardy that began on 11/15/19, was removed on 12/5/19, when the facility reassessed all residents to determine who was at risk for elopement and the care plans were updated as needed, the doors and wanderguard system was checked for proper functioning the day of the elopement and ongoing, the door codes were being changed every 30 days as part of the preventative maintenance program, the elopement risk binders were audited and updated, an audit of placement and function of all residents with wanderguards was completed and the staff were being educated on the elopement policy and procedure, which included responding to door alarms before their next scheduled shift, which was ongoing as of the exit date of 12/6/19. This Federal tag related to Complaint IN 266. 3.1-45(a)(2)

Based on observation, interview and record review, the facility failed to implement pressure ulcer interventions for 1 of 1 residents reviewed for pressure ulcers (Resident #32). This deficient practice resulted in Resident #32 developing a Stage III pressure ulcer to his left gluteal fold (prominent fold that marks the upper limit of the thigh from the lower limit of the buttock). Findings include: The record of Resident #32 was reviewed on 09/22/15 at 09:30 a.m. [DIAGNOSES REDACTED]. A 30-day scheduled Minimum Data Set (MDS) assessment, dated 8/25/15, indicated Resident #32 was at risk for pressure ulcers. It also indicated Resident #32 needed extensive assistance with bed mobility and transfers and was always incontinent of bowel and bladder. The assessment did not indicate Resident #32 was on turning/repositioning program. The physician's recapitulation orders for Resident #32, dated August 2015, included, but were not limited to, the following orders: 5/21/15 - [MEDICATION NAME] moist barrier cream, apply topically to coccyx every shift after incontinence episodes 8/12/14 - ROHO cushion (helps with skin/soft tissue protection and support) in recliner at all times related to history of stage IV wound on right inner buttock The September 2015 recapitulation did not include orders for the ROHO cushion or barrier cream. A Braden scale assessment (a document for predicting pressure ulcer risk), dated 7/28/15, indicated the resident scored 14. This score indicated the resident was at moderate risk for developing a pressure ulcer. A Braden scale assessment, dated 8/25/15, indicated the resident scored 16. This score indicated the resident was at risk for developing a pressure ulcer. A non-pressure skin condition record, dated 09/10/15, indicated Resident #32 had excoriation (skin that is scraped or abraded) to his left gluteal fold, measuring 6.0 x 4.1 cm (centimeters). No drainage was present and the wound edges were red with a macerated (softening and breaking down of skin resulting from prolonged exposure to moisture) periwound (area around the wound) area. A pressure ulcer record for Resident #32 indicated the following: 09/17/15 - A stage 3 pressure wound (full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present, but does not obscure the depth of tissue loss. May include undermining and tunneling.) to the left gluteal fold, measuring 3.0 x 1.2 x 0.3 cm. The wound bed was red with granulation tissue (new connective tissue and tiny blood vessels that form on the surfaces of a wound during the healing process). Wound edges were red with red periwound area. There was moderate pink/red serosanguineous (fluid with small amounts of blood) drainage. 09/23/15 - The wound was documented as a .questionable . healing stage 3, measuring 1.9 x 0.9 x less than 0.2 cm. The wound bed was dull yellow with slough (a layer of dead tissue separated from living tissue) with rolled edges and small serous (watery, transparent fluid) drainage. The periwound area was irregular. An undated care plan indicated Resident #32 had an ADL (Activities of Daily Living) self care deficit related to limited mobility, requiring the resident to be totally dependent on staff for bed mobility each shift. A pressure ulcer care plan, dated 4/29/15, indicated, .Potential for skin breakdown r/t (related to) tensile skin not as strong as original A pressure ulcer care plan, dated 9/17/15, indicated Resident #32 had a stage 3 pressure ulcer on his left gluteal fold. Approaches included .follow product list for appropriate treatment option as ordered .specialty bed .obtain labs .document weekly An Interdisciplinary Progress Note, dated 09/23/15, indicated, .Res (resident) remains on LAL (low air loss) mattress, is turned and repositioned, continues to receive barrier cream q (every) shift and PRN (as needed), roho cushion in wc (wheel chair) .on 9-10-15 res has excoriation identified on L (left) glut (gluteal) fold that measured 6.0 x 4.1 (cm) and presented as redness. Was tx (treated) c (with) routine barrier cream. On 9-17-15 excoriation resolved + (and) ulcer appeared 3.0 x 1.2 x 0.3 cm this site has appearance of st III (stage 3) pressure ulcer. It is not over a bony prominence but is on a dependent area .As of 9-23-15 site now measures 1.9 cm x 0.9 cm x 0.2 cm .site is dull yellow c (with) irregular edges . During a wound measurement observation on 09/23/15 at 9:05 a.m., with the Regional Director of Clinical Services (Regional DCS) and LPN #7, Resident #32 was observed to have a wound measuring 1.9 x 0.9 x 0.2 cm. The wound base was 100% yellow with clear drainage. The Regional DCS indicated she was unsure if the wound was pressure. During an interview on 9/22/15 at 10:40 a.m., Licensed Practical Nurse (LPN) #7 indicated the wound on Resident #32's left gluteal fold appeared to be red/macerated on 9/10/15. She indicated the wound was intact, and then opened up on 9/17/15 and was classified as a stage III pressure wound. She indicated barrier cream to the reddened area had been used. During an interview on 09/13/15 at 4:50 p.m., the Director of Clinical Services (DCS) indicated the physician's orders [REDACTED]. She indicated there was no documentation to show that these interventions had been implemented for the month of September. There was also no documentation for other interventions, such as turning and repositioning. A document, titled Guidelines for Unavoidable Wounds, dated 9/23/15, provided by the DCS at 4:50 p.m., indicated the resident had an unavoidable pressure wound. A current policy, titled Unavoidable Pressure Ulcer, dated 11/30/14, provided by the DCS on 9/23/15 at 6:15 p.m., indicated, .A determination that development of a pressure ulcer was unavoidable may be made only if routine preventative and daily care was provided consistently. Routine preventative care includes but is not limited to turning and proper positioning .providing good skin care 3.1-40(a)(2)

A. Based on record review, and interview the facility failed to ensure residents with dementia who had a history of [REDACTED]. (Resident # 66, # 57 and # 33). Resident # 66 intrusively wandered into Resident 8's room, hit and grabbed her and into Resident # 82's room and threw a pillow at him. Resident # 8, #19, # 5 and # 88 indicated they were afraid of the residents that wandered into their rooms. An Immediate Jeopardy was identified on 9/25/14 at 4:50 p.m. The Immediate Jeopardy began on 7/22/14 when Resident # 66 wandered into Resident # 8's room, hit and grabbed her. During interviews with Resident #8, #19, #5 and #88, they indicated they were fearful of the residents who wandered into their rooms. The Administrator, Regional Director of Clinical Operations and the Director of Clinical Services (DCS) were notified of the Immediate Jeopardy on 9/25/14 at 5:20 p.m. The immediate jeopardy was removed on 9/26/14, but noncompliance remained at the lower scope and severity level of no actual harm with the potential for more than minimal harm that is not immediate jeopardy. B. Based on record review, observation and interview the facility failed to ensure fall interventions and investigations for root cause were completed and implemented to prevent further fall for 2 of 3 residents reviewed for accidents in a sample of 3. Resident # 66 sustained a head injury and 5 staples to his head after he had a fall when he was not being supervised by staff as his plan of care indicated. (Resident #66 and # 47) Findings include: A1. Resident # 66's record was reviewed on 9/24/14 at 11:09 A.M. [DIAGNOSES REDACTED]. The resident was readmitted to the facility after an admission at a Geriatric Psychiatric hospitalization in March 2014. A document titled "Psychiatric Evaluation", dated 2/11/14, indicated "...He has been wandering into other peers' rooms, he has been very focused on exploring the area at (name of facility) but, he is difficult to redirect and has created some increased anxiety amongst female peers because of his wanderings...The wandering is not going to respond to medication so providing a safe environment for him to wander would be likely an important piece of the environmental control. Unfortunately, when he wanders into peers' rooms that leads to increased peer-peer interaction and conflict." A document titled "Psychiatry Progress Note and Treatment Summary", dated 7/24/14, indicated "Asked to see emergently, with more anger, aggression and quite agitated...Quick to anger...Poor Judgement...Progressive decline with intense anger/aggression now...Medications: 1. Arrow Up (Increased) Depakote Sprinkles to 250 mg Q (every) A.M. & 375 mg Q 1700 (5 P.M.) 2. Resume Risperdal 0.25 mg Q 1700 (5 P.M.) (delusions/aggression) 3. Cont (continue) Klonopin 0.25 mg Q 1700 (5 P.M.) 4. Now Zoloft 75 mg Q A.M. (Recent Increase). He remains impulsive & lacks safety awareness. May be better on a secured dementia unit." The resident had a Care Plan, dated 8/12/13, that addressed the problem of resident sensitive to care, resistive to care, poor safety awareness and impulse control, cursed at staff, hit and kicked staff, wandered, refused care and attempted to take other residents food. Approaches included, but were not limited to, "8/10/13--Resident without touching, call the resident by name, tell him to stop, be kind but firm...Ensure safety, re-approach, Change caregiver...1/14/14--Redirect with act when wandering...." The resident had a Care Plan, dated 9/12/13, that addressed the problem Resistive to care due to decreased comprehension and progressive dementia and 8/5/14 required antipsychotic and antidepressant medications. Approaches included, but were not limited to, "1/10/12--...Monitor for behaviors...." The resident had a Care Plan, undated, that addressed the problem physical behavior toward other residents. Approaches included, but were not limited to, "7/31/14--1. Redirect resident away from peers rooms...8/15/14--3. Walk with the resident 5. At first sign of frustration separate from source of agitation and take to an area where he can gain a sense of calm." "Behavior Detail Report" indicated the resident wandered into other resident rooms and the behavior was not easily altered, on the following dates: "3/27/14 at 9:15 p.m., 4/26/14 at 8:46 a.m., 7/04/14 at 10:29 p.m., 7/16/14 at 3:45 p.m., 7/16/14 at 6:40 p.m., 7/18/14 at 10:22 p.m., 7/23/14 at 2:52 a.m., 7/27/14 at 9:58 p.m., 7/29/14 at 1:43 p.m., 08/06/14 at 8:52 p.m., and 9/11/14 at 3:49 p.m." The Interdisciplinary Progress Notes had indicated the resident had intrusively wandered into other resident's rooms. On 7/22/14, the resident was wandering all evening into multiple residents' rooms and became somewhat hostile at times. On 7/23/14, the resident was found face down on the floor in another resident's room. He cussed the staff during the assessment. On 8/6/14, the resident continued to wander into other residents' rooms and took their food and drinks. He became combative when the staff attempted to redirect him. On 8/7/14, the nurse sent a fax to the Physician in regards to the resident wandering into other residents' rooms and taking their things. He became combative and hit staff when they attempted to redirect him. On 9/13/14, the resident wandered up and down the hallways and in and out of the residents' rooms. On 9/15/14, the resident wandered up and down the hallways and into other residents' rooms The resident had resident to resident altercations with these residents: On 7/22/14 at 6 A.M., Resident #8 reported that Resident #66 hit and grabbed her left upper arm as he tried to enter her room. On 7/24/14 AT 5:30 P.M., Resident #66 walked into Resident #82's room where he and a family member were visiting with his dog. Resident #66 started to pet Resident #82's dog, then became agitated and cursed at the dog. Resident #66 picked up a pillow and threw it at Resident #82. On 8/19/14 at 7:20 A.M., Resident #66 was ambulating in the North hallway common area when he grabbed Resident #68's arm. Resident #68 raised his fist to Resident #66 and Resident #68 did the same back to him. During an interview on 09/25/2014 at 2:44 P.M., Resident #19 indicated during the night an old man walked into her room with her door closed unannounced and she yelled at him to get out or she would hit him with her walker. She indicated he scared her. She indicated she had her walker by her bedside and if he did not leave when she told him to, she would hit him with her walker because she did not want men in her room. She indicated she had not told any staff that she was afraid of the man coming into her room because no one (staff) was your friend They did not help anyone here when you need help, so that was why she did not tell them. She indicated, "I will use my walker and fight him off." During an interview on 09/25/2014 at 2:53 P.M., Resident #88 indicated that a male roamed into her room one day this week with a blank stare on his face. She indicated she was not afraid because she had 6 other people in her room visiting her, but if she was alone she might be afraid of him if he roamed into her room. During an interview on 09/25/2014 2:54 P.M., Resident #60 indicated she had a male resident who was not really all there who has wandered into her room a couple of times in the past. She indicated she was afraid of him until the staff told her he would not hurt her. She indicated he came to the foot of her bed in the evenings and talked to her, but he really was not talking because he can not talk. During an interview on 09/25/2014 at 3:11 P.M., Resident #27 indicated no one had come into his room to his knowledge without his permission and they better not if they know what was good for them. During an interview on 09/25/2014 at 3:12 P.M., Resident #60 indicated Resident #66 came into his room and stood and looked around. He indicated he did not scare him. During an interview on 09/25/2014 3:34 P.M., NA (Nursing Assistant) #1 indicated other residents did not like it when residents wandered into their rooms. She indicated Resident #33 and Resident #66 were the residents who intrusively wandered into other residents' rooms. During an interview on 09/25/2014 at 3:37 P.M., CNA #2 indicated some of the residents were annoyed and impatient when the residents wandered into their rooms and want them out of their room. He indicated the residents that wandered were Resident #66 and Resident #57. During an interview on 09/25/2014 at 3:39 P.M., LPN #3 indicated other residents objected when Resident #66 was ambulating by himself. He would wander into the resident rooms. During an interview with the Regional Director of Clinical Services (RDCS) on 09/25/2014 at 2:37 P.M., additional information was requested regarding Resident # 66's intrusive wandering. During interview on 09/25/2014 at 3:31 P.M., the RDCS indicated she had not gathered any information related to Resident # 66's intrusive wandering. During interview on 09/25/2014 3:59 P.M., the Director of Clinical Services (DCS) provided Resident Council meeting minutes for July 2014. The minutes indicated residents felt safe in the facility. He indicated these were the only resident interviews related to Resident #66's intrusive wandering and resident to resident altercations that could be located. During an interview on 09/25/2014 at 4:39 P.M., the RDCS indicated the staff informed her they had spoken to the resident's daughter. She said he had been on a dementia unit before. She had no additional information to provide regarding the Psychiatric recommendation for a dementia unit or additional assessments or interventions for this resident. During an interview on 9/25/14 at 4:50 P.M., the Social Service Director indicated she was the staff member responsible for contacting a family member and discussing transferring their loved one to a facility with a secured dementia unit. She indicated she had not contacted the resident's family member who was responsible for him until today, regarding placing him on a secured dementia unit. She indicated the family member indicated she would talk to the rest of the family and let her know, but she was not surprised and had been expecting this. The Social Service Director indicated she had not documented any follow-up on this resident since 7/26/14. She indicated she thought she had followed up on his psychosocial needs after the resident to resident altercation on 7/22/14 and 7/24/14 , but after she reviewed the Interdisciplinary Progress Notes she indicated she had not followed up with the resident. A2. The record for resident # 57 was reviewed on 9/26/14 at 8:21 a.m. Current [DIAGNOSES REDACTED]. A plan of care, dated 5/12/14 and updated 8/12/14, indicated the resident wandered into others rooms, with approaches that included, but were not limited to, "redirect inappropriate behavior as needed." The goal indicated the resident would wander safely and be direct away from others rooms daily. A psychiatric progress note dated 6/20/14, indicated the resident wandered about and was "quick to anger! He will grab staff's arms/wrists & (and) twist violently...." A psychiatric note, dated 7/24/14, indicated the resident had no safety awareness and poor impulse control. A social service note, dated 7/9/14, indicated the resident was up frequently during the night and easily annoyed. A 7/16/14 social service note, indicated the resident wandered frequently throughout the night. The Interdisciplinary Progress Notes indicated the resident had intrusively wandered into other resident's rooms on the following dates: "6/19/14 at 10 p.m., continued to wander and entered several other resident rooms. The other residents used call lights to alert the staff the resident was in their room. Urinated in one of the other resident rooms. 6/20/14 at 6 a.m., continued to wander into others rooms. 6/21/14 at 5 a.m., continued to wander into others rooms. 6/22/14 resident wandered up and down the halls. 6/24/14 at 10 p.m., wandered into resident rooms many times throughout the evening requiring 1:1 supervision. 6/27/14 and 6/28/14 continued to wander into others rooms. 7/1/14 at 3 a.m., wandered into other resident rooms. 7/4/14 at 6 a.m., wandered into other resident rooms. 7/5/14 at 11:14 p.m., "...has continued to be active, mobile and going in other residents' rooms...." 7/15/14 at 2:35 p.m., has exhibited aggressive behavior toward staff, hitting CNA in the stomach and twisting the thumb of a nurse. Has been wandering into other resident rooms needing frequent redirection. 7/23/14 at 9 p.m., resident was up wandering all shift continues on 15 minute checks, easily redirected, but continues to wander in and out of other resident rooms. 7/24/14 at 9 p.m., continued to wander facility, enters other resident rooms, staff redirected multiple times when resident was found in other resident rooms. Continued on 15 min checks. 7/28/14 at 4 a.m., continued to wander into other resident rooms, on 15 minute checks. 8/3/14 started on an antibiotic and on 8/11/14 he was in a wheelchair. 8/20/14 at 9 p.m., wandered up and down the halls and in and out of other resident rooms...." During an interview on 09/25/2014 at 3:16 P.M., Resident # 8 indicated Resident #57 came into her room at night and once he tried to crawl into bed with her and had hit her on the leg. She indicated there was another resident that lived at the other end of the hallway that came into her room at night and he slapped at her leg also. She indicated was frightened when these men came into her room. She indicated she had told the nurses when they came to get Resident #57 and the other man out of her room that she was afraid of them. She indicated the staff informed her they could not help that these residents wandered, but they would try to keep them out of her room. During an interview on 09/25/2014 at 3:37 P.M., CNA #2 indicated some of the residents were annoyed and impatient when the residents wandered into their rooms and want them out of their room. He indicated Resident # 57 wandered. A3. The record for resident # 33 was reviewed on 9/26/14 at 9:27 a.m. Current [DIAGNOSES REDACTED]. A plan of care, dated 9/22/14, indicated the resident was combative with care, hitting, grabbing and yelling. The plan also indicated he wandered about the facility and his behavior would escalate with redirection. Approaches included, but were not limited to, "redirect the resident by talking to him about his wife." A 9/22/14 social service note indicated the resident wandered in the facility. Nursing notes indicated, on 7/5/14, wandered down the halls. A "Behavior Detail Report" indicated the resident wandered into other resident rooms on 4/4/14 and was not easily altered. The report also indicated the resident was verbally and physically abusive to staff, by hitting, punching, kicking, shoving, screaming, cursing, and scratching. The report indicated the resident wandered in the hallways and common areas. During an interview on 09/25/2014 at 3:34 P.M., NA #1 indicated Resident #33 intrusively wandered into other residents' rooms. During an interview on 09/25/2014 at 3:39 P.M., LPN #3 indicated other residents objected when Resident #33 intrusively wandered into their rooms. A4. On 9/30/14 at 10:20 a.m., CNA #9 indicated they were very short staffed. She indicated she had worked here for 5 years and this is the worse it has been. She indicated Resident # 57 was one on one while the survey was on-going and the survey was completed. She indicated there are just not enough staff to keep an eye on Residents # 66, # 57 and # 33. She indicated the staff that are present do not help answer lights or keep an eye on residents as much as they should. On 9/30/14 at 11:00 a.m., CNA #12 indicated Resident # 66 and # 57 wandered a lot. CNA #12 indicated it was very difficult in the evening. She indicated the CNA's tried to do activities, but the residents would get up and walk away. CNA# 12 indicated there was just not enough help to watch the residents. A5. A policy titled "Behavior Monitoring" was provided by the RDCO on 9/26/14 at 9:30 a.m., and deemed as current. The policy indicated: "Policy Residents demonstrating behaviors that place a resident at risk, or interfere with care and other residents will be monitored and interventions initiated as an individualized approach to minimizing behavior...11. Interdisciplinary team will review behaviors, causative factors/triggers and or root cause to determine individualized interventions to minimize or eliminate targeted behaviors. 12. Resident's plans of care will be updated as needed." B. 1. On 9/23/14 at 9:35 A.M., Resident #66 was observed laying in bed and his bed alarm box did not indicate it was functioning. The light to indicate "in use" was not flashing green. On 9/23/14 at 10:57 A.M., the resident was observed laying in bed and his bed alarm box did not indicate it was functioning. The light to indicate "in use" was not flashing green. On 9/23/14 at 11:47 A.M., CNA #9 and CNA #12 were observed transferring the resident from the bed to a standing position. When the two CNA's transferred the resident to a standing position at the side of the bed, there was no alarming sound observed from the alarm box to indicate the bed alarm was functioning and the green light that indicated "in use" was not flashing. Neither CNA were observed checking the alarm box and pad when the box did not alarm. CNA #12 ambulated the resident to the North end dining room to eat lunch. When Resident #66 sat in the dining room chair, there was no chair alarm observed on the chair seat. On 09/23/2014 at 3:19 P.M., the resident was observed laying in bed and his bed alarm box did not indicate it was functioning. The light to indicate "in use" was not flashing green. On 9/23/14 at 5:00 P.M., the resident was observed laying in bed and his bed alarm box did not indicate it was functioning. The light to indicate "in use" was not flashing green. During an interview on 9/23/14 at 5:10 P.M., the DCS indicated the resident's bed alarm box was not on or was not functioning. During an interview on 9/23/14 at 5:12 P.M., LPN #3 indicated she did not know the resident's alarm was not functioning. She had not checked his bed alarm for proper functioning since she came on shift today because he had not gotten out of bed on this shift yet. She indicated the resident was usually up ambulating around by himself getting into everything. She indicated there was no place on the Medication Administration Record to document that the bed alarm had been checked each shift, so she could not indicate the bed alarm had been checked each shift and was functioning. During an interview on 9/23/14 at 5:20 P.M., the DCS indicated he changed the battery in the bed alarm box and changed the bed alarm pad on the resident's bed and the resident's bed alarm was functioning appropriately now. On 9/23/14 at 5:25 P.M., NA #1 and CNA #14 were ambulating the resident down to the dining room for dinner. They indicated at times it required two CNA's to ambulate the resident depending on how unsteady he was on his feet. When Resident #66 sat in the dining room chair, there was no chair alarm observed on the seat. On 9/24/14 at 11:00 A.M., the resident was observed sitting in the North end lounge in a recliner chair and no chair alarm was observed on the recliner chair. On 9/24/14 at 11:35 A.M., Activities Staff Member #13 left the North end lounge to transport another resident to the Main dining room leaving Resident #66 unattended until 11:37 A.M. when two CNA's came into the dining room to check another resident's wheelchair then they left. At 11:38 A.M., Activities Staff Member #13 came back and transported another resident to the Main dining room and left Resident #66 unattended. At 11:42 A.M., LPN #5 walked into the nurses' station across from the lounge then left the station. At 11:44 A.M., CNA #12 and LPN #5 were observed transferring Resident #66 out of the recliner chair to ambulate him. There was no alarm sounding when the staff transferred the resident out of the recliner chair. There was no pad for a chair alarm in the recliner chair after he was transferred. On 9/24/14 at 1:10 P.M., Resident #66 was sitting at a table unattended in the North end lounge without a chair alarm under him on the chair. On 9/24/14 at 1:16 P.M., the resident stood up unassisted from the chair he was sitting in at the lounge table and there was no chair alarm sounding when he stood up. The Social Service Designee was at the table at this time talking to a family member and sat the resident back down in the chair. Resident #66's record was reviewed on 9/24/14 at 11:09 A.M. [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set assessment ((MDS) dated [DATE], indicated the resident's cognitive skills for daily decision making were severely impaired. The resident's functional status for transfers indicated he was an extensive assist and one person physical assist. He required an extensive assist with one person physical assist for his locomotion. Walking in his room or the hallways he required limited assist and one person physical assist. A Physician order [REDACTED]. Original order date 3/25/14-Bed and chair alarm at all times. Original order date 3/24/14-Bed alarm while in bed. Check function and presence every shift. Original order date 3/24/14-Up with assist with one person. The resident had a Care Plan, dated 9/12/13, that addressed the problem required assistance with transferring and ambulating and history of falls with the last three months. Approaches included, but were not limited to, "9/12/13-...Assist w/ (with) 1, Utilize alarm Type: Bed & chair...7/23/14-15 min (minute) checks x (times) 72 hours...." On 9/25/14 at 9:15 A.M., the "Fall Investigation" reports from all the resident's falls from 6/12/14 to 9/14/14 and the 15 minute checks for the 7/23/14 fall was requested from the Director of Clinical Services (DCS). During an interview on 9/23/14 at 9:49 A.M., the Assistant Director of Clinical Services (ADCS) indicated the resident ambulated and wandered the hallways at night and when he was ready for bed he sat down on the floor. The "Interdisciplinary Progress Notes" and "Fall Worksheet for Incident/Accident/Unusual Occurrence Reporting" document indicated Resident #66 had a history of [REDACTED]. On 6/12/14 at 8 P.M., the resident had an unwitnessed fall and was found on the floor in the North end dining room. He was found on the floor. Prior to the fall, he was observed standing up in the space between the seat of the wheelchair and the elevated foot rests. Two hours prior to the fall, the resident had been easily redirected to sit back down into the wheelchair several times. There was no bruising or redness found upon assessment of the resident. The resident had not had a bowel movement for 3 days prior to the fall. The "Fall Follow-up Assessment" indicated there were no alarms in place as an intervention at the time of the fall. On 7/4/14 at 7:45 P.M., the resident had an unwitnessed fall and was found by a CNA on the floor laying on his left side. He had bleeding from the left side of his head and had lost consciousness for one minute after the fall. Emergency 911 was called due to a possible head injury. The resident had been side stepping and looking at his feet while ambulating earlier in the shift. The "Fall Follow-up Assessment" indicated there were no alarms in place as an intervention at the time of the fall. At 8:15 P.M., when 911 arrived to transfer the resident to the hospital, a left frontal head laceration approximately one inch in length was discovered with a large amount of coagulated blood on his left cheek. The resident had slight bruising at his left cheek and left eye orbit. On 7/5/14 at 12:20 P.M., the resident returned from the hospital with five staples to the left side of his forehead. An "Emergency Department Physician Medical Record", dated 7/4/14, indicated Resident #66's chief complaint for being at the emergency room was a fall. The record indicated the resident had a four centimeter vertical laceration to his left forehead and he received five staples to the laceration. The record indicated the resident had a Head injury with dementia and a facial laceration. During an interview on 9/24/14 at 4:28 P.M., the Medical Records staff member indicated the resident's orders for the September 2014, Medication Administration Record (MAR) were dated for 7/5/14, but were the same orders he originally had when he was admitted back from the hospital on [DATE]. She indicated when he went to the emergency roiagnom on [DATE], he was not back by midnight, so the way their computer system functioned the nurses had to discharge him. When he came back to the facility on [DATE] after midnight the computer automatically dated the residents' orders with the new admitted even if they have not been gone over 24 hours. On 7/15/14 at 12:10 A.M., the resident had a witnessed fall. He was by the nurses station in the hallway and lost his balance and fell backwards landing on his buttocks. No visible injuries. The "Fall Worksheet for Incident/Accident/Unusual Occurrence Reporting" document indicated he did not have any personal or sensor alarms on at the time of the fall. On 7/23/14 at 10:50 A.M., the resident had an unwitnessed fall while wandering throughout the facility and was found in another resident's room on the floor. He had a small bruise with an abrasion noted to the left side of his forehead. The immediate intervention was 15 minute checks for 72 hours. The "Fall Worksheet for Incident/Accident/Unusual Occurrence Reporting" document indicated he did not have any personal or sensor alarms on at the time of the fall. On 8/3/14 at 6:45 P.M., the resident had an unwitnessed fall and was found by another resident sitting on the floor on his buttocks. There were no injuries found upon assessment of the resident. The "Fall Follow-up Assessment" indicated there were no alarms in place as an intervention at the time of the fall. On 8/17/14 at 8 P.M., the resident had an unwitnessed fall. He was found in the Southside lounge laying on his left side. There were no injuries found upon assessment of the resident. The "Fall Followup Assessment" indicated alarms were in place at the time of the fall, but the record did not indicate whether the alarms were ringing at the time of the fall. The "Fall Investigation" indicated the resident was ambulating in the hallway prior to the fall and he tripped over his own feet. It also indicated there was no new intervention implemented after this fall. On 9/14/14 at 9:50 P.M., the resident had an unwitnessed fall in another resident's room. He was found sitting on the floor on his buttocks, then laid onto his back. The resident was ambulating prior to being found on the floor. There were no injuries noted upon assessment of the resident after the fall. The "Fall Follow-up Assessment" indicated there were no alarms in place at the time of the fall. The "Fall Investigation" document indicated there was no new interventions initiated after the resident's fall. During an interview on 9/25/14 at 1:48 P.M., the DCS indicated he could not find the fall report for 6/12/14, 7/4/14, and 8/3/14. He indicated he had called the prior DCS and she had told him where to look for them, but he was unable to locate them. He indicated he did not realize the resident was to have a chair alarm or was to be up with one assist. During an interview on 9/29/14 at 10:15 A.M., the ADCS indicated the resident was in an unoccupied room on 7/4/14 when he fell and sustained the laceration to the left side of his head and the head injury. She indicated the "Fall Investigation" report could not be found for this fall and the immediate intervention was to send him to the emergency room for treatment. She indicated she could not remember the new intervention for this fall. During an interview on 9/30/14 at 9:18 A.M., the DCS indicated the initials in the box for the night and dayshift on 9/23/14, for the order Bed alarm-Check function and placement every shift did not indicate the bed alarm was checked for function and placement for those two shifts. He indicated that order was initiated on the September 2014, MAR on 9/23/14 on the evening shift. DCS indicated he could not locate the 72 hour 15 minute checks that were completed for Resident #66's 7/23/14 fall. B2. Resident #47's record was reviewed on 9/24/2014 at 5:20 P.M. [DIAGNOSES REDACTED]. The resident's document, "Fall Risk Identification and Plan of Care", dated 8/22/13, indicated the resident was not consistently oriented to her own limitations. The back of the document, "Risk Identification Review" indicated the resident fell on [DATE] and 1/22/14 and that interventions were updated. The resident's record indicated the resident had a recent fall on 7/21/14. The "Fall Investigation", dated as having occurred on 7/21/14, indicated the resident fell and sustained a facial hematoma. Under care plan must be updated, it indicated the following, "...Indicate what caused the accident...Res(resident) left unattended in room, res. attempted to wheel self into hallway (sign for with) brakes locked. When res couldn't go she attempted to stand resulting in fall." The resident's record lacked an updated care plan. During an interview on 9/30/14 at 10:35 A.M., the Assistant Director of Clinical Services indicated she thought she had updated the care plan, but was unable to find the update revising the care plan that indicated the resident should not be left unattended. At this time the Director of Clinical Services (DCS) indicated the procedure should be that a fall's root cause should be identified. Interventions should be written and they should go along with the identified root cause of the fall to prevent reoccurrence. As of exit on 9/30/14 at 2:15 P.M., no other information was provided. The immediate jeopardy that began on 9/25/14 was removed on 9/26/14 when the facility had discharged Resident #66 to the hospital and placed Resident # 57 and # 33 on 1:1 supervision. All staff in servicing had been completed for staff prior to beginning their shifts for all departments. A Behavior Management Meeting was held on 9/25/14 and the care plans for Resident # 57 and # 33 were updated. Resident interview had been completed for interviewable residents and total body assessments had been completed for non-interviewable residents. The noncompliance remained a lower scope and severity level of no actual harm with the potential for more than minimal harm that is not immediate jeopardy. 3.1-45(a)(1) 3.1-45(a)(2)

Based on observation, interview and record review, the facility failed to ensure safe transfer and transport of residents, in that when residents were dependent upon staff for transfer/transport, the nursing staff failed to ensure residents did not receive injury for 3 of 3 resident's reviewed for injury in a sample of 7. (Resident's "A", "D" and "E") Findings include: 1. The record for Resident "A" was reviewed on 01-02-14 at 10:30 a.m. [DIAGNOSES REDACTED]. These [DIAGNOSES REDACTED]. Review of the nurses progress notes indicated the following: "12-01-12 at 0045 (12:45 a.m.) Resident was sitting in recliner chair. When CNA (certified nurse aide) went to give incontinent care, she lowered pt. (patient) to the floor d/t (due to) unable to follow directions (resident) placed left forearm to the floor. Obtained injury swelling and bruising noted. Ordered x-ray ordered (sic). M.D. (Medical Doctor) aware and notified. Nurse on call aware and family aware and notified." "12-01-12 11:00 a.m. Results of x-ray left forearm marked as soft tissue swelling notes. Left hip x-ray shows mild osteoarthritis to left hip. MD on call notified of results and awaiting on call back due to a diffeur (sic) from 11-16-12." "12-02-12 at 0430 (4:30 a.m.) Left forearm swelling persist. Left hip swelling and bruising noted." "12-02-12 Left arm edematous, firm and reddened." "12-03-12 at 0100 (1:00 a.m.) Resting in bed. Yells out with T & R (turning and repositioning) et (and) ADL (activities of daily living) care. 3+ edema to left elbow, moves arm without grimaces or yelling out. Left hip discoloration cont. (continues)." "12-03-12 at 1400 (2:00 p.m.) note left arm still edematous, reddened and firm area opened - lg. (large) amount of bleeding. Area cleansed and dressed. Note lg. (large) bruise cont. left hip. swelling cont. but has not moved past previously marked and measured area. Phys. (physician) response to monitor bruising." "12-03-12 at 2100 (9:00 p.m.) Bruise left hip continues, Res. grimaces in pain when staff moves left leg. Area on left arm bleeding times 1 this shift, dressing changed." "12-04-12 at 1000 (10:00 a.m.) (Name of physician) here. Discussed aspirating blood pool from left arm. Phys. thinks it would not benefit. Order noted to re-X-ray left hip d/t cont. pain - refusal to bear weight. Note bruising and swelling cont. left hip and left arm." "12-04-12 at 1900 (7:00 p.m.) Note area left arm bleeding lg. (large) amts. (amounts) c/o (complains of) little disc. (discomfort) with arm but yells and grimaces with movement of left leg." "12-06-12 at 1400 (4:00 p.m.) Note discomfort esp. (especially) when leg moved. Note copious amts. of blood from left arm - swelling decreased." "12-06-12 at 2100 (9:00 p.m.) Dressing left arm CDI (clean, dry and intact) Bruise remains and is bigger left upper leg. Res. not standing as good as (resident) once did." "12-07-12 at 0500 (5:00 a.m.) Res. has hole in left forearm 1/2 " by 1/2 " around and 5 " deep. Large amount of yellow green discharge. left forearm was cleansed, wet to dry packing with NS (normal saline) 0.9 % placed into wound. MD notified that res. needs ATB (antibiotic) and dressing changed to BID (two times a day) wet to dry packing until healed." "12-08-12 at 0730 (7:30 a.m.) Res. left forearm dressing dry. Large amount of discharge with odrt (sic) brown in color. Res. to start ATB as ordered." "12-08-12 at 2100 (11:00 p.m.) Note copious amount of milky red drainage coming from left forearm wound when doing dressing change. Left arm warm to the touch. Tunneling at least four inches back toward elbow. Sent fax (facsimile) to MD asking for wound consult." Continued review of nurses notes indicated: "12-09-12 at 2100 (8:00 p.m.) Bruise on left upper leg remains. Wet to dry dressing change done (in regard to the left forearm) and note moderate amount of milky red drainage. Left hand +1 edema and left arm continues to feel warm to the touch. Res. continues to grimace and say 'ouch' when having to transfer or roll from side to side. Awaiting reply from MD regarding wound consult." "12-12-12 at 1420 (2:20 p.m.) Left forearm cleanse with woud (sic) cleanser, apply silvadene 1 % cr. (cream) cover with non-adhesive drsg., wrap with Kerlix the wrap with coband." The nurses note indicated the area measured 3.3 cm (centimeters) by 1.4 cm by .5 cm." In addition the nursing staff received a subsequent physician order [REDACTED]. The resident's record indicated that on 12-14-12 at 1510 (3:00 p.m.), the resident was found non-responsive while seated in the lounge area of the South Station, and was subsequently transported to a local area hospital for evaluation and treatment. On 01-03-13 at 1:00 p.m., review of the original report sent to the physician's office on 12-08-12 at 2130 (9:30 p.m.) from licensed nurse employee #7 indicated, "Note moderate amount of milky red drainage coming from wound on left forearm. Hole is approx. (approximately) 1 inch by 1/2 in and is easily 1/2 inch deep and tunnels back toward elbow approx. 4 inches. Left arm is very warm to the touch. Res. is in pain and only has PRN (as needed) pain meds at this time. I realize you are already aware of resident's wound but I feel res. could really stand to have a wound ostomy consult ASAP (as soon as possible)." Review of the mobile vendor x-ray service company report on 01-03-13 at 10:00 a.m., indicated a completed the x-ray of the left hip on 12-12-12 and faxed the result to the facility. Further review of the radiology report, received at the facility on 12-14-12 at 10:27 a.m., indicated "No acute abnormality. The findings are unchanged from 12-04-12. Follow up advised given history. If there is high suspicion for fracture, recommend CT (cat scan) or MRI (magnetic resource imaging)." During the Exit conference on 01-03-13 at 2:00 p.m., the facility administrative staff were unable to provide documentation the physician was notified of the radiology recommendation. Review of the hospital emergency room department notes on 12-31-12 at 8:45 a.m., and dated 12-14-12 at 1603 (4:03 p.m.), indicated the following, "10 cm by 10 cm red (illegible word) area to left lateral hip, warmth, bruising to left flack region. After sterile prep (preparation)/drape used #11 blade and made 3 cm incision with blood/clot expressed. No bleeding after collapse. Packed with iodoform and Zosym (an antibiotic) started." Review of the emergency room nurses narrative notes on 12-31-12 at 9:00 a.m., dated 12-14-12 at 2030 (8:30 p.m.), indicated Left FA (forearm) wound measures at or about 2 inches by 4 inches and appears to be Stage 4 (terminology used to describe pressure areas - full thickness loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the ulcer bed. Often includes undermining and tunneling). Left hip wound draining large amounts serosanguinous fluid." Review of the hospital "History and Physical," on 12-31-12 at 9:00 a.m., dated 12-15-12 at 0900 (9:00 a.m.), indicated "Final Dx. (diagnosis): Sepsis." On 01-02-13 at 1:21 p.m., interview with a concerned family member indicated "they told us when (resident) originally hurt (resident) arm. They told us it was a skin tear. When I was at the hospital the nurse started to remove the dressing, and the non stick pad was stuck, as she pulled it off pus oozed out and the smell was terrible, just like you would think an infection would smell like. (Family member) was at the nursing home on 12-05-12 and everything seemed OK they didn't tell us anything any different. The sore on (resident) arm was more than a skin tear - it was all the way to the bone and I would guess it measured 5 inches by 4 inches." 2. The record for Resident "D" was reviewed on 01-02-13 at 12:35 p.m. [DIAGNOSES REDACTED]. These [DIAGNOSES REDACTED]. The resident's Minimum Data Set Assessment, dated 10-25-12, indicated the resident required extensive assistance and two + staff persons, to safely transfer the resident. Review of the facility "Incident/Accident Listing," on 01-02-13 at 9:50 a.m., indicated the resident received a "skin injury" on 12-29-12 at 12:00 p.m. The physician was notified of the "skin injury" to the left lower leg, and the nursing staff received an order to "apply steri-strips to the skin tear on the left lower extremity." The "skin grid," dated 12-29-12, indicated the area measured 1.8 cm (centimeters) by 1.8 cm and had a small amount of serous drainage which was red in color. Review of the facility investigation of the resident's injury indicated the CNA attempted to transfer the resident independently from bed to the wheelchair rather than with the assistance of another staff member when the resident received the skin tear. During an observation on 01-03-13 at 1:10 p.m., the resident was seated in a wheelchair with a family member in attendance. The licensed nurse, employee #1, received approval by the resident to assess the left lower leg. The licensed nurse raised the resident's pant leg. The skin tear/area was without steri-strips, appeared red in color with skin intact. 3.. The record for Resident "E" was reviewed on 01-02-13 at 1:45 p.m. [DIAGNOSES REDACTED]. These [DIAGNOSES REDACTED]. Review of the skilled nursing notes," dated 12-17-12 at 1900 (7:00 p.m.), indicated CNA (certified nurse aide) accidentally hit residents hand into wall while pushing in wheelchair. 3 by 3 1/2 skin tear to left hand. Cleansed applied steri-strips, bacitracin and gauze." Review of the "skin grid" indicated this skin tear occurred on 12-17-12 with a notation in regard to drainage: small moderate, serous with no odor, color pink/red. In addition to this skin tear, the resident also had a skin tear noted on 12-24-12, which measured 2.8 centimeters by 3.0 centimeters and 12-31-12 which measured 2.7 cm by 3.0 cm, with a notation in regard to each area as "drainage: small moderate, serous with no odor, color pink/red." During an observation on 01-03-13 at 11:50 a.m., the resident was seated in a wheelchair. The licensed nurse, employee #1, requested and received approval by the resident to assess the left hand. As the licensed nurse removed the dressing, brown drainage was observed on the dressing. The resident's left hand had an obvious wound, in the process of healing, without redness. This Federal tag relates to Complaint IN 500. 3.1-45(a)(2)

Based on record review and interview, the facility failed to ensure a resident received the necessary care and services to maintain the highest quality of life in regard to an injury received during transfer for 1 of 3 resident's reviewed for injury in a sample of 7. (Resident "A") Findings include: The record for Resident "A" was reviewed on 01-02-14 at 10:30 a.m. [DIAGNOSES REDACTED]. These [DIAGNOSES REDACTED]. Review of the nurses progress notes indicated the following: "12-01-12 at 0045 (12:45 a.m.) Resident was sitting in recliner chair. When CNA (certified nurse aide) went to give incontinent care, she lowered pt. (patient) to the floor d/t (due to) unable to follow directions (resident) placed left forearm to the floor. Obtained injury swelling and bruising noted. Ordered x-ray ordered (sic). M.D. (Medical Doctor) aware and notified. Nurse on call aware and family aware and notified." "12-01-12 11:00 a.m. Results of x-ray left forearm marked as soft tissue swelling notes. Left hip x-ray shows mild [MEDICAL CONDITION] to left hip. MD on call notified of results and awaiting on call back due to a diffeur (sic) from 11-16-12." "12-02-12 at 0430 (4:30 a.m.) Left forearm swelling persist. Left hip swelling and bruising noted." "12-02-12 Left arm [MEDICAL CONDITION], firm and reddened." "12-03-12 at 0100 (1:00 a.m.) Resting in bed. Yells out with T & R (turning and repositioning) et (and) ADL (activities of daily living) care. 3+ [MEDICAL CONDITION] to left elbow, moves arm without grimaces or yelling out. Left hip discoloration cont. (continues)." "12-03-12 at 1400 (2:00 p.m.) note left arm still [MEDICAL CONDITION], reddened and firm area opened - lg. (large) amount of bleeding. Area cleansed and dressed. Note lg. (large) bruise cont. left hip. swelling cont. but has not moved past previously marked and measured area. Phys. (physician) response to monitor bruising." "12-03-12 at 2100 (9:00 p.m.) Bruise left hip continues, Res. grimaces in pain when staff moves left leg. Area on left arm bleeding times 1 (one) this shift, dressing changed." "12-04-12 at 1000 (10:00 a.m.) (Name of physician) here. Discussed aspirating blood pool from left arm. Phys. thinks it would not benefit. Order noted to re-X-ray left hip d/t cont. pain - refusal to bear weight. Note bruising and swelling cont. left hip and left arm." "12-04-12 at 1900 (7:00 p.m.) Note area left arm bleeding lg. (large) amts. (amounts) c/o (complains of) little disc. (discomfort) with arm but yells and grimaces with movement of left leg." "12-06-12 at 1400 (4:00 p.m.) Note discomfort esp. (especially) when leg moved. Note copious amts. of blood from left arm - swelling decreased." "12-06-12 at 2100 (9:00 p.m.) Dressing left arm CDI (clean, dry and intact) Bruise remains and is bigger left upper leg. Res. not standing as good as (resident) once did." "12-07-12 at 0500 (5:00 a.m.) Res. has hole in left forearm 1/2 " by 1/2 " around and 5 " deep. Large amount of yellow green discharge. left forearm was cleansed, wet to dry packing with NS (normal saline) 0.9 % placed into wound. MD notified that res. needs ATB (antibiotic) and dressing changed to BID (two times a day) wet to dry packing until healed." "12-08-12 at 0730 (7:30 a.m.) Res. left forearm dressing dry. Large amount of discharge with odrt (sic) brown in color. Res. to start ATB as ordered." "12-08-12 at 2100 (11:00 p.m.) Note copious amount of milky red drainage coming from left forearm wound when doing dressing change. Left arm warm to the touch. Tunneling at least four inches back toward elbow. Sent fax (facsimile) to MD asking for wound consult." Continued review of nurses notes indicate: "12-09-12 at 2100 (8:00 p.m.) Bruise on left upper leg remains. Wet to dry dressing change done (in regard to the left forearm) and note moderate amount of milky red drainage. Left hand +1 [MEDICAL CONDITION] and left arm continues to feel warm to the touch. Res. continues to grimace and say 'ouch' when having to transfer or roll from side to side. Awaiting reply from MD regarding wound consult." "12-12-12 at 1420 (2:20 p.m.) Left forearm cleanse with woud (sic) cleanser, apply [MEDICATION NAME] 1 % cr. (cream) cover with non-adhesive drsg., wrap with Kerlix the wrap with coband." The nurses note indicated the area measured 3.3 cm (centimeters) by 1.4 cm by .5 cm." In addition the nursing staff received a subsequent physician order [REDACTED]. The resident's record indicated that on 12-14-12 at 1510 (3:00 p.m.) the resident was found non-responsive while seated in the lounge area of the South Station, and was subsequently transported to a local area hospital for evaluation and treatment. On 01-03-13 at 1:00 p.m., review of the original report sent to the physician's office on 12-08-12 at 2130 (9:30 p.m.) from licensed nurse employee #7 indicated, "Note moderate amount of milky red drainage coming from wound on left forearm. Hole is approx. (approximately) 1 inch by 1/2 in and is easily 1/2 inch deep and tunnels back toward elbow approx. 4 inches. Left arm is very warm to the touch. Res. is in pain and only has PRN (as needed) pain meds at this time. I realize you are already aware of resident's wound but I feel res. could really stand to have a wound ostomy consult ASAP (as soon as possible)." Review of the mobile vendor x-ray service company report on 01-03-13 at 10:00 a.m., indicated a completed the x-ray of the left hip on 12-12-12 and faxed the result to the facility. Further review of the radiology report, received at the facility on 12-14-12 at 10:27 a.m., indicated "No acute abnormality. The findings are unchanged from 12-04-12. Follow up advised given history. If there is high suspicion for fracture, recommend CT (cat scan) or MRI (magnetic resource imaging)." Review of the hospital emergency room department notes on 12-31-12 at 8:45 a.m., and dated 12-14-12 at 1603 (4:03 p.m.), indicated the following, "10 cm by 10 cm red (illegible word) area to left lateral hip, warmth, bruising to left flack region. After sterile prep (preparation)/drape used #11 blade and made 3 cm incision with blood/clot expressed. No bleeding after collapse. Packed with [MEDICATION NAME] and Zosym (an antibiotic) started." Review of the emergency room nurses narrative notes on 12-31-12 at 9:00 a.m., dated 12-14-12 at 2030 (8:30 p.m.), indicated Left FA (forearm) wound measures at or about 2 inches by 4 inches and appears to be Stage 4 (terminology used to describe pressure areas - full thickness loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the ulcer bed. Often includes undermining and tunneling). Left hip wound draining large amounts serosanguinous fluid." Review of the hospital "History and Physical," on 12-31-12 at 9:00 a.m., dated 12-15-12 at 0900 (9:00 a.m.), indicated "Final Dx. (diagnosis):[MEDICAL CONDITION]." On 01-02-13 at 1:21 p.m., interview with a concerned family member indicated "they told us when (resident) originally hurt (resident) arm. They told us it was a skin tear. When I was at the hospital the nurse started to remove the dressing, and the non stick pad was stuck, as she pulled it off pus oozed out and the smell was terrible, just like you would think an infection would smell like. (Family member) was at the nursing home on 12-05-12 and everything seemed OK they didn't tell us anything any different. The sore on (resident) arm was more than a skin tear - it was all the way to the bone and I would guess it measured 5 inches by 4 inches." On 01-03-12 at 1:30 p.m., interview with the Assistant Director of Nurses indicated the nurse should not have faxed information to the physicians office about a wound consult, because it was a weekend (Saturday) and the physician's office was closed at that time. The Assistant Director of Nurses also indicated the nurse "refaxed" the information to the physician's office the following day (Sunday). The Assistant Director of Nurse indicated when she interviewed the nurse he stated he knew the wound care clinic was not opened on the weekend anyway. Interview on 01-03-13 at 12:15 p.m., Staff Nurse employee #3 indicated, "The area on (resident) forearm was awful and it was large. The hip was the thing - I couldn't count how many times we x-rayed it. I was the one who actually marked the edges of the bruise and what was funny was that there was swelling/[MEDICAL CONDITION] lower to that (in regard to the bruise)." During the Exit conference on 01-03-13 at 2:00 p.m., the facility administrative staff were unable to provide documentation the physician was notified of the radiology recommendation. This Federal tag relates to Complaint IN 500. 3.1-37(a)