Every finding on record at Maple Park Village

Based on observation, interview and record review, the facility failed to protect the residents' right to be free from physical abuse by a CNA for 2 of 3 residents reviewed for abuse. (Resident D and F) This deficient practice resulted in Resident D thinking a staff member was going to kill him and signs he was scared after the abuse. Resident F had a history of abuse as a child and had two loose teeth in her mouth. The deficient practice was corrected on 2/20/26, prior to the start of the survey, and was therefore past noncompliance.Findings include:1. During an interview, on 3/3/26 at 2:21 p.m., the Executive Director, Director of Nursing and Regional Director of Operations were in attendance and indicated Resident D was blind, had became combative while he was being changed, and CNA 5 put his hands on the resident.The clinical record for Resident D was reviewed on 3/5/26 at 2:29 p.m. The diagnoses included, but were not limited to, dementia with mood disturbance, major depressive disorder, legal blindness, and pain.A care plan, dated 1/15/25, indicated Resident D was legally blind, would not experience negative consequences of vision loss, and would remain physically safe.A care plan, dated 1/15/25, indicated Resident D had hearing loss, would hear and understand communication, and to obtain the resident's attention prior to speaking to him.A nursing progress note, dated 2/10/26 at 10:00 p.m., indicated a head-to-toe assessment was completed. Resident D had a bruise and skin tear measuring 0.5 centimeters (cm) to his left outer arm. His left eyebrow area appeared to be swollen. He had redness observed near the right side of his mouth. He complained of a headache and neck pain.A social service progress note, dated 2/11/26 at 8:17 a.m., indicated Resident D did not sleep well the night before.A facility progress note, dated 2/11/26 at 8:35 a.m., indicated the Executive Director (ED) had spoken to Resident D's daughter regarding the resident's interaction with the CNA last night.During an interview, on 3/3/26 at 11:36 a.m., CNA 3 indicated, on 2/10/26, she heard Resident D yelling in a muffled sound. She arrived at the resident's door at the same time as LPN 4. CNA 3 did not see what CNA 5 was doing to Resident D. CNA 5 was standing next to the bed. LPN 4 told CNA 5 to go home immediately. CNA 3 and LPN 4 finished Resident D's care after they allowed him to rest for a while. Resident D was shaking and frightened after the incident. He had a frightened look on his face. Resident D told CNA 3 that man held his hand over my mouth and tried to kill me Resident D complained of pain in his neck later and had asked for ibuprofen that night and the next day. CNA 5 was suspended, then he was terminated.During an interview, on 3/3/26 at 2:39 p.m., Resident D when asked about the incident, indicated some man attacked him and he thought he was going to die.During an interview, on 3/3/26 at 3:01 p.m., LPN 4 indicated she was on her way to another resident's room when she heard Resident D yelling out in a muffled way, so she went to his room. Without knocking on his door, she walked into his room and found CNA 5 with his left knee bent onto the bed by the resident's side and both his hands over the resident's mouth and nose. CNA 5 was telling the resident to Shut the hell up as he was raising his hands up and down off the resident's nose and mouth. LPN 4 immediately told CNA 5 to leave and go home. She indicated when she walked into Resident D's room and seen CNA 5 standing over the resident with his hands over his nose and mouth he looked like a crazy person. Resident D had a skin tear on his left arm. Resident D told LPN 4 and CNA 3 That bastard tried to kill me. Resident D was visibly shaken and frightened. 2. During an interview, on 3/3/26 at 12:36 p.m., the Regional [NAME] President of Operations indicated the abuse allegation for Resident F was discovered during the investigation of the abuse allegation for Resident D. CNA 5 had indicated he had military knowledge and used a tactic move to break Resident F's grip on him when she had a hold of his wrists. The tactic used was a circular motion with one hand moving in a clockwise motion and one hand moving in a counterclockwise motion to break Resident F's grip. CNA 5 hit Resident F's left side of her chin during this move. The facility was not aware of this incident until the other abuse was investigated.The clinical record for Resident F was reviewed on 3/5/26 at 3:06 p.m. The diagnoses included, but were not limited to, dementia, psychotic disorder with delusions, psychotic disorder with hallucinations, generalized anxiety disorder, osteoarthritis, and major depressive disorder.A care plan, dated 1/16/24, indicated Resident F had experienced trauma and was a survivor of abuse. She was at risk for experiencing re-traumatization, feeling unsafe, untrusting, and/or distressed. An associated trauma trigger was the sight of a male resident. The interventions included, but were not limited to, ensure the resident had a sense of emotional and physical safety (provide female caregivers during personal care when possible and explain the care before and during the care related to a history of trauma). The trauma symptoms identified were intrusive thoughts, feeling upset, and anger and irritability. At the time of the incident with CNA 5, Resident F was being provided personal care by a male caregiver. Her care plan indicated to provide female caregivers when possible. There was no actual date determined for the abuse of Resident F. CNA 5's timecard indicated he had worked on 12/24/25, 12/26/25, 12/30/25 and 12/31/25 on the evening shift. The bruise on Resident F's chin and bilateral cheeks was discovered on 1/1/26. A social service progress note, dated 12/30/25 at 2:06 p.m., indicated the nurse notified social services about the resident's loose teeth. A nursing progress note, dated 12/30/25 at 2:06 p.m., indicated Resident F was observed to have three loose/wiggling front teeth on the left side.A nursing progress note, dated 1/1/26 at 1:22 p.m., indicated the nurse was notified a bruise was observed on Resident F when removing the resident's clothing protector after lunch. The nurse assessed and noted a bruise under Resident F's chin and her bilateral cheeks with various stages of healing. A facility document, titled Event Report, dated 1/1/26 at 1:16 p.m., indicated Resident F had bruising in various stages under her chin and bilateral cheeks observed on 1/1/26. The wound was not from a fall. The area measured 10 cm (centimeters) by 2 cm for the chin and 1 cm by 1 cm to each of her cheeks. All the bruises were in various stages of healing. A nursing progress note, dated 1/1/26 at 9:39 p.m., indicated the bruised areas to the resident's bilateral cheeks and under her chin remained. There were also bruises noted to her bilateral anterior hands with various stages of healing.A nursing progress note, dated 1/2/26 at 7:34 p.m., indicated the bruising remained under Resident F's chin which was yellow and dark purple in color.A nursing progress note, dated 1/3/26 at 5:21 a.m., indicated the bruising remained under Resident F's chin and bilateral cheeks. The bruising was mostly yellow in color with localized dark purple areas. A nursing progress note, dated 1/4/26 at 12:20 a.m., indicated the bruising to the resident's chin continued to resolve.A nursing progress note, dated 1/4/26 at 10:55 a.m., indicated the bruising remained under the chin and was yellow and deep purple in color. A nursing progress note, dated 1/6/26 at 10:31 a.m., indicated the bruising to the resident's chin continued to resolve in various stages of colors. A progress note, dated 1/7/26 at 12:10 p.m., indicated Resident F was observed crying inconsolably in the main dining room prior to lunch service. Therapeutic communication was attempted but was not effective. She seemed to be reliving past traumas of her family's deaths. She had severe cognitive impairment. The root cause of the crying was thought to be overstimulation in the dining room. A nursing progress note, dated 1/9/26 at 12:59 p.m., indicated the resident had bruising under her neck and to her left hand which was resolving.Resident F had a consult with the dentist, on 1/9/26, for a limited oral evaluation for loose teeth. The exam indicated she had lost a bridge between teeth 9 through 11. The teeth have mobility in them. A referral was made to the oral surgeon to have those teeth extracted. A typed facility statement indicated, on 1/1/26, LPN 18 was informed when a CNA removed Resident F's clothing protector after eating, the resident indicated Ouch, my neck hurts. Upon assessing the resident's neck, LPN 18 observed bruising around Resident F's neck and a small bruise to her bilateral cheek/jaw line area. The bruises were already in the healing processes at the time of the assessment. The Executive Director and Assistant Director of Nursing were notified regarding the bruising.A handwritten facility statement, dated 2/13/26, indicated CNA 19 was informed LPN 4 and RN 17 knew about the bruising to Resident F's chin and bilateral cheeks prior to 1/1/26. Her teeth were discovered to be loose on 12/30/25. Another staff member indicated CNA 5 was responsible for Resident F's teeth being missing. The resident did something to CNA 5 and he moved his arms somehow and her teeth fell out. Supposedly management knew about the missing teeth. A handwritten facility statement, dated 2/13/26, indicated LPN 4 and CNA 3 entered Resident F's room, and CNA 5 came running up to them and asked what they were doing. LPN 4 told CNA 5 they were looking at the resident's bruise. CNA 5 indicated he had to Declaw the cat. LPN 4 asked CNA 5 what that meant and he indicated he had to clip the resident's nails. A handwritten facility statement, undated, indicated CNA 5 told CNA 3 he may have had something to do with the bruising on Resident F. He demonstrated a hand motion. She took him to the ADON at that time and made her aware of the situation. During an interview, on 3/3/26 at 11:36 a.m., CNA 3 indicated CNA 5 was putting Resident F to bed, she scratched him, and he cut her fingernails. CNA 5 had indicated he had struggled to get her personal care done and place her in bed. Resident F was then found to have bruising on the bilateral sides of her chin. The bruise was greenish purplish in color and was a solid line. CNA 5 told CNA 3 he had to hold his arms crossed in front of his chest (a tactic he learned in the forces) and might have hit her in the chin with his elbow to avoid getting hit. During the facility investigation of abuse, staff members were asked abuse questions regarding CNA 5 and these statements included, but were not limited to, the following:On 2/11/26, CNA 3 indicated CNA 5 had been stressed at times and needed to take a break.On 2/11/26, CNA 19 indicated CNA 5 had indicated he was stressed and needed a break.On 2/11/26, CNA 20 indicated CNA 5 showed signs of burn-out.On 2/12/26, CNA 21 indicated CNA 5 was stressed and frustrated one time when she worked with him.On 2/12/26, CNA 22 indicated CNA 5 was observed performing unsafe and rushed transfers.On 2/13/26, CNA 23 indicated she observed CNA 5 frustrated with his workload and he was fatigued.On 2/12/26, CNA 24 indicated CNA 5 was always frustrated. She had observed unusual bruises on a resident's face and teeth and she had reported them.On 2/11/26, CNA 25 indicated some of the residents did not want CNA 5 to take care of them because they were scared of him. He would be a little stressed out sometimes when someone asked him something.A facility document, titled Employee Communication Form, dated 2/17/26, indicated CNA 5 was terminated for gross carelessness or gross negligence or inattention to duty, including acts, omissions or substandard quality or quantity of work, which result in potential or actual loss to the Company or harm to residents, co-workers, guests or yourself. The policy/procedure he violated was carelessness. The details of the policy violation were that CNA 5 made physical contact with two residents while providing care for them. One incident occurred, on 12/25/25, with Resident F and the other incident occurred, on 2/10/26, with Resident D. A current facility policy, titled Abuse Prohibition, Reporting, and investigation, provided by the Executive Director indicated .will not permit residents to be subjected to abuse by anyone, including employees.Examples of Abuse: Willful, used in the definition of abuse, means the individual must have acted deliberately, not that the individual intended to inflict injury or harm. Abuse.Physical Abuse-A willful act against a resident by another resident, staff member, or other individual(s). Examples may include but not be limited to hitting, slapping, punching, and choking.Mental Abuse-Verbal or nonverbal infliction of anguish, pain or distress that results in psychological or emotional suffering. This includes any episode of staff to resident.if it appears to be willfully directed to specific resident. Examples of mental abuse include but are not limited to.Yelling or hovering over a resident, with the intent to intimidate.This deficient practice was corrected by 2/20/26 after the facility implemented a systemic plan that included the following actions: Skin sweeps were completed on cognitively impaired residents, alert and oriented residents were interviewed, and nursing staff were interviewed regarding CNA 5. Education on abuse, signs of burnout, stress, behaviors and the response to behaviors was completed with the staff. The management team performed abuse audits to ensure staff were educated on abuse during orientation and continuously thereafter. CNA 5 was terminated.This citation relates to Intake 2740744 and 2789352.410 IAC (Indiana Administrative Code) 16.2-3.1-27(a)(1)

Based on observation, interview and record review, the facility failed to ensure staff wore Personal Protective Equipment (PPE) properly, wore the appropriate PPE when entering an isolation room, preformed hand hygiene, and changed gloves during a dressing change for 3 of 7 residents reviewed for infection control. (Resident 57, 34 and 5)Findings include:1. During a random observation, on 9/10/25 at 9:53 a.m., CNA 4 was observed to put on a protective gown, mask, and gloves outside of Resident 57's room. The gown was not tied at the neck. She then entered the room which had a sign posted to indicate it was a droplet/contact isolation room. The sign indicated to put on a gown and to tie the gown.During an interview, on 9/10/25 at 10:11 a.m., CNA 4 indicated the sign did indicate she should have tied her gown.During a random observation, on 9/11/25 at 8:48 a.m., CNA 3 was observed to put on a gown, mask, and gloves and enter Resident 57's room. She was not observed to put on the eye protection required for droplet precautions.During an interview, on 9/11/25 at 8:52 a.m., CNA 3 indicated she did not wear eye protection, and she should have applied the Personal Protective Equipment indicated on the sign posted.The clinical record for Resident 57 was reviewed on 9/11/25 at 8:53 a.m. The diagnoses included, but were not limited to, hypertension, type 2 diabetes mellitus without complications, and cough.A physician's order, dated 9/10/25, indicated Resident 57 was in isolation due to having an active infection with highly transmissible or epidemiologically significant pathogens which had been acquired by physical contact or airborne or droplet transmission. The type of isolation required would be contact/droplet related to a cough.A care plan, dated 9/10/25, indicated the resident had a need for isolation related to infectious diseases: cough.2. During an observation of catheter care, on 9/12/25 beginning at 1:31 p.m., Resident 34 was observed in bed. CNA 6 filled a wash basin with water, set the basin on the bedside table with the clean linen, put on a protective gown, and then put on gloves. She was not observed to perform hand hygiene prior to donning her gloves.During an interview, on 9/12/25 at 1:37 p.m., CNA 6 indicated she did not use hand sanitizer or perform hand washing after touching items in the resident's environment and she should have performed hand hygiene prior to putting on her gloves.3. During an observation of wound care, on 9/15/25 beginning at 10:35 a.m., RN 8 and LPN 7 put on PPE. LPN 7 was observed to remove a dressing from the right buttock area of Resident 5 and discarded it. LPN 7 cleaned the area on the right buttock with wound cleaner and a clean 4 by 4 dressing. After cleaning the area, she discarded the 4 by 4. She was not observed to change her gloves or perform hand hygiene prior to continuing. She opened the packaging for sterile cotton tip applicators and the Santyl (an ointment used to remove dead or damaged tissue to promote healing of wounds) she had removed from a plastic bag. LPN 7 then applied the Santyl to the wound and discarded the applicator. She then opened an emulsion dressing (a nonadherent gauze mesh), folded it in half and applied the dressing to the wound. The area was then covered with a dressing. LPN 7 then removed her gloves, discarded the gloves, and washed her hands with soap and water. During an interview, on 9/15/25 at 9:21 a.m., the Infection Preventionist indicated hand hygiene was to be performed after touching items in the resident's environment. Gowns were to be tied at the neck, and the back, masks and face shields were to be used (as indicated by isolation type), and hand hygiene was to be completed before donning gloves and after removing gloves.A current facility document, titled ISOLATION DROPLET/CONTACT PRECAUTIONS, indicated .wear all PPE listed below. The PPE listed on the sign was gown, N95 respirator, eye protection, and gloves. The sign was posted outside the room of Resident 57.A current facility procedure, titled Dressing Change Clean Technique (Incision or Wound), dated as revised in 7/2025 and received from LPN 7 on 9/12/25 at 10:50 a.m., indicated .Remove old dressing from resident and put directly in trash receptacle .Remove gloves and discard .Perform hand hygiene and put on new gloves A current facility policy, titled Hand Hygiene Policy, dated as revised 12/2021 and received from the Executive Director on 9/16/25 at 8:47 a.m., indicated .5 Moments of hand hygiene - a term that describes the hand hygiene opportunities that prevent infection transmission linked to healthcare activities.Before touching a resident.Before Clean/Aseptic procedure.After touching resident surroundings.Healthcare personnel should use an alcohol-based hand rub or wash with soap and water for the following clinical indications.Before moving from work on a soiled body site to a clean body site on the same resident.Indication for Hand-rubbing but not limited to.Before and after removing glove.A current facility policy, titled Standard and Transmission-Based Precautions (Isolation) Policy, dated as last revised 2/2025 and received from the Executive Director on 9/16/25 at 8:47 a.m., indicated .Change gloves during care and perform hand hygiene if hands move from a contaminated site to a clean site.3.1-18(b)(1)3.1-18(b)(2)3.1-18(l)

Based on interview and record review, the facility failed to ensure a medication was held according to the ordered parameters and the physician was notified of blood glucose readings as ordered for 2 of 5 residents reviewed for quality of care. (Resident 7 and 6)Findings include:1. The clinical record for Resident 7 was reviewed on 9/12/25 at 8:26 a.m. The diagnoses included, but were not limited to, chronic diastolic heart failure, hypertensive heart, and chronic kidney disease with heart failure.A physician's order, dated 4/15/25 and discontinued 8/18/25, indicated to administer Entresto (a medication used to treat chronic heart failure) 49-51milligrams (mg) twice a day, with special instructions to hold the medication for a systolic blood pressure of less than 120.The Medication Administration Record (MAR), dated 7/1/25 to 7/31/25, indicated Entresto had been administered 13 times when Resident 7's systolic blood pressure was less than 120.The MAR, dated 8/1/25 to 8/18/25, indicated Entresto had been administered 5 times when Resident 7's systolic blood pressure was less than 120.During an interview, on 9/12/25 at 11:13 a.m., the Medical Records staff indicated a parenthesis on the MAR indicated the medication had been held and an asterisk on the MAR indicated the medication had been given and the nurse had documented a note with the administration. The Medical Records staff reviewed the MAR and indicated the medication should have been held according to the physician's order.During an interview, on 9/16/25 at 12:11 p.m., the Director of Nursing (DON) indicated the medication should have been held according to the physician's order.2. The clinical record for Resident 6 was reviewed on 9/11/25 at 12:21 p.m. The diagnoses included, but were not limited to, type 2 diabetes, hypertension, and mixed hyperlipidemia.A care plan, dated 8/9/19, indicated Resident 6 was at risk for adverse effects of hyperglycemia/hypoglycemia related to the use of medications for diabetes. An intervention, dated 8/9/19, indicated to document abnormal findings and notify the physician.A physician's order, dated 9/12/19, indicated to notify the physician if Resident 6's blood glucose reading was greater than 350 or below 60.The Medication and Treatment Administration Records (MAR/TAR) indicated the following:a. On 6/1/25 at 8:00 a.m., the resident's blood glucose reading was 400. The MAR/TAR indicated the physician was not notified.b. On 9/4/25 at 5:00 p.m., the resident's blood glucose reading was 360. The MAR/TAR indicated the physician was not notified.There were no progress notes or observation documentation to show the physician had been notified of the blood glucose reading according to the physician's order.During an interview, on 9/16/25 at 12:19 p.m., LPN 9 indicated if a medication had a hold parameter or instructions to notify the physician, the nurse would be responsible for verifying the medication was held or the physician was notified immediately so the nurse could get further instructions on how to proceed.During an interview, on 9/16/25 at 12:04 p.m., the Executive Director indicated the facility did not have a policy related to physician ordered hold parameters. He indicated holding medications according to the physician's order was an expectation.A current facility policy, titled Resident Change of Condition Policy, dated as revised in 11/2018 and received from the Executive Director on 9/16/25 at 12:24 p.m., indicated .all changes in resident condition will be communicated to the physician.and that appropriate, timely, and effective intervention takes place.All symptoms and unusual signs will be documented in the medical record and communicated to the attending physician promptly.The nurse in charge is responsible for notification of physician.3.1-37(a)

Based on interview and record review, the facility failed to ensure physician ordered medications included an appropriate supporting diagnosis and a medication included a stop date for 3 of 5 residents reviewed for unnecessary medications. (Resident 11, 5 and 13)Findings include:1. The clinical record for Resident 11 was reviewed on 9/12/25 at 10:36 a.m. The diagnoses included, but were not limited to, dementia, muscle weakness, and encounter for other specified aftercare. A review of Resident 11's obsolete diagnoses indicated a diagnosis of herpes viral infection was placed on 5/20/24 and resolved on 7/23/24. A physician's visit note, dated 7/7/25, indicated Resident 11 had been experiencing painful blisters on her bilateral thighs and vaginal area, which was a chronic issue, and had been treated in the past. The treatment plan was to initiate a topical antiviral cream for 5 days, followed by valacyclovir (an antiviral medication used to treat infections) 500 milligrams (mg) every day. The physician's note did not include instructions regarding when the medication would be stopped or supporting documentation for the duration of use. A physician's order, dated 7/7/25, indicated valacyclovir 500 mg was prescribed for the diagnosis of encounter for other specified aftercare. The medication did not include a stop date or an appropriate supporting diagnosis. During an interview, on 9/16/25 at 11:05 a.m., the Director of Nursing (DON) indicated medical records would follow up on physician's orders to ensure medications contained a supporting diagnosis and stop date. The DON indicated the diagnosis for valacyclovir was not appropriate and the medication was missing a stop date. 2. The clinical record for Resident 5 was reviewed on 9/15/25 at 10:30 a.m. The diagnoses included, but were not limited to, sepsis (a life-threatening condition where the body's immune system overreacts to an infection, leading to widespread inflammation and organ damage), encephalopathy (a disturbance in brain function), and chronic kidney disease. A physician's order, dated 8/25/25, indicated to administer amlodipine (a medication for hypertension) 10 mg for the diagnosis of encounter for other specified aftercare. A physician's order, dated 8/26/25, indicated to administer aspirin (a medication used for fever, pain, preventing clotting and/or inflammation) 81 mg for the diagnosis of encounter for other specified aftercare. A physician's order, dated 8/26/25, indicated to administer atorvastatin (a medication used for high cholesterol) 80 mg for the diagnosis of encounter for other specified aftercare. A physician's order, dated 9/9/25, indicated to give Meropenem (an antibiotic) 2 grams in 100 milliliters of normal saline intravenously every eight (8) hours for the diagnosis of encounter for other specified aftercare. 3. The clinical record for Resident 13 was reviewed on 9/10/25 at 3:08 p.m. The diagnoses included, but were not limited to, psoriasis, insomnia, and anxiety. A physician's order, dated 8/14/25, indicated to give amlodipine (a medication used to treat high blood pressure) 10 mg daily for the diagnosis of encounter for other specified aftercare. A physician's order, dated 8/14/25, indicated to give aspirin 81 mg daily for the diagnosis of encounter for other specified aftercare. A physician's order, dated 8/14/25, indicated to give atorvastatin (a medication used to high cholesterol) 20 mg daily for the diagnosis of encounter for other specified aftercare. A physician's order, dated 8/14/25, indicated to give famotidine (a medication used to treat reflux) 20 mg at bedtime for the diagnosis of encounter for other specified aftercare. A physician's order, dated 8/15/25, indicated to give amantadine (a medication used to treat Parkinson's disease) 100 mg daily for the diagnosis of encounter for other specified aftercare. A physician's order, dated 9/9/25, indicated to administer Humira (a medication used to treat autoimmune disorders and inflammatory diseases) 40 mg by subcutaneous injection every other Thursday. The diagnosis used for the administration of the medication was extrapyramidal and movement disorders. During an interview, on 9/16/25 at 9:36 a.m., RN 10 indicated when staff received a medication order from the physician, the order was entered into the electronic health record (EHR). The diagnosis of Encounter for specific aftercare was a short-term diagnosis the nurses could use if the appropriate diagnosis could not be found at the time they were placing the order. The nurse would be responsible for ensuring the short-term diagnosis was changed to the correct supporting diagnosis for the medication. RN 10 indicated if a medication did not include a stop date, the nurse would contact the physician to clarify when the medication would be stopped. During an interview, on 9/15/25 at 9:27 a.m., the Infection Preventionist indicated the diagnosis for the antibiotic Meropenem and the immunosuppressant Humira did not have correct diagnoses. Medications needed to have appropriate diagnoses. During an interview, on 9/16/25 at 11:37 a.m., the DON indicated the facility did not have a policy regarding medications with supporting diagnoses or stop dates. A current facility policy, titled Medication Regimen Reviews and Pharmacy Recommendations, dated as last revised on 10/2018 and received by the Executive Director on 9/16/25, indicated .the facility maintains the resident's highest practicable level of physical, mental, and psychosocial well-being and prevents or minimized adverse consequences related to medication therapy to the extent possible by providing oversight by a licensed Pharmacist, Attending Physician, Medical Director, and Director of Nursing. 3.1-48(a)(2) 3.1-48(a)(4)

Based on observation, interview and record review, the facility failed to ensure a resident with continuous feeding through a Jejunostomy tube (J-tube) received the ordered amount of nutrient formula at the correct rate in the ordered time frame for 1 of 2 residents reviewed for enteral feedings. (Resident B) The deficient practice was corrected on 10/15/24, prior to the start of the survey, and was therefore past noncompliance. Findings include: During an interview, on 10/18/24 at 8:42 a.m., the Executive Director indicated Resident B had received a total of 1000 ml (milliliters) of enteral feeding over a four (4) hour period via her J-tube. During an observation, on 10/18/24 at 1:29 p.m., the feeding pump was assessed. The Director of Nursing, Executive Director, Corporate Support Nurse and Regional [NAME] President of Operations were present. The history was not assessable as the pump had been disconnected from a power source since 10/14/24. The Executive Director indicated they had attempted to access the pump memory but kept receiving an error message. It was noted when the power was restored to the pump it had shown a rate of 400 milliliters per hour (ml/hr.). At that time, the Executive Director indicated that was the factory reset. The pump did not go above 400 ml/hr. The clinical record for Resident B was reviewed on 10/18/24 at 11:13 a.m. The diagnoses included, but were not limited to, multiple sclerosis, quadriplegia, encounter for attention to tracheostomy, and coronary artery disease. A physician's order, dated 7/4/24, indicated to give Osmolyte 1.5 (nutritional formula) at 45 milliliters per hour via J-tube (tube placed through the skin of the abdomen into the midsection of the small intestine). A facility document, untitled and dated 10/13/24, indicated the night shift nurse (LPN 1) had informed the writer (RN 3) the pump was not working. It said system failure. RN 3 checked the pump and confirmed it was not functioning properly. She called tech support, and a technician was to call back. She went and retrieved a new feeding pump, replaced the old pump, and set the flow rate on the new pump to 45 ml/hr for the feeding and 45 ml/hr. for the water flush. She noted she had double checked the rates with the order. She noticed when changing rates, the default rate of infusion was 400 ml/hr. The feeding pump was primed and infusing by 9:00 a.m., on Sunday morning (10/13/24). She was in the facility until 10:00 p.m. on Sunday (10/13/24) and did not hear of any concerns with Resident B or the feeding pump. She had called the company, using the number on the side of the pump, at about 7:00 a.m. that morning and the company returned the call at around 7:30 p.m. that evening. LPN 1 received the call and since the pump was running, he told them they were no longer needed. A facility document, untitled and dated 10/15/24, indicated LPN 1 had gone to Resident B's room at 5:00 a.m., to give medication and change the tube feeding. He turned the pump off, removed the old container, hung the new container, turned the pump on, kept the previous settings, and primed the line. During that time, he checked for placement and residual, administered the resident's medication, and then connected the J-tube to the feeding pump and started the machine. He then left the room to tend to a resident who was attempting to get out of bed. He did return to Resident B; she wanted to see him. He readjusted her in bed, and she began to cough. He suctioned her, offered her a drink of water, and then left the room. He checked on her once more. She informed him she was warm and wanted the sheet off. He did as she requested and left the room. She was not in distress. He then gave report to the oncoming shift and left the facility. Additional information added to the statement indicated the bottle of feeding he removed was dated for the previous day (10/13/24) and when he checked on the resident around 6:20 a.m., that morning the formula was at the top of the bottle, where it would be, if it was infusing at the correct rate. A facility document, dated 10/15/24, indicated Housekeeper 6 entered the room on 10/14/24 at 7:24 a.m., and left a cup if ice water. The resident was sleeping. She did not hear the feeding tube machine alarming. A facility document, untitled and dated 10/15/24, indicated Staff 5 entered Resident B's room on 10/14/24 at 8:59 a.m. She was in the room for less than a minute. Resident B signaled she needed assistance. Staff 5 did not notice if the resident was in distress. She then went and informed RN 2 the resident required assistance. She did not hear the feeding tube alarming. A facility document, untitled and dated 10/15/24, indicated CNA 7 responded to Resident B's call light at 9:00 a.m. The resident requested a drink of water and CNA 7 noticed yellow emesis on her face and gown. She informed Resident B she needed to get the nurse. She informed the nurse she was needed in the resident's room; the resident had emesis on her face and gown and the pump was beeping. The nurse went to the room looked at the pump, took the resident's vital signs and informed the CNA she would be back. Another CNA had reported to the room; and both CNAs cleaned up the resident. A facility document, untitled and dated 10/15/24, indicated CNA 8 was picking up room trays on the hall around 8:30 to 9:00 a.m. She heard Resident B call, so she answered and found the resident had yellow emesis on her gown and the pump was beeping. CNA 8 cleaned the resident's face and informed the nurse. She did observe the nurse to enter the room and followed to see if additional assistance was needed. After the nurse had assessed the resident's vital signs and checked the feeding pump, CNA 8 and another CNA cleaned the resident and changed her gown. A facility document, untitled and undated, indicated RN 2 upon entry to Resident B's room noticed yellow fluid emesis and the feeding pump was completely infused. She turned off the pump and staff provided care for the resident while she notified the provider on call of the current situation. The bottle of feeding formula was dated for that morning by the previous shift. She received new orders. The scheduled medications and as needed medications were given. She suctioned the resident's tracheostomy and noted a small amount of white phlegm. She assessed the vital signs; the resident's heart rate and respirations were increased. She notified the on-call provider and new orders were received. The medication was provided. She noted the resident's spouse was present in the room. A second nurse came to the room to check the resident's condition. There was no improvement, and the residents pulse oximetry indicated her oxygen saturation was down to 58 percent. The second nurse contacted the physician. Physician 4, who was present in the facility, came to the resident's room and placed the artificial manual breathing unit on the tracheostomy and provided breaths until the emergency response team arrived. A hospital document, dated 10/14/24, indicated the resident was seen at 11:38 a.m. She presented to the hospital, via EMS, to be evaluated for shortness of breath and decreased oxygen saturation. EMS reported increased shortness of breath and decreased oxygen saturation after patient received tube feedings. There was concern for aspiration. Upon arrival the patient was hypotensive (low blood pressure), had a Glasgow Coma score of 3 (lowest score) and her oxygen saturation level was about 50 percent. The resident had diffuse cyanosis (blue coloring), did not respond to external stimuli, her pupil response was sluggish, and white frothy sputum was noted at the tracheostomy. During a telephone interview, on 10/18/24 at 8:50 a.m., the county coroner's office staff member indicated the final cause of death report would not be available for 4-6 weeks. They did not know the cause of death and lab reports were pending on fluid in the resident's lungs. She indicated Resident B had about 200 ml of fluid in her belly. During a telephone interview, on 10/18/24 at 11:28 a.m., LPN 1 (the night nurse) indicated he went to the room, around 5:00 a.m., to change the feeding set and administer medications. He hung the new bottle of feeding and set machine to prime the line. He then administered medication with 30 milliliters (ml) flush before and 30 ml flush after. He indicated medications were given via the gastronomy tube (g-tube, a line inserted into the stomach), but the feedings were given via j-tube and the ports are labeled as such. He flushed the j-tube with 60 ml water and connected the j-tube to the pump. The setting was 45 ml/hr for the feeding and he did not change the setting as it was already programmed into the machine. He then left the room. Everything was running fine. He checked on the resident again, that morning, at 6 something. The CNA told him the resident wanted him. The resident wanted to be adjusted in the bed. She was alert and voicing her needs, she was also coughing. LPN 1 suctioned her tracheostomy once, at that time. He indicated coughing was usual for her. Once he finished suctioning her tracheostomy, he left the room. LPN 1 indicated she was breathing ok, all was fine. He did return to the room once more at about 6:15 a.m. He wanted to check if she was still coughing, sometimes she did and she would have mucus come out of her mouth. The pump was fine, it was almost full, it was running fine, and resident was breathing fine. She had no signs of distress. During an interview, on 10/18/24 at 11:51 a.m., RN 2 indicated she passed Resident B's room many times and had peeked in to ensure the resident was okay and had her blow tube for the call light. She had entered the room because the resident had told her she was thirsty and wanted a drink of water. RN 2 indicated Resident B would only take sips, enough to wet her whistle. RN 2 then left the room. She indicated she would administer Resident B's medications last because it did take a little more time, and she did not want to delay the other residents' medication administration. RN 2 indicated she was at the nursing station working when the resident's call light came on. The CNA, while on the way to the room, indicated the pump was beeping. RN 2 responded. The pump was sounding, and the infusion had completed. She immediately turned off the pump because there was air in line. The resident had emesis (vomited) a moderate amount. It was not a lot but enough to be on her chin, chest and tracheostomy dressing. It was yellow in color. The resident never forcefully vomited, it just rolled out of her mouth. She changed the tracheostomy dressing and collar. While the CNA was cleaning up the resident, RN 2 returned to the nursing station and contacted the provided to notify them of the emesis. She had not yet assessed lung sounds; she was going to after she administered a breathing treatment. RN 2 indicated she did administer a breathing treatment and suctioned the tracheostomy. She noted a small amount of white phlegm on the first suction pass and nothing on the second, so she stopped suctioning the resident. She did assess the resident's lung sounds and found them to be diminished. RN 2 indicated this was normal for the resident since her return from the hospital in September (2024). The resident had been on a ventilator for two weeks and returned to the facility on three liters of oxygen through her tracheostomy. The resident had never required oxygen continuously prior to the September hospitalization . They had tried to titrate the oxygen to two liters, but the residents blood oxygen levels would drop so she had to be on three liters. RN 2 indicated she felt like she was going through the same situation she went through in September when the resident's oxygen saturations had dropped, and she had to be sent to the hospital. During a telephone interview, on 10/18/24 at 3:06 p.m., Physician 4 indicated the feeding to the small bowel would continue to slide south (downwards) to the small bowel. There would not be a significant issue with nausea. The worst case a little bit of feeding could slide back to the stomach, but the majority would go to the small bowel. He indicated he felt Resident B had been living at the end of her life for the past 2 years. She had very little reserve from day to day and the facility team cared for her and maintained her life. Recently she had a similar event and went to the hospital. She returned to the facility, and he did see her. He felt she had no reserve. During an interview, on 10/18/24 at 3:35 p.m., the policy for following physician's orders was requested. The Corporate Support Nurse indicated the information would be included in the medication administration policy. It was standard practice to follow physician's orders and to monitor residents throughout the day. A current facility policy, titled General Dose Preparation and Medication Administration, dated as last revised 4/30/24 and received from the Executive Director on 10/18/24 at 3:39 p.m., indicated .Verify each time a medication is administered that is .at the correct rate The deficient practice was corrected by 10/15/24 after the facility implemented a systemic plan that included the following actions: The facility investigated the incident involving Resident B, educated the staff on enteral feeding protocol, use of enteral pumps, and nursing assessments for residents with emesis and enteral feedings. Audits were initiated for other residents receiving enteral feedings to ensure they were getting the correct flow rate and rates were checked hourly. The facility initiated two (2) nurses were to sign a validation for the correct flow rate when a new bottle was initiated. Nursing managers began to audit residents with enteral feeding orders for the correct flow rates and correct formula daily. Enteral nutrition and Enteral pump skill validation tools were completed. This citation relates to Complaint IN00445223. 3.1-44(a)(2)

Based on interview and record review, the facility failed to conduct care plan meetings at least quarterly for 2 of 2 residents reviewed for care plan conferences/meetings. (Resident 5 and 59) Findings include: 1. The clinical record for Resident 5 was reviewed on 10/8/24 at 1:49 p.m. The diagnoses included, but were not limited to, chronic obstructive pulmonary disease with (acute) exacerbation, chronic systolic heart failure, and hypertension. The last documented care plan meeting for Resident 5 was in March 2024. During an interview, on 10/10/24 at 2:34 p.m., the Social Service Director indicated the resident had a care plan in March of this year (2024). The resident should have had one in May and another one in early August. The resident was missing 2 care plan meetings. 2. The clinical record for Resident 59 was reviewed on 10/10/24 at 2:29 p.m. The diagnoses included, but were not limited to, hydronephrosis (a condition where one or both kidneys swell due to a buildup of urine), chronic atrial fibrillation, and acute chronic diastolic heart failure. The last documented care plan meeting for Resident 59 was on 6/5/24. During an interview, on 10/10/24 at 2:30 p.m., the Social Service Director indicated care plan meetings were completed quarterly. Resident 59 was due for a care plan meeting in September 2024 and currently there was not a care plan meeting scheduled. A facility document, titled MDS COORDINATOR, updated 5/2018 and received from the Executive Director on 10/11/24 at 8:30 a.m., indicated .The MDS Coordinator is responsible for the .Interdisciplinary Care planning process .establishes and maintains a cyclical schedule related to the .care planning process ensuring adherence to strict federal timelines .Coordinates interdisciplinary care plan meetings and conferences with Social Services, family members and residents to encourage/facilitate family and/or resident participation A current facility policy, titled IDT Comprehensive Care Plan Policy, dated as last reviewed 8/2023 and received from the Corporate Support Nurse on 10/10/24 at 3:16 p.m., indicated .It is the policy of this facility that each resident will have an interdisciplinary comprehensive person-centered care plan developed and implemented .The care plan review may be conducted face to face, via phone conference, video conference, or through written communication per resident and/or representative preference 3.1-35(d)(2)(B) 3.1-35(e)

Based on interview and record review, the facility failed to ensure medications were held according to the physician's ordered hold parameters for 2 of 2 residents reviewed for quality of care. (Resident 36 and 55) Findings include: 1. The clinical record for Resident 36 was reviewed on 10/10/24 at 11:02 p.m. The diagnoses included, but were not limited to, essential hypertension, type 2 diabetes, and hyperlipidemia. A physician's order, with a start date of 1/23/24, indicated to give metoprolol succinate (a blood pressure medication) 100 milligrams (mg) extended-release tablet once a day. Hold for a systolic blood pressure (SBP) less than 110 or heart rate (HR) less than 60. A current care plan, with a start date of 1/30/24, indicated the resident was at risk for ineffective tissue perfusion related to hypertension and to administer medications as ordered. A review of the Medication Administration Record (MAR) indicated metoprolol succinate was administered on the following dates outside of the physician's ordered hold parameters: On 7/1/24, with a systolic blood pressure of 101 and a heart rate of 55. On 7/6/24, with a heart rate of 52. On 7/9/24, with a heart rate of 55. On 7/17/24, with a heart rate of 59. On 7/18/24, with a heart rate of 56. On 7/27/24, with a systolic blood pressure of 103. On 8/2/24, with a heart rate of 56. On 9/1/24, with a heart rate of 57. On 9/12/24, with a heart rate of 57. On 10/4/24, with a heart rate of 57. During an interview, on 10/10/24 at 4:00 p.m., the Director of Nursing (DON) indicated the documentation indicated the medications were administered during those dates and times. 2. The clinical record for Resident 55 was reviewed on 10/9/24 at 11:02 a.m. The diagnoses included, but were not limited to, essential hypertension, type 2 diabetes, and edema. A physician's order, with a start date of 2/15/24, indicated to give metoprolol succinate 50 mg and to hold the medication for a systolic blood pressure of less than 120 or a heart rate of less than 55. A current care plan, with a start date of 2/11/23, indicated the resident was at risk for ineffective tissue perfusion related to hypertension and to administer medications as ordered. A review of the Medication Administration Record (MAR) indicated metoprolol succinate was administered on the following dates outside of the physician's ordered hold parameters: On 7/15/24, with a systolic blood pressure of 116. On 7/16/24, with a systolic blood pressure of 119. On 7/17/24, with a systolic blood pressure of 112. On 7/21/24, with a systolic blood pressure of 117. On 7/22/24, with a systolic blood pressure of 110. On 7/29/24, with a systolic blood pressure of 110. On 7/30/24, with a systolic blood pressure of 110. On 8/6/24, with a systolic blood pressure of 113. On 8/12/24, with a systolic blood pressure of 113. On 8/23/24, with a systolic blood pressure of 114. On 9/1/24, with a systolic blood pressure of 119. On 9/2/24, with a systolic blood pressure of 118. On 9/17/24, with a systolic blood pressure of 115. On 9/27/24, with a systolic blood pressure of 104. During an interview, on 10/10/24 at 4:00 p.m., the DON indicated the documentation indicated the medications were administered during those dates and times. The facility did not provide a policy on following physician's orders. 3.1-37(a)

Based on observation, interview and record review, the facility failed to ensure unlabeled food was not stored in a medication room refrigerator and medications were stored in the original containers in 1 of 2 medication rooms and 1 of 3 medication carts reviewed for medication storage. (200 hall refrigerator and 300 hall medication cart) Findings include: 1. During an observation and interview, on 10/11/24 at 11:49 a.m., the 200-hall medication room supplement refrigerator had 2 unlabeled cans of Canada Dry and a grocery sack with a to-go container of food in it which was unlabeled. Registered Nurse (RN) 3 indicated she was unsure who the 2 cans of Canada Dry and the food belonged to. They did not have labels on them, and they should have had labels. During an interview, on 10/11/24 at 12:05 p.m., the Director of Nursing (DON) indicated food put in the refrigerator should be labeled. 38872 2. During an observation of the Moving Forward South medication cart there were 20 white oval tablets with marking 4H2 (cetirizine) and one round white table found in the bottom drawer. There was no bottle found to match up with the 20 white oval tablets. During an interview, on 10/11/24 at 12:08 p.m., RN 5 indicated it was possible something spilt. During an interview, on 10/11/24 at 12:29 p.m., the Director of Nursing indicated the cart had been cleaned that morning. A current facility policy, titled Safe Food Handling for Your Loved One, undated and received from the Executive Director upon entrance, indicated .When brought into the facility the food must be labeled as Resident Personal Food. This label will need to include resident name, the name of the item being stored (if not already clearly identified), the date the item is brought into the facility and the date the item must be discarded A current facility policy, titled Storage and Expiration Dating of Medications and Biologicals, dated as last revised on 8/1/24 and received from the Executive Director on 10/11/24 at 1:38 p.m., indicated, .Facility should ensure that the medications and biologicals for each resident are stored in the containers in which they were originally received 3.1-25(j)

Based on observation, interview and record review, the facility failed to ensure staff prepared pureed food in a sanitary manner for 1 of 1 staff member observed to puree food. (Cook 6) Finding includes: During an observation, on 10/8/24 at 10:36 a.m., [NAME] 6 was preparing pureed tuna casserole for lunch. During an observation, on 10/8/24 at 10:44 a.m., while preparing the pureed tuna casserole, [NAME] 6 licked the pureed tuna casserole off the first finger of her right hand. [NAME] 6 then attempted to take the food processor bowl off the base of the appliance to transfer the pureed food into a different container. During an interview, on 10/8/24 at 10:44 a.m., [NAME] 6 indicated she should not have licked the food off her finger and instead, she should have washed her hands. A current facility policy, titled Food Handling, dated 11/15 and received from the Director of Nursing on 10/10/24 at 8:49 a.m., indicated .To provide quality food that is handled in a safe and sanitary manner .All food preparation and serving areas shall be maintained in accordance with state and local sanitation standards, food handling, food preparation, and meal service 3.1-21(i)(3)

Based on observation, interview and record review, the facility failed to ensure a narcotic pain patch was administered at the correct time and new sites were used for the transdermal patch administration for 1 of 1 resident reviewed (Resident B) and failed to ensure staff were signing the narcotic count sheets for 4 of 6 medication cart narcotic logs reviewed. Findings include: 1. During an interview, on 8/28/24 at 9:55 a.m., Resident B indicated she was experiencing pain and had been provided medication for the pain. The resident allowed observation of her Fentanyl pain patch. It was located on her right upper arm and dated 8/27/24. She indicated the patch was changed every three days. She was not aware of any missed doses of medications, including the narcotic pain patch. The clinical record for Resident B was reviewed on 8/28/24 at 11:29 a.m. The diagnoses included, but were not limited to, fibromyalgia, chronic pain, and polyneuropathy. A physician's order, initiated on 12/30/23 and discontinued on 7/22/24, indicated to administer one Fentanyl patch 50 mcg per hour every 72 hours. The special instructions indicated to rotate sites. The time of administration was 4:00 p.m., (the evening shift). The documentation on the MAR/TAR indicated, on 7/21/24, RN 1 checked off he had removed the old patch and placed a new patch to the resident's left shoulder at 2:12 p.m. The reason provided for the early administration of the medication indicated .Ls There was no other documentation to explain why the medication was administered early. The Controlled Substance Record indicated RN 1 signed out the narcotic patch on 7/21/24 at 3:00 p.m. The nursing schedule was reviewed on 8/29/24 at 2:27 p.m. RN 1 was scheduled and worked the day shift. His hours he worked were documented, on the schedule, as 6:27 a.m. to 3:14 p.m. During an interview, on 8/28/24 at 2:27 p.m., the Executive Director indicated RN 1 was not able to say why he administered the Fentanyl patch early or if anyone witnessed the destruction of the old patch. RN 1 had pulled a patch which was due at 4:00 p.m., he could not recall if he placed the patch on the resident or if the patch had fallen off. He could not say why he pulled the medication early. During an interview, on 8/29/24 at 9:24 a.m., LPN 5 indicated staff were to check medication orders for the dose, resident, and time the medication was due to be administered. They also were to count the narcotics pre and post shift. The staff were to count all narcotic cards, bottles, patches, and medications. Two nurses were required to destroy medications and sign off on the form. 2. During an interview, on 8/29/24 at 9:42 a.m., RN 6 indicated staff were to destroy medications with two nurses and sign off on the (destruction) sheet. The narcotic book should be signed at the beginning and end of every shift after the count. Old medication patches were to be removed and a new one put on with another nurse present, sites should be rotated, and staff should sign off the patch and destroy the old patch with another nurse. During the review of the MAR/TAR for Resident B it was noted a Fentanyl 50 mcg transdermal patch was administered to the resident's left shoulder on 7/18/24, a new patch was administered on 7/21/24 to the resident's left shoulder, and a new patch was administered on 7/25/24 to the resident's left shoulder. A physician's order, initiated on 12/30/23 and discontinued on 7/22/24, indicated to administer one Fentanyl patch 50 mcg per hour every 72 hours. The special instructions indicated to rotate sites. A physician's order, initiated on 7/25/24, indicated to administer one Fentanyl patch 50 mcg per hour every 72 hours. The special instructions indicated to remove the old patch first and rotate sites. 3. During an interview, on 8/29/24 at 9:04 a.m., RN 4 indicated staff were to count all narcotic cards, bottles and patches. Staff needed to sign on/off in the narcotic logbook. Staff were to check for placement of medication patches every shift. Medication destruction needed to be completed with two nurses and both nurses must sign off on the destruction. The narcotic count sheets were reviewed for all units on 8/29/24 in conjunction with the medication pass administration. An untitled document used to count controlled substances, dated August 2024, for the Cottage (memory care) unit indicated the On-coming nurse signature and Off-going nurse signature was found to be missing signatures for the on-coming nurse for 3 of 85 entries and 7 of 85 entries for the off-going nurse. An untitled document used to count controlled substances, dated August 2024, for the Hall 2 North unit indicated the On-coming nurse signature and Off-going nurse signature was found to be missing signatures for the on-coming nurse for 1 of 85 entries and 2 of 85 entries for the off-going nurse. An untitled document used to count controlled substances, dated August 2024, for the Moving Forward North unit indicated the On-coming nurse signature and Off-going nurse signature was found to be missing signatures for the on-coming nurse for 4 of 85 entries and 4 of 85 entries for the off-going nurse. An untitled document used to count controlled substances, dated August 2024, for the Moving Forward South unit indicated the On-coming nurse signature and Off-going nurse signature was found to be missing signatures for the on-coming nurse for 2 of 85 entries and 5 of 85 entries for the off-going nurse. A facility policy, titled General Dose Preparation and Medication Administration, dated as last revised 4/30/24 and received from the Executive Director on 8/29/24 at 1:20 p.m., indicated .Verify each time a medication is administered .at the correct time .Follow .medication administration guidelines .rotating transdermal patch sites A facility policy, titled Inventory of Controlled Substances, dated 2/1/18 and received from the Executive Director on 8/29/24 at 12:35 p.m., indicated .Facility will utilize the Shift change Verification of Controlled Substances form to count all controlled substance for each medication cart in the facility This Federal tag relates to Complaint IN00439443. 3.1-25(b) 3.1-25(e)(3) 3.1-25(s)(8)

Based on observation, interview and record review, the facility failed to ensure residents received non-disposable utensils to eat their meals with for 17 of 17 residents reviewed for dining on the locked dementia unit. Finding includes: During an observation, on 10/5/23 at 11:34 a.m., the residents were sitting in the dementia dining area. The residents' trays were served by taking food off the tray. Plastic utensils were provided for all residents. During an observation, on 10/5/23 at 12:01 p.m., the residents in the main dining room were being served with non-disposable utensils. During an observation, on 10/11/23 at 11:42 a.m., the residents in the dementia dining room were being served paper napkins and plastic silverware including a spoon, knife, and fork. The staff put the residents' drinks in non-disposable plastic cups. During an interview, on 10/11/23 at 11:52 a.m., CNA 8 indicated a resident owned a restaurant and would take the silverware. CNA 8 indicated the resident might have gone after someone with a fork and everyone got plastic. During an interview, on 10/12/23 at 4:00 p.m., the Dementia Unit Manger and the Director of Nursing Services (DNS) indicated they were only supposed to be using the plasticware for one resident. The resident was care planned for using plastic utensils. The kitchen had sent the non-disposable plastic utensils on the cart for lunch. A Resident Rights policy was not available at the exit conference. 3.1-3(t)

Based on interview and record review, the facility failed to give medications within the prescribed time for 6 of 6 residents reviewed for quality of care. (Residents B, C, D, E, F, G) Findings include: 1. The record for Resident B was reviewed on 10/12/23 at 4:28 p.m. Diagnoses included, but were not limited to, chronic obstructive pulmonary disease, congestive heart failure, hypertension, atrial fibrillation, dementia, unspecified severity with other behavioral disturbance, depressive disorder, and anxiety disorder. A physician's order, dated 11/3/21, indicated clonazepam (for anxiety) 0.5 mg tablet, to give 0.25 mg tablet twice a day related to anxiety. A physician's order, dated 12/2/22, indicated acetaminophen (a pain medication) 500 mg (milligram) tablet, to give 2 tablets three times a day related to chronic pain. A physician's order, dated 6/30/23, indicated simethicone (relieves painful symptoms of too much gas in the stomach) chewable 80 mg to give 2 tablets by mouth daily. The Medication Administration Record (MAR) indicated the following medications were administered late: a. clonazepam 0.5 mg tablet was administered late on 9/5/23. b. acetaminophen 500 mg tablet was administered late on 9/8/23, 9/11/23, 9/22/23, 9/25/23, 10/10/23, 10/11/23 and 10/12/23. c. simethicone chewable 80 mg tablet was administered late on 9/8/23, 9/11/23, 9/22/23, 9/25/23, 10/10/23, 10/11/23 and 10/12/23. During an interview, on 10/5/23 at 2:56 p.m., Resident B indicated medications could be given late depending on what nurses were working and what shift. 2. The record for Resident C was reviewed on 10/12/23 at 4:55 p.m. Diagnoses included, but were not limited to, chronic pulmonary edema, congestive heart failure, and hypertension. A physician's order, dated 10/25/22, indicated acetaminophen 325 mg tablet, to give 1 tablet three times a day related to pain. A physician's order, dated 12/5/22, indicated ferrous sulfate (for anemia) 325 mg tablet, to give 1 tablet by mouth twice a day related to anemia. A physician's order, dated 2/17/23, indicated torsemide (a diuretic) 20 mg tablet, to give 2 tablets twice a day. The MAR indicated the following medications were administered late: a. acetaminophen 325 mg tablet was administered late on 10/9/23, 10/10/23, 10/11/23 and 10/12/23. b. ferrous sulfate 325 mg tablet was administered late on 10/9/23, 10/10/23, 10/11/23 and 10/12/23. c. torsemide 20 mg tablet was administered late on 10/9/23, 10/10/23, 10/11/23, 10/12/23. 3. The record for Resident D was reviewed on 10/12/23 at 5:28 p.m. Diagnoses included, but were not limited to, quadriplegia (paralysis of all four limbs), asthma, and constipation. A physician's order, dated 8/11/23, indicated docusate sodium (a stool softener) 100 mg capsule, to give 1 capsule three times a day. A physician's order, dated 8/11/23, indicated torsemide (a diuretic) 20 mg tablet, to give 2 tablets by mouth daily. A physician's order, dated 8/24/23, indicated Tylenol Extra Strength (for pain) 500 mg tablet, to give 2 tablets three times a day. A physician's order, dated 8/11/23, indicated senna (a laxative) 8.6 mg tablet, to give 2 tablets daily. A physician's order, dated 8/11/23, indicated enoxaparin (an anticoagulant) 40 mg/0.4 milliliter(ml), give 40 mg subcutaneous (injection given just under the skin) daily. A physician's order, dated 9/15/23, indicated hydrocodone-acetaminophen (for pain) 5-325 mg tablet, to give 1 tablet twice a day. The MAR indicated the following medications were administered late: a. docusate sodium 100 mg capsule was administered late on 9/1/23, 9/6/23, 9/13/23, 9/21/23, 9/23/23. b. Tylenol extra strength 500 mg tablet was administered late on 9/1/23, 9/6/23, 9/13/23. c. senna 8.6 mg tablet was administered late on 9/20/23. d. enoxaparin 40 mg subcutaneous was administered late on 9/20/23. e. hydrocodone-acetaminophen 5-325 mg tablet was administered late on 9/15/23 and 9/20/23. 4. The record for Resident E was reviewed on 10/12/23 at 3:22 p.m. Diagnoses included, but were not limited to, Alzheimer's disease, dementia, and pain. A physician's order, dated 4/10/23, indicated acetaminophen 500 mg tablet, to give 2 tablets three times a day related to chronic pain. The MAR indicated the following medication was given late: a. acetaminophen 500 mg tablet was administered late on 9/23/23 and 10/9/23. 5. The record for Resident F was reviewed on 10/12/23 at 3:22 p.m. Diagnoses included, but were not limited to, dementia, pain, hypertension, and Alzheimer's disease. A physician's order, dated 8/19/23, indicated acetaminophen 500 mg tablet, give 1 tablet three times a day related to chronic pain. The MAR indicated the following medication was administered late: a. acetaminophen 500 mg tablet was administered late on 9/6/23 and 9/26/23. 6. The record for Resident G was reviewed on 10/12/23 at 4:00 p.m. Diagnoses included, but were not limited to, chronic obstructive pulmonary disease (COPD), asthma, and G-J tube (allows food to be given directly into the jejunum, bypassing the mouth, throat, and stomach). A physician's order, dated 6/29/23, indicated famotidine (for gastric reflux) 40 mg/5 ml suspension (liquid), give 20 mg daily. A physician's order, dated 9/8/23, indicated guaifenesin (for congestion) 100 mg/5 ml, give 600 mg twice a day related to congestion. A physician's order, dated 9/8/23, indicated magnesium oxide (for gastric reflux) 400 mg tablet give daily. A physician's order, dated 9/8/23, indicated multivitamin with folic acid (a supplement) 400 microgram (mcg) tablet, give 1 tablet daily. The MAR indicated the following medications were administered late: a. famotidine 40 mg/5 ml suspension 20 mg daily was administered late on 9/21/23, 9/22/23, and 9/26/23. b. guaifenesin 100 mg/5 ml, 600 mg twice a day was administered late on 9/30/23. c. magnesium oxide 400 mg tablet daily was administered late on 9/30/23. d. multivitamin with folic acid 400 microgram tablet was administered late on 9/30/23. During an interview, on 10/12/23 at 3:39 p.m., RN 3 indicated sometimes staff would get sidetracked when passing medication and would have to just chart late. During an interview, on 10/12/23 at 3:44 p.m., LPN 7 indicated things came up, you got too busy, or you just did not have time and medications were passed out late. A current policy, titled Medication Pass Procedure, revised 12/2016 and received from the Director of Nursing Services on 10/12/23 at 3:53 p.m., indicated .1. Medication administered within 60 minutes before and/or after time ordered .6. Perform the 5 rights of medication Right Resident, Right Medication, Right Dose, Right Route, Right Time .16. Medication administration will be recorded on the MAR/EMAR or TAR after given This Federal tag relates to Complaint IN00418152. 3.1-37(a)

Based on observation, interview and record review, the facility failed to ensure the Minimum Data Set (MDS) assessment included the resident had a wanderguard for 1 of 1 resident reviewed for elopement. (Resident E) Finding includes: During an observation, on 10/5/23 at 3:28 p.m., Resident E had a wanderguard on her right ankle. The record for Resident E was reviewed on 10/10/23 at 10:44 a.m. Diagnoses included, but were not limited to, depression, dementia with mood disturbance, cognitive communication deficit, difficulty in walking, and a history of a traumatic brain injury. An MDS assessment, dated 8/11/23, indicated the resident did not use a wanderguard. During an interview, on 10/10/23 at 2:33 p.m., the MDS Coordinator indicated the resident did not have a physician's order for the wanderguard which was placed on 8/7/23. The only way she found out if the resident had a wanderguard was by reviewing the physician's orders. Since there was no physician's order then she did not code the MDS assessment with the wanderguard. During exit, the facility indicated they used the RAI (Resident Assessment Instrument) manual for instructions to complete MDS assessments. 3.1-31(d)(3)

Based on observation, interview and record review, the facility failed to ensure a resident with a wanderguard (an alarm bracelet) had a physician's order, daily assessment for placement and a care plan for the alarm for 1 of 1 resident reviewed for elopement. (Resident E) Finding includes: During an observation, on 10/5/23 at 3:28 p.m., Resident E had a wanderguard on her right ankle. During an observation, on 10/10/23 at 2:21 p.m., the resident was in her room watching television and had the door to her room closed. During an observation, on 10/10/23 at 10:54 a.m., the resident was sitting up in a chair in the dining room and listening to music with other residents. The resident had not been observed wandering or trying to leave the locked unit. The record for Resident E was reviewed on 10/10/23 at 10:44 a.m. Diagnoses included, but were not limited to, depression, dementia with mood disturbance, cognitive communication deficit, difficulty in walking, and a history of a traumatic brain injury. A care plan, dated 5/1/23, indicated the resident was at risk for elopement as evidenced by walking up to the exit doors, intrusive wandering into other resident's room, asking for keys to her car and stating she needed to get out the doors to go upstairs. The interventions included, but were not limited to, offer assistance, all facility exits secured, resident resides on a secured unit, and to redirect to activities of interest. The care plan interventions did not include a wanderguard. A physician's order, dated 6/12/23, noted it was clinically indicated for the resident to reside on a secured unit. During an interview, on 10/11/23 at 11:00 a.m., the Minimum Data Set (MDS) Coordinator indicated there was no physician's order for the resident's wanderguard. The wanderguard was placed on 8/7/23. The resident knew the code to the dementia unit. Since there was no physician order, there was no documentation the wanderguard was checked daily for function and placement. A current policy, titled Elopement Prevention and Response Program, revised on 10/20 and received from the Executive Director (ED) on 10/10/23 at 3:58 p.m., indicated .Residents at risk for elopement may utilize a security bracelet [if the facility utilizes an electronic monitoring system and need for device is present on the care plan] per physician's order that will be checked for placement and function no less often than daily. Security bracelets will be placed on residents appropriately and per manufacturer's instructions 3.1-45(a)(1)

Based on interview and record review, the facility failed to identify and implement resident specific preventative nursing measures for a resident with multiple repeat urinary tract infections (UTI) for 1 of 3 residents reviewed for UTIs. (Resident F) Finding includes: The record for Resident F was reviewed on 10/10/23 at 3:55 p.m. Diagnoses included, but were not limited to, Alzheimer's disease, chronic kidney disease stage 3, need for assistance with personal care, urinary tract infection, and difficulty in walking. The Surveillance Log indicated the resident had the following UTIs and treatments: 1. October 6-13, 2022, ceftriaxone for a urine culture positive for E coli. 2. October 26-November 11, 2023, amoxicillin for a culture report positive for P. mirabilis (a bacteria which causes UTIs). 3. January 1-7, 2023, Macrobid (an antibiotic for UTIs). There was no culture report. 4. February 15- 20, 2023, cephalexin (an antibiotic) for a urine culture positive for proteus mirabilis. 5. March 24-29, 2023, Augmentin for a urine culture positive for E. Coli (a bacteria found in stool). 6. April 4, 2023, Keflex (an antibiotic) for a UTI with no urine culture results on the log. 7. April 21, 2023, cephalexin for a UTI with no urine culture results on the log. 8. June 16, 2023, cephalexin as preventative for a UTI. 9. July 21-August 5, 2023, Bactrim DS for a UTI with no urine culture results on log. 10. September 26-October 3, 2023, cephalexin for a UTI with a culture report positive for E. Coli. A care plan, dated 7/5/22 and last reviewed/revised on 9/28/23, indicated the resident required assistance with toileting due to incontinence. The goal was the resident would not exhibit adverse effects from incontinence. The interventions included, but were not limited to, assist with clothing, incontinent care as needed, and toilet before rising, before or after meals and at bedtime. The care plan was not updated to include the repeat UTIs or the specific type of peri care to prevent stool from entering the urinary tract. During an interview, on 10/12/23 at 2:06 p.m., the Director of Nursing Services (DNS) indicated the resident's care plans were started and stopped each time the antibiotics for the UTIs were started and stopped. Even though the resident was being seen by a urologist and had repeat UTIs with E. Coli (a bacteria found in stool) there was no care plan for the repeat UTIs, and no care planned interventions for the repeat UTIs. A current policy, titled Infection Prevention System of Surveillance, revised 05/2023 and received from the Executive Director (ED) on 10/5/23 at 2:20 p.m., indicated .To conduct surveillance activities that will identify infections and prevent the spread of infections .SURVEILLANCE COMPONENTS .Investigation . Document/Records .Monitor .Data Analysis .Implementation .Report .MONITOR .Provide ongoing tracking to rule out an infection, the development of new/recurrent infections and/or spread of infections 3.1-41(a)(2)

Based on observation, interview and record review, the facility failed to identify significant weight changes, implement timely interventions, and notify the provider and family in a timely manner for 2 of 4 residents reviewed for nutrition. (Resident 31 and E) Findings include: 1. The record for Resident 31 was reviewed on 10/12/23 at 12:10 p.m. Diagnoses included, but were not limited to, iron deficiency anemia, chronic obstructive pulmonary disease, dementia, feeding difficulties, and fracture of the right femur. A weight log indicated the following: a. On 9/7/23, the resident's weight was 144 pounds. b. On 10/4/23, the resident's weight was 131 pounds. c. On 10/6/23, the resident's weight was 131 pounds. The resident had a 9.03%- or 13-pound weight loss in 27 days. A progress note, dated 10/06/2023 at 3:15 p.m., indicated an MDS (Minimum Data Set) significant change assessment was initiated for a significant weight loss. The facility did not contact the provider or family after recognizing the significant weight loss. A progress note, dated 10/12/23 at 12:28 p.m., indicated the facility notified the provider and called the family about the significant weight loss on 10/11/23. A progress note, dated 10/12/23 at 1:02 p.m., indicated the facility spoke with the son of the resident and he indicated the resident loved sliced ham, peanut butter sandwiches, ice cream, and cakes. The facility would add ice cream to the dinner tray with a peanut butter sandwich at lunch. During an interview, on 10/12/23 at 1:55 p.m., the DNS (Director of Nursing Services) indicated the provider was not notified until 10/11/23 because the facility reviewed weights on Mondays. The NP (Nurse Practitioner) was notified on 10/11/23. There was a 7-day gap between when the resident had a significant weight loss, and the provider and family were notified. The resident had the weight loss on 10/4/23 and the facility recognized the weight loss on 10/6/23 when an MDS significant change assessment was initiated but did not notify the provider or family until 10/11/23. 36454 2. The record for Resident E was reviewed on 10/10/23 at 10:44 a.m. Diagnoses included, but were not limited to, nutritional anemia, dementia with mood disturbance, cognitive communication deficit, need for assistance with personal care, and a history of a traumatic brain injury. A care plan, dated 5/1/23 and last reviewed/revised on 8/18/23, indicated the resident was at a nutritional risk due to the diagnoses of metabolic encephalopathy and protein-calorie malnutrition. The goal indicated the resident would not have a significant weight change. The interventions included, but were not limited to, honor known food preferences, monitor weight, and notify physician/family of significant weight changes. A Registered Dietician (RD) note, dated 5/5/23 at 11:44 a.m., indicated the resident's diagnoses may increase her nutritional risks. The current weight was 142 pounds and the resident's usual body weight was 130-140 pounds. The resident had the following weights: a. On 4/29/23, the weight was 135.8 pounds. b. On 5/16/23, the weight was 145 pounds which was a 6.77% increase in 17 days. c. On 7/6/23, the weight was 152 pounds which was a 11.93% increase in 68 days. d. On 8/4/23, the weight was 157 pounds which was a 15.61% increase in 97 days. e. On 8/14/23, the weight was 160 pounds which was a 17.88% increase in 107 days. f. On 10/4/23, the weight was 168 pounds which was a 23.71% weight increase since the admission weight on 4/29/23. The resident's body mass index (BMI) on 10/4/23 was 27.11. During an interview, on 10/11/23 at 3:26 p.m., the Director of Nursing Services (DNS) indicated the family was notified of the weight gain in August and there were no notifications to the physician or the family prior to August 2023. The computer variance report only triggered for significant weight changes at 30 days, 90 days, and 180 days. If the significant changes happened at other times, the computer would not show the changes. The facility did not recognize the continued weight gain after August. There was no documentation to show if the significant weight gain was desired, the cause of the significant weight gain, or if interventions were needed for the significant weight gain. A current policy, titled Resident Weight Monitoring, reviewed in July 2023 and received from the DNS on 10/11/23 at 11:10 a.m., indicated .Residents who have experienced a significant wight loss or gain of 5% in 30 days .The physician/health care practitioner will be notified of unplanned significant weight loss/gains A current policy, titled Resident Change of Condition Policy, reviewed in November 2018 and received from the DNS on 10/12/23 at 3:37 p.m., indicated .It is the policy of this facility that all changes in resident condition will be communicated to the physician and family/responsible party, and that appropriate, timely, and effective intervention takes place .All symptoms and unusual signs will be documented in the medical record and communicated to the attending physician promptly .The nurse in charge is responsible for notification of physician and family/responsible party prior to the end of assigned shift when a significant change in the resident's condition is noted 3.1-46(a)(1)

Based on observation, interview and record review, the facility failed to ensure residents oxygen tubing was dated and replaced for 2 of 3 residents reviewed for respiratory care. (Residents 38 and 76) Findings include: 1. During an observation, on 10/5/23 at 11:52 a.m., Resident 38's oxygen tubing did not have a date on it. The record for Resident 38 was reviewed on 10/10/23 at 10:45 a.m. Diagnoses included, but were not limited to, restrictive lung disease, dyspnea (difficulty breathing), chronic respiratory failure, and obstructive sleep apnea. A physician's order, dated 9/22/23, indicated the resident was on 3 liters of oxygen continuously. A physician's order, dated 9/22/23, indicated to change the oxygen tubing once a day on Sundays. During an interview, on 10/5/23 at 2:48 p.m., RN 9 indicated the oxygen tubing should have been dated. During an interview, on 10/10/23 at 3:53 p.m., the ED (Executive Director) indicated the oxygen tubing for residents should be dated. 2. During an observation, on 10/5/23 at 2:45 p.m., Resident 76's oxygen tubing was dated 8/6/23. The record for Resident 76 was reviewed on 10/10/23 at 9:24 a.m. Diagnoses included, but were not limited to, chronic respiratory failure and cognitive communication deficit. A physician's order, dated 6/9/23, indicated the resident was to wear 3 liters of oxygen continuously. A physician's order, dated 6/8/23, indicated to change the oxygen tubing once a day on Sundays. During an interview, on 10 /5/23 at 2:48 p.m., RN 9 indicated the oxygen tubing should have been changed. A current policy, titled Oxygen Therapy and Devices, received from the ED on 10/10/23 at 11:00 a.m., indicated .Change out weekly and PRN 3.1-47(a)(6)

Based on record review and interview, the facility failed to ensure symptom monitoring was in place for the use of an antipsychotic medication prescribed and a gradual dose reduction (GDR) was considered for 1 of 5 residents reviewed for unnecessary medications. (Resident F) Finding includes: The record for Resident F was reviewed on 10/10/23 at 3:55 p.m. Diagnoses included, but were not limited to, dementia with other behavioral disturbance, delusional disorder, major depressive disorder, generalized anxiety disorder, and a cognitive communication deficit. A care plan, dated 2/23/23, indicated the resident was at a risk for adverse side effects related to the use of an antipsychotic. The interventions included, but were not limited to, administer the medication as ordered and observe for effectiveness, the interdisciplinary team (IDT) to review routinely, and to attempt a gradual dose reduction unless contraindicated by the physician. A physician's order, dated 4/10/23, indicated risperidone (an antipsychotic) 0.5 milligram (mg) twice a day for a delusional disorder. The resident had the following documented behaviors: 1. On 5/21/23 at 2:33 p.m., the resident was observed by staff to kneel on the floor and then laid down. 2. On 5/24/23 at 9:58 a.m., the resident was witnessed sitting herself on the floor in her room. 3. On 6/9/23 at 10:57 a.m., the interdisciplinary team met to discuss the resident behavioral expression of the resident laying on the floor. She had intermittent periods of laying on the floor. 4. On 6/27/23 at 2:20 p.m., the resident was walking around in the common area getting up and down out of the chairs and the recliner. The resident was seated in the recliner and scooted forward and slid on the floor. The resident was sitting upright and continued scooting. A Pharmacy Consultation report, dated 7/26/23, indicated the resident had a diagnosis of dementia and received risperidone 0.5 mg twice daily for dementia and related behaviors. Antipsychotics had a boxed warning for the increased risk of mortality in older adults with psychosis related to dementia. Additionally, the antipsychotics were associated with other potentially serious adverse effects including movement disorders, metabolic abnormalities, and orthostatic hypotension. Please consider attempting a gradual dose reduction of risperidone to 0.25 mg twice daily with the end goal of discontinuation. An evaluation of gradual dose reduction of psychotropic medication, dated 8/2/23, indicated the risperidone 0.5 mg supporting diagnosis was delusional disorders. The physician's response included to not reduce the medication since it was clinically contraindicated related to the family was resistant to the dose reduction. The documentation did not include any delusions, for the months of May, June, and July 2023, prior to the GDR being declined on 8/2/23. During an interview, on 10/11/23 at 11:08 a.m., the Dementia Unit Manager (UM) indicated the staff would document delusions in the progress notes or events section of the electronic record if the resident had them. The UM did not remember Resident F having any delusions and she did not mark her as having delusions. During an interview, on 10/11/23 at 12:01 p.m., the Dementia UM indicated the care plan for delusions was stopped in July 2023 and she did not know why it was discontinued. If the resident was not having delusional behaviors, then the care plan would not be kept. During an interview, on 10/12/23 at 10:42 a.m., the Director of Nursing Services (DNS) indicated there was no documentation to show the resident's delusions were monitored after the care plan was discontinued in July 2023. The resident had behaviors when the medication was restarted and not delusions. A current policy, titled Psychotropic Management, revised on 7/22 and received from the Dementia Unit Manager on 10/11/23 at 4:08 p.m., indicated .It is the policy of American Senior Communities to ensure that a resident's psychotropic medication regimen helps promote the resident's highest practicable mental, physical and psychosocial well-being with person centered intervention and assessment. These medications are managed in collaboration with professional services and facility staff to include non-pharmacological interventions, assessment and reduction as applicable .Residents are not given psychotropic drugs unless the medication is necessary to treat a specific condition as diagnoses, and this is documented in the medical record. Each resident receiving psychotropic medication will have an adequate indicate for use and supporting diagnosis for use which is documented in the clinical record .Symptoms and therapeutic goals must be clearly documented prior to initiating or increasing a psychotropic medication .Gradual dose reductions [GDR] and use of non-pharmacological interventions will occur for residents receiving psychotropic medication unless contraindicated by the prescriber with a specific rationale .For antipsychotic medications, diagnoses alone do not necessarily warrant the use [of]these medications. Antipsychotic medications may be indicated if .behavioral symptoms present a danger to the resident or others .expressions or indications of distress that are significant distress to the residents .Non-pharmacological approaches have been attempted, but did not relieve the symptoms which are presenting a danger or significant distress .GDR was attempted but symptoms returned .Prescribers will evaluate the efficacy and risks for psychotropic medications and document their assessment in the medical record .Psychotropic medications may be considered regularly for potential GDR including during monthly pharmacy reviews, during behavioral health services visits, and when the IDT is evaluating behavioral expressions .When considering a GDR, the prescriber will assess the risks/benefits of the reduction. The prescriber may reduce the medication or clinically contradict the GDR based on relevant clinical standards of practice 3.1-48(a)(3) 3.1-48(b)(2)

Based on observation, interview and record review, the facility failed to label medications with an open date on medications with a shortened expiration date once opened in 1 of 2 medication storage refrigerators and 2 of 3 medication carts (300 Unit, 100 Unit and 300 North Unit). Findings include: 1. During an observation, of 300-unit medication storage room and refrigerator, on 10/5/23 at 12:55 p.m., with LPN 2 in attendance, a bottle of Tuberculin (the testing solution for a Tuberculosis skin test) was found open in the medication storage refrigerator. It did not have an open date. During an interview, on 10/5/23 at 12:55 p.m., LPN 2 indicated it should have been labeled with the open date when it was opened. 2. During an observation, of the 100 Unit Medication Cart, on 10/10/23 at 9:21 a.m., with RN 3 in attendance, an Advair inhaler was found outside the original foil packaging. The inhaler had 56 of 60 doses left. The label on the packaging indicated the medication expired 30 days after opening. There was no open date on the packaging or inhaler. During an interview, on 10/10/23 at 9:21 a.m., RN 3 indicated the inhaler should have been labeled with an open date. 3. During an observation, on 10/10/23 at 9:30 a.m., with LPN 2 in attendance, a Novolin insulin pen was found open in the drawer of the 300 North Hall cart. The pen had approximately 200 units left. There was no open date on the packaging or pen. During an interview, on 10/10/23 at 9:30 a.m., LPN 2 indicated it should have been dated when opened and the insulin pen was good for 28 days after opening. A current facility policy, titled Storage and Expiration Dating of Medications, Biologicals, dated as last revised on 8/7/2023 and received from the Director of Nursing Services on 10/10/23 at 11:32 a.m., indicated .Facility staff should record the date opened on the primary medication container (vial, bottle, inhaler) when the medication has a shortened expiration date once opened 3.1-25(j)

Based on observation, interview and record review, the facility failed to ensure a catheter bag was not touching the ground for 1 of 1 resident reviewed for infection control related to catheters. (Resident 14) Finding includes: During an observation, on 10/11/23 at 10:21 a.m., Resident 14 was being seen for wound care. The resident's catheter bag was observed to be touching the ground. During an observation, on 10/11/23 at 10:33 a.m., the bed was lowered back down after wound care was completed and the catheter bag touched the ground again. The basin to protect the catheter bag from touching the floor was underneath the bed towards the head of the bed and not underneath the catheter bag. The record for Resident 14 was reviewed on 10/11/23 at 3:09 p.m. Diagnoses included, but were not limited to, obstructive and reflux uropathy, history of urinary tract infections, and dementia. During an interview, on 10/11/23 at 10:37 a.m., the ADON (Assistant Director of Nursing) indicated the catheter bag should have a basin which the catheter bag sat in to prevent it from touching the ground. During an interview, on 10/12/23 at 11:37, the DNS (Director of Nursing Services) indicated the basin was in place when staff set up the wound care but must have been kicked under the bed before it was observed. The basin was not in place during wound care. A CDC (Centers for Disease Control) guideline, titled GUIDELINES FOR PREVENTING CATHETER-ASSOCIATED URINARY TRACT INFECTIONS 2009, dated 2009 and updated 6/6/2019 indicated .Keep the collecting bag below the level of the bladder at all times. Do not rest the bag on the floor 3.1-18(b)

Based on interview and record review, the facility failed to protect a resident from injury when the resident was left unattended in a bed which was not in the lowest position, and without a fall mat on the floor. The resident fell out of bed, sustained a laceration to the left side of the forehead and an acute left femoral neck fracture (a type of hip fracture of the thigh bone, just below the ball of the ball-and-socket hip joint). (Resident B) The facility also failed to ensure staff providing care were using/following the care sheet or electronic record which provides information on safety precautions put in place, resulting in Resident C had to be lowered to the floor, for 2 of 3 residents reviewed for accidents. (Resident B and C) The deficient practice was corrected on 9/12/23, prior to the start of the survey, and was therefore past noncompliance. Findings include: 1. During a phone interview, on 9/19/23 at 10:04 a.m., the Power of Attorney (POA) for Resident B indicated Resident B was dressed and prepped for a full body mechanical lift, which should have had two people to perform. After the resident was dressed, the other staff member should have remained in the room with Resident B. The POA indicated she felt the facility was not following protocol and the resident sustained injury during the lift and indicated she was dropped during a Hoyer [mechanical lift] transfer. She did not see her [the resident] having the strength to roll out of bed. During an interview, on 9/19/23 at 1:02 p.m., Resident 7 (Roommate for Resident B) indicated she was awake when Resident B fell . The CNA came in, got her ready, and put the Hoyer pad under her then left the room to get the lift. She did not know why she did not bring it with her, they usually did, but she heard a thud like a basketball hitting the floor. Another aide who was working on the hall, must have seen her on the floor. She was the one who responded. The record for Resident B was reviewed on 9/19/23 at 11:13 a.m. Diagnoses included, but were not limited to, dementia, unspecified fracture of unspecified femur, and fracture of unspecified part of neck of right femur subsequent encounter for closed fracture with routine healing status after a partial hip replacement procedure. A care plan, with a problem start date of 6/11/17, indicated Resident B was at risk for falls related to, but not limited to, dementia, impulsive and polyneuropathy (simultaneous malfunction of many peripheral nerves throughout the body). The interventions included the bed was to be in the lowest position when the resident was in the bed. A physician's order, with a start date of 4/20/22, and end date of 9/15/23, indicated .Mattress on floor next to bed when in bed .every shift The Medication and Treatment Record was signed off by the nurse, on the day of the fall, to indicate the mattress/mat was present on the floor at the bedside, when the nurse checked Resident B. A Care Sheet (resident care profile), provided by LPN 2 on 9/19/23, at 1:31 p.m., indicated .Bed in lowest position when resident is in the bed A nursing note, dated 9/8/2023 at 7:36 a.m., indicated .CNA called writer et [and] said resident is on the floor. Writer went in et saw resident lying on her left side bleeding from her L [left] forehead. Had 3x.5 cm [centimeter] cut; Pressure applied to stop bleeding. As per aide, resident rolled out of bed as she reached out to get Hoyer lift [full body mechanical lift] to transfer resident A radiology report, dated 9/8/23, indicated Resident B had an acute left femoral neck fracture. An Incident Report to the Indiana State Department of Health, dated 9/8/23, indicated the resident was found on the floor next to the bed. The resident had a laceration to the forehead and was complaining of hip pain. A statement provided by the Executive Director, on 9/20/23 at 11:40 a.m., indicated .I [CNA 1 name] was getting Resident B dressed for the day. After dressing the resident, the lift pad was placed under her, and she was left laying on her back .I believe she tried to get up from the bed when I went to get a spotter/the nurse to help me with the Hoyer lift. When I stepped out and return, she was laying on the floor The statement was unsigned and undated. A statement provided by the Executive Director, on 9/20/23 at 11:40 a.m., indicated Resident B had been witnessed moving in the bed unassisted. The statement was signed by LPN 4 on 9/8/23. A statement provided by the Executive Director, on 9/20/23 at 11:40 a.m., indicated Resident B was witnessed moving by herself in bed and there were times where she had witnessed Resident B sitting up in bed and the resident would attempt to get out of bed herself. She would have her legs out of bed sitting upright as if she was going to stand and try to get up. The statement was signed by Staff 5 on 9/11/23. A statement provided by the Executive Director, on 9/20/23 at 11:40 a.m., indicated Resident B was observed independently moving her body and repositioning herself. The statement was signed by LPN 6 on 9/15/23. During an interview, on 9/19/23 at 1:29 p.m., the Director of Nursing indicated the CNAs could find safety information on their care sheets. They could also pull up the information electronically. During an interview, on 9/19/23 at 2:10 p.m., the Director of Nursing indicated staff were supposed to follow the care plan and the CNA was supposed to follow the care sheet. During a telephone interview, on 9/19/23 at 2:20 p.m., CNA 1 indicated she was getting Resident B up and dressed. She put the full body mechanical lift sling under Resident B after she dressed her. She left the room to get a spotter (second person to assist with the lift transfer) and when she returned Resident B was on the floor. She indicated the bed was not high at all, maybe medium, she left Resident B lying on her back in the bed. She believed the resident tried to get up. She did not have the CNA care/assignment sheet, she did not know they (the facility) had them and she did not know where to find them. It was her first time working the night shift and the front hall. The resident did not have a mat on the floor beside her bed when she entered the room. During an interview, on 9/19/23 at 2:46 p.m., LPN 3 indicated when she responded to the fall for Resident B, the bed was at hip height (her hip height) and indicated the bed was to be in a low position when the resident was in bed. She also indicated the mat was on the floor at the bedside during the shift; she did check it during her shift. A document, titled Employee Communication Form, provided by the Executive Director on 9/20/23 at 11:40 a.m., indicated .Res [resident] was left unattended without fall precautions being put back in place, that resulted with res falling out of bed The document was signed by CNA 1 and the Assistant Director of Nursing on 9/12/23. 2. The record for Resident C was reviewed on 9/19/23 at 12:50 p.m. Diagnoses included, but were not limited to, unspecified dementia with other behavioral disturbance, essential hypertension, and generalized muscle weakness. A care plan, initiated on 12/30/21, indicated the resident required assistance with activities of daily living (ADLs) including transfers. An intervention, initiated on 7/7/22, indicated the resident was to be an assist x 2 with transfers (two people were needed to transfer the resident). A nurses' note, dated 7/5/23 at 10:26 a.m., indicated .Resident being assisted from toilet to wheelchair and started to sit down before in contact with wheelchair. Staff lowered her to floor to prevent injury. Resident assisted off floor and into wheelchair and then bed. No injuries noted. ROM [range of motion] WNL [within normal limits]. Denies pain. Did not hit head On 9/19/23 at 1:29 p.m., a care plan policy and safety intervention policy were requested of the Director of Nursing. During an interview, on 9/19/23 at 2:10 p.m., the Director of Nursing indicated the facility did not have a policy on safety interventions and she provided the care plan policy. During a telephone interview, on 9/19/23 at 2:50 p.m., CNA 7 indicated it was her first day. She was working the other side and she did not have Resident C on her assignment. She heard Resident C yelling for help and thought it was an emergency, so she responded. She was not aware of how the resident transferred and thought she was a limited transfer. She transferred the resident with a gait belt to toilet, she changed the resident on the toilet, and put on socks with the gripper (nonskid). When she went to transfer the resident back to the chair, the resident said she was going to fall. CNA 7 called for another CNA, in the hall, and together they gently lowered the resident to floor and then got the nurse. She indicated she did not have a resident care sheet, it was electronic. During an interview, on 9/20/23 at 8:54 a.m., the Executive Director (ED) indicated the resident care profile were to be carried on the CNA along with a gait belt. CNA care profiles are in a three (3) ring binder at each nursing station. The CNAs knew where to find them, even clinical resource group (corporate as needed pool of employees) are educated in training on where they can be found for all facilities. He and management complete rounds in the morning and check to be sure gait belts and care sheets are with the CNAs. A current policy, titled IDT Comprehensive Care Plan Policy, dated as last reviewed on 8/2023 and received from the Director of Nursing on 9/19/23 at 2:10 p.m., indicated .It is the policy of this facility that each resident will have an interdisciplinary comprehensive person-centered care plan developed and implemented .The care plan must include .resident specific interventions based on the residents needs and preferences to promote the psychosocial well-being. Physician's orders are considered part of the comprehensive plan of care The deficient practice was corrected by 9/12/23 after the facility implemented a systemic plan that included the following actions: The facility investigated the incident involving Resident B, disciplined CNA 1, educated the staff on fall prevention, began audits on safety precautions in place for all residents with fall risks, and ensured Resident B received medical care as well as follow up care and monitoring. This Federal Tag relates to Complaint IN00417153. 3.1-45(a)(2)

Based on observation, interview and record review, the facility failed to ensure a resident received treatment and care in accordance with professional standards of practice and to notify the physician with a change of condition for 2 of 2 residents reviewed for catheter care. (Resident 49 and 290) Resident 49 was not provided care to address concerns which developed after a urinary catheter was placed which led to a hospitalization with intravenous antibiotic intervention for the development of [CONDITION(S)]. Findings include: 1. The record for Resident 49 was reviewed on 9/30/22 at 10:55 a.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility document, titled Admit Discharge Report, dated 8/1/22 to 10/31/22, indicated Resident 49 was discharged /transferred to the hospital on 9/10/22. A care plan, dated of 9/16/22, indicated Resident 49 was readmitted to the facility with a [CONDITION(S)] (Urinary Tract Infection) and directed staff to report concerns for urinary tract infection such as acute confusion, urgency, frequency, bladder spasms, nocturia, burning, pain/difficulty urinating, nausea, emesis, chills, fever, low back/flank pain, malaise, foul odor, concentrated urine and blood in urine. The care plan further directed staff to: a. Administer antibiotic as ordered. b. Provide assistance for catheter care. c. Change catheter per MD order. d. Keep catheter system a closed system as much as possible. e. Manipulate tubing as little as possible during care. f. Position bag below level of bladder. g. Avoid obstructions in the drainage. h. Store collection bag inside a protective dignity pouch. i. Do not allow tubing or any part of the drainage system to touch the floor. Physician's orders, dated 9/16/22, included, but were not limited to, a. Catheter orders: to change Foley catheter and urinary drainage bag as needed for dislodgement, leakage, or occlusion. b. Catheter orders to change Foley catheter monthly Size: 16 Fr (French) - 10 ml (milliliter) bulb. Once a Day on the 15th of the month. c. Catheter orders for Foley catheter care. Nurse to record output every shift. d. Catheter orders to change catheter bag weekly on Sunday. A hospital discharge summary, dated 9/16/22, indicated the resident was treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility document, titled Healthcare Associated Infection Report, dated 8/22, indicated a total of 12 types of infection with an infection rate of 4.5 percent. The facility document, titled Surveillance Log of Resident infections and antibiotic use, indicated, on 9/17/22, Resident 49 was started on [MEDICATION(S)] antibiotic for [CONDITION(S)] and urinary tract infection. The surveillance log indicated Resident 49 had a Healthcare-Associated Infection (HAI). A review of the nurse progress notes, from 9/9/22 at 10:42 p.m., until 9/10/22 at 2:11 p.m., indicated Resident 49 had no urine output, no bladder scan completed and no call to the provider to notify of concerns of no urine output. A nurse progress note, dated 9/10/22 at 2:11 p.m., indicated the resident had no output of urine after a Foley placement. Blood was noticed in Resident 49's catheter tube. The Nurse Practitioner was notified and directed staff to remove Foley and reinsert Foley due to possible swelling. Upon reinsertion of the Foley catheter, blood had begun to flow from penis. The NP directed staff to send Resident 49 to the emergency room for evaluation. A nurse progress note, dated 9/10/22 at 2:43 p.m., indicated Resident 49 was transferred to the hospital. A nurse progress note, dated 9/10/22 at 11:29 p.m., indicated the hospital notified the facility Resident 49 was admitted to the intensive care unit with the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A nurse progress note, dated 9/10/22 at 6:00 a.m., indicated Resident 49 had 16 Fr/30 cc Foley catheter inserted at the end of 2nd shift on 9/9/22. No output was noted from the resident's Foley catheter at the time of this entry. The progress note indicated a reinsertion was attempted of the Foley catheter with no effective results and staff would continue to monitor. The progress note lacked indication the provider was notified. A nurse progress note, dated 9/16/22 at 5:25 p.m., indicated Resident 49 had returned to the facility after hospitalization at 5:00 p.m. A nurse progress note, dated 9/16/22 at 1:56 a.m., entered at as a late entry on 9/17/22 at 2:03 a.m., indicated Resident 49 was on intravenous antibiotic [MEDICATION(S)] and had a midline placed in the left upper extremity. A nurse progress note, dated 9/23/22, indicated Resident 49 was on intravenous antibiotic for [CONDITION(S)] and urinary tract infection. During an interview, on 10/5/22 at 11:05 a.m., the Assistant Director of Nursing (ADON) indicated Resident 49 was hospitalized from 9/10/22 to 9/16/22 for the treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 49 had Enterobacter urinary tract infection. The catheter was placed, on 9/9/22, for the treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] During an interview, on 10/5/22 at 12:15 p.m., the Director of Nursing (DON) indicated Resident 49 had a hospital admission due to bacteremia related to catheter associated infection. The DON and Corporate Regional Director of Clinical Services indicated a nurse made insertion of a catheter attempt twice and left it in place with no urine output. At around 2:00 p.m., a nurse found blood in the catheter tube and notified the Nurse Practitioner (NP). The RN had no documentation of the output of urine after Foley placement and later noticed blood in urine tube of the Foley catheter. When the catheter was originally placed and the staff did not get urine return, the nurse should have notified the provider and completed a bladder scan. The DON and Corporate Regional Director of Clinical Services indicated no documentation was completed until after 2:00 p.m., and the staff should have checked within 6 to 8 hours for urine return. A resident could be at risk each time a catheter was attempted or placed. During an interview, on 10/6/22 at 9:50 a.m., Nurse Practitioner (NP) 22 indicated staff should notify the provider if there was no urine output for an 8-hour shift and complete a bladder scan if available, straight catheterization, or insert a Foley catheter. She was not notified until after 2:00 p.m., with the concern about blood in the catheter tubing and the resident was at risk for hospitalization due to repeat catheterizations and no urine output for more than 16 hours. During an interview, on 10/6/22 at 11:18 a.m. the Infection Preventionist (IP) indicated the facility did have residents who had recurrent [CONDITION(S)]'s, who had catheters. He had provided education to staff on Hand Hygiene and Peri care, also staff were provided with skills validation regarding catheter insertion and catheter cares. He found no trends related to urinary tract infections within the facility. When Resident 49 was admitted to the hospital or readmitted to the facility, he would review the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During the review of the surveillance records, no trends were found for [CONDITION(S)]. No formal audits were completed on catheters and infections. At least one resident in the last month developed a [CONDITION(S)] with a catheter. Nursing staff were given skills validation for catheter insertion upon hire and nursing assistants are given education on peri care. During an interview, on 10/6/22 at 1:30 p.m., the Executive Director (ED) indicated nursing staff could look on the Electronic Medical Record (EMR) for information on how to perform a procedure. 2. During an observation, on 9/29/22 at 12:03 p.m., Resident 290's catheter was in place and the Foley catheter bag hung on the right side of the wheelchair, at waist level. The urine was dark yellow in color and no dignity bag covered the catheter bag. During an interview, on 9/29/22 at 12:03 p.m., a family member indicated Resident 290 had a catheter placed while in the hospital because he had urinary retention after surgery. Resident 290 had a trial for the catheter removal but required staff to reinsert it because Resident 290 was suffering from significant abdominal pain. She had observed on multiple occasions the catheter bag was hung too high to drain. During an observation, on 9/30/22 at 2:10 p.m., Resident 290's Foley catheter tubing was located under the brace of the right leg with the Foley catheter bag hung on the right side of the recliner chair. The record for Resident 290 was reviewed on 10/3/22 at 8:30 a.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An admission Minimum Data Set (MDS) assessment, dated 9/28/22, indicated Resident 290 had a severe cognitive impairment, moderately impaired vision, and required a total assist with activities of daily living (ADL's) and mobility. A care area assessment (CAA), dated 09/28/22, indicated Resident 290 triggered for an indwelling catheter related to post-op urinary retention. Resident 290 had a failed trial of a catheter removal and had the catheter reinserted. A care plan, dated 9/25/22, indicated Resident 290 was admitted with an indwelling urinary catheter related to post-op urinary retention and was at risk for infection. The care plan directed staff to use approaches to avoid obstructions in the drainage, change the catheter per MD order and do not allow tubing or any part of the drainage system to touch the floor. The care plan directed staff to keep catheter system a closed system as much as possible and manipulate tubing as little as possible during care. Resident 290's care profile, printed on 9/30/22 at 6:30 a.m., indicated he had a Foley catheter and denuded skin to the groin and penile area. A physician's orders report, dated 10/1/22 to 10/5/22, included, but were not limited to, the following orders: a. On 9/22/22, change Foley catheter monthly, size 16 French (Fr) with 10 ml balloon on the 21st of each month. b. On 9/22/22, change Foley catheter and urinary drainage bag as needed for dislodgement, leakage, or occlusions. c. On 9/22/22, Foley Catheter care, nurse to record output every shift. d. Change Foley catheter drainage bag weekly. A nurse progress note, dated 9/23/22 at 1:07 a.m., indicated Resident 290 had a 16 Fr 10 cc Foley catheter upon admission. A nurse progress note, dated 9/24/22 at 12:43 p.m., indicated Resident 290 had an 18 Fr Foley catheter. A nurse progress note, dated 9/25/22 at 10:39 p.m., indicated Resident 290 had an 18 Fr Foley catheter. A nurse progress note, dated 9/27/22 at 7:28 p.m., indicated Resident 290 did not have urinary output and an 18 Fr Foley catheter was re-anchored. Obtained 600 cc of clear urine. A nurse progress note, dated 9/28/22 at 1:01 p.m., indicated Resident 290's tip of penis was red and swollen and night staff saw him tugging and pulling on the Foley. A nurse progress note, dated 9/28/22 at 4:00 p.m., indicated Resident 290 passed a small amount of urine, complained of abdominal discomfort, irritation of penis and groin. A nurse progress note, dated 9/28/22 at 4:10 p.m., indicated Resident 290 had a new intervention initiated with discontinue of Foley catheter. A nurse progress note, dated 9/28/22 at 7:03 p.m., indicated Resident 290 had abdominal distention and no urine output, an 18 Fr Foley catheter re-anchored. A nurse progress note, dated 9/28/22 at 9:22 p.m., indicated Resident 290 upon assessment at the beginning of the shift was complaining of severe abdomen pain. The abdomen was very distended and hard to touch. Resident 290 indicated he could not urinate. A bladder scan was done and read 800 cc of urine in the bladder. The resident's groin area was very red, swollen and painful to touch. A Foley catheter 18 Fr/10 cc was inserted. Urine return noted of 1200 cc of bloody urine return. The procedure was painful to Resident 290. A Treatment Administration History, dated from 9/22/22 to 10/5/22, indicated Resident 290: a. Had no urine output on 9/26/22, from 10:30 p.m., to 6:30 a.m. b. A small amount of urine output, on 9/27/22, for the shift from 6:30 a.m. to 2:30 p.m. c. On 9/27/22, for 2:30 p.m. to 10:30 p.m., indicated discontinued, and no urine output was documented. d. On 9/28/22 at 10:57 p.m., indicated 600 ml urine output. An acute care visit physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . The progress note further indicated new orders were given to remove Foley and monitor for urine output. A progress note indicated Resident 290 was scheduled for an appointment with Urology on 9/28/22 and had been rescheduled for 10/5/22. During an interview, on 10/5/22 at 12:34 p.m., the Director of Nursing (DON) indicated Resident 290 had a catheter in place for urinary retention. On 9/27/22 at 10:30 a.m., an order was placed to remove the catheter and reinsert/re-anchor if no urine output. The physician's order did not indicate a time frame for notification of no urine output. She had concerns about the lack of documentation of the removal of Resident 290's catheter and amount of urine output. Resident 290's progress note, on 9/27/22 at 7:28 p.m., indicated the resident had no urine output and a catheter was reinserted with 600 cc of urine returned. During an interview, on 10/5/22 at 1:50 p.m., the Medical Records staff and Director of Nursing (DON) indicated Resident 290 had a conflict with having an orthopedic and urology appointment on the same date and time. Medical Records staff spoke to the Nurse Practitioner, on 9/27/22 at 10:30 a.m., and entered the order for the removal of the catheter and notified the nurse on duty to remove the catheter and monitor urine output. The DON indicated the staff should have used nursing judgement and used a nursing assessment. During an interview, on 10/6/22 at 9:50 a.m., Nurse Practitioner (NP) 22 indicated her expectation for staff would be to notify the provider if there was no urine output after removing a catheter in an eight-hour shift. Staff did not notify her of concerns for no urine output. Her expectation would be for staff to notify the provider, complete a bladder scan if available, attempt a straight catheterization or reinsert a Foley catheter if needed. A current policy, titled Resident Change of Condition Policy, dated as revised 11/18, indicated all changes in resident condition will be communicated to the physician and family, timely and effective intervention takes place. The policy directed staff to communicate any sudden or serious change in condition manifested by a marked change in physical or mental behavior. The policy directed staff to document in the medical record all nursing actions and interventions. A current policy, titled Urinary Catheter Insertion, with a review date of 12/12, directed staff to confirm physician order, including catheter and balloon size. The policy further directed staff to check the catheter and tubing for drainage. The policy lacked indication of monitoring for urinary output and reporting concerns to provider. A current policy, titled Indwelling Urinary Catheter Care, Emptying Drainage Bag, and Catheter Removal, with a review date of 12/12, lacked indication of monitoring for urinary output and reporting concerns to provider. This Federal tag relates to Complaint IN 366. 3.1-41(a)(2)

Based on observation, interview and record review, the facility failed to thoroughly assess and document a resident's change in respiratory status, to notify the physician of signs of respiratory distress and when a [CONDITION(S)]/[CONDITION(S)] (machine used to help with breathing) was not available for a resident who was at risk for respiratory complications and required a hospitalization (Resident 293), and to ensure the humidification was used and wore correctly, infection control measures were in place by labeling and storing equipment appropriately for [CONDITION(S)] care (a tube surgically placed in the throat to assist with receiving air into the lungs) (Resident 49) and failed to obtain a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: 1. During an observation and interview, on 9/29/22 at 1:53 p.m., Resident 293's door was closed. The resident was found lying in bed with the head of the bed at a 75 degree angle. The resident's eyes were closed and she was positioned with her hips past the crease in bed, head on the wall, and right leg hanging over the side of the bed. An oxygen concentrator was on at 4 liters per minute (LPM), there was no label on the tubing or the [CONDITION(S)]/[CONDITION(S)]. She was observed to have abdominal retractions and audible grunting was heard with breathing. Staff were requested to come to the room. The Infection Preventionist (IP) indicated the oxygen concentrator was on at 4 LPM, no label was on the oxygen tubing and the resident was in a poor position. During observation and interview, on 9/29/22 at 03:49 p.m., Resident 293's door was closed, and resident was observed lying in bed with nasal cannula on the bedside table and out of reach of the resident. Oxygen concentrator was set at 1.5 LPM. Resident was attempting to communicate but the words were nonsensical, abdominal retractions were noted. IP verified oxygen concentrator settings and nasal cannula was not on, he indicated Resident 293 must have taken the oxygen off. During an observation, on 9/30/22 at 8:26 a.m., the resident's door was closed and she was observed to be seated at the side of the bed. Her nasal cannula and tubing were on the dirty floor. The oxygen concentrator was set at 2.5 LPM. The resident had a deep moist cough, mouth breathing and bilateral lower extremity [CONDITION(S)] from her toes to her knees. The resident seemed to be confused and tried to communicate but words were nonsensical. During an observation, on 9/30/22 at 2:36 p.m., the resident was observed lying in bed with head of bed at a 30 degree angle. Her head was positioned on the wall, her hips pass the crease in bed and her legs were dangling over the exit side of bed. The oxygen was set on 2.5 liters via nasal cannula. The [CONDITION(S)]/[CONDITION(S)] mask and tubing were lying under the bed on the dirty floor. During an observation, on 10/3/22 at 9:32 a.m., Resident 293's door was closed. She was found lying in bed with the head of bed up at an 80 degree angle, her eyes were closed and a loud grunting noise was heard with each breath with expiratory wheeze. The resident had oxygen on via nasal cannula at 2.5 LPM. The oxygen tubing was not labeled. During an observation, on 10/3/22 at 12:33 p.m., with Registered Nurse (RN) 24, Resident 293's door was observed to be shut. She was found to be hallucinating and was nonsensical, moving her arms and legs up and down. The resident was moving her hands up and down and appeared to be sewing her gown. Her [CONDITION(S)] mask was on the floor, audible wheezes with retractions were observed with an elevated respiratory rate over 30. The nasal cannula was found lying on the bed. The record for Resident 293 was reviewed on 10/4/22 at 8:30 a.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An admission MDS (Minimum Data Set) assessment, dated 9/29/22, indicated Resident 293 had a moderate cognitive impairment. A Care Area Assessment (CAA), dated 9/29/22, indicated the resident triggered for required total assist with activities of daily living (ADL's) and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A care plan, dated 9/25/22, indicated the resident had a risk for impaired gas exchange related to [CONDITION(S)] with shortness of breath while lying flat and obstructive sleep apnea (OSA). The Care Plan directed staff to assess vital signs and lung sounds as needed, [CONDITION(S)] as ordered, elevate the head of the bed to alleviate shortness of breath while lying flat, monitor oxygen saturations as needed, nebulizer treatments as ordered, observe for nonverbal signs of anxiety such as furrowed brows, pacing, change in mental status, and behaviors, to observe for verbal signs of stress and anxiety, the resident used oxygen at 2 LPM. A resident profile, printed on 9/30/22 at 6:30 a.m., indicated the resident used oxygen at 2 LPM via nasal cannula, but lacked direction for staff to elevate head of bed. A hospital discharge summary, dated 9/23/22 at 12:09 p.m., indicated Resident 293 had discharge diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The summary indicated for the resident to wear her [CONDITION(S)]/[CONDITION(S)] at nighttime. A Respiratory Administration History Report, dated 9/23/22 to 10/3/22, indicated Resident 293 was admitted to the facility, on 9/23/22, and orders included, but were not limited to, the following: a. Elevate head while in bed to alleviate shortness of breath while lying flat related to [CONDITION(S)] diagnosis. b. A [CONDITION(S)]. A review of the administration history indicated Resident 293 did not have an available [CONDITION(S)] to use from 9/24/22 to 9/28/22. c. Oxygen continuously at 2 liters per minute (LPM). On 9/28/22, the history indicated Resident 293 was given oxygen at 4 LPM. d. Oxygen continuously at 4 liters per minute (LPM) per nasal cannula to keep oxygen saturations greater than 90 percent started on 10/3/22. A progress note, on 9/24/22 at 11:38 a.m., indicated a respiratory company was contacted with a new admission, [CONDITION(S)] order and information given. The facility was waiting for a return call. A nurse progress note, dated 9/27/22 at 10:50 p.m., indicated the resident was not acting as usual, had increased confusion, frequency, urgency, tried to climb out of bed and she became combative. A urine sample was collected. A nurse progress note, dated 9/28/22 at 3:03 p.m., indicated the resident was complaining of shortness of breath and was yelling out incoherent statements. Oxygen saturation (measures the amount of oxygen in the body) were 85 percent (normal oxygen saturation level is between 95% and 100%). Increased oxygen via nasal cannula to 3 liters per minute and oxygen saturations rose to 88%. The staff worked with the resident on remaining calm and saturations were at 94%. The oxygen was decreased to 2 liters per minute (LPM) and oxygen saturations remained at 91 to 92%. A nurse progress note, dated 9/28/22 at 11:59 p.m., indicated the resident was found hanging off the side of the bed and staff lowered the resident to the floor. She was found to have a 2 inch by 2-inch skin tear noted to her right lower extremity. The physician and family were notified and the call light was placed within reach. A progress note, dated 9/28/22 at 12:28 p.m., indicated a respiratory company was contacted regarding [CONDITION(S)] delivery and was still working on it. A nurse progress note, dated 9/29/22 at 4:17 p.m., indicated the resident had been combative during the shift, refused to wear oxygen or [CONDITION(S)] mask and the resident remained confused and combative with care. A nurse progress note, dated 10/3/22 at 2:56 p.m., indicated the resident had been confused and combative with staff. The Nurse Practitioner was notified oxygen saturations were 88-91% and new order to utilize oxygen titration and [CONDITION(S)]/[CONDITION(S)] as needed in addition to the nightly order. A new order of [MEDICATION(S)] (oral steroid) was also written. A nurse progress note, dated 10/3/22 at 7:01 p.m., entered as a late entry on 10/4/22 at 2:34 a.m., indicated Resident 293 had trouble responding to verbal stimuli, was wheezing, and used extreme effort to breath. Respirations were short and labored with oxygen saturations 94% on 2 LPM, heart rate was 113. The nurse practitioner was notified and the resident was sent to hospital for evaluation. A Hospital History and Physical Report, dated 10/4/22 at 2:11 a.m., indicated Resident 293 was brought to the Emergency Department by Emergency Medical Services for altered mental status and [CONDITION(S)] with oxygen saturations at 80 percent. Labs taken revealed a B-type natriuretic peptide BNP (hormone produced by your heart to indicate heart failure) of 800, [MEDICATION(S)] of 8, and chest X-ray revealed low long volumes with diffuse opacities concerning for pulmonary [CONDITION(S)]. Resident 293 was admitted for Respiratory distress. The record review lacked indication the physician was notified Resident 293 did not have her [CONDITION(S)] to wear until 9/28/22, as ordered on 9/23/22, when discharged from the hospital. 2. During an observation and interview, on 9/29/22 at 12:25 p.m., Resident 49 was found lying in his bed with his head facing the wall. The mask of the humidified air was positioned onto the side of his neck. His humidified air, water canister, tubing, mask, [MEDICATION(S)] suction tube and suction canister was not labeled. The water canister for the humidified air was empty with water pooled in the tubing. Licensed Practical Nurse (LPN) 25 indicated the mask was not on Resident 49's [CONDITION(S)] opening and his equipment was not labeled. During an observation and interview, on 9/29/22 at 12:39 p.m., Nursing Assistant (NA) 26 indicated the resident's humidified air mask was not on Resident 49 and it was the nurse's responsibility to ensure it was in place. During an observation and interview, on 9/29/22 at 2:19 p.m., LPN 25 indicated the resident was poorly positioned with his chin tucked to his chest and humidified air mask on his neck. All equipment should be labeled when opened. During an observation, on 9/30/22 at 10:15 a.m., Resident 49's respiratory equipment which included [MEDICATION(S)] suction tube was dated 9/28/22. The humidified water bottle was not dated. The suction canister was not labeled or dated. During an observation, on 10/3/22 at 11:11 a.m., Resident 49's equipment which included suction tubing, water canister and nebulizer tubing was found to be not dated. The [MEDICATION(S)] suction tube was dated 9/30/22. The canister for suctioning had roughly 60 cc of green, yellow colored liquid. The resident was lying in bed with his head facing the wall and humidifier air mask positioned on the side of his neck. During an observation and interview, on 10/3/22 at 11:17 a.m., the Director of Nursing (DON) indicated Resident 49's respiratory equipment was undated and not labeled. Her expectation would be for staff to ensure equipment was changed as directed and labeled appropriately. The humidified air was not over the [CONDITION(S)] and the nursing staff and the NA could reposition as needed. Agency staff was working last night and could be the reason for items not being taken care of. The record for Resident 49 was reviewed on 9/30/22 at 10:55 a.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A care plan, dated 9/25/22, indicated Resident 49 was readmitted and had a problem with Pseudomonas in his [CONDITION(S)]. The care plan directed staff to document and notify MD of any abnormal findings, observe for continued or worsening symptoms of [CONDITION(S)] infection (increased secretion's, increased odor from [CONDITION(S)] site, increased temp), observe for adverse side effects of antibiotic (GI upset, nausea, diarrhea, rash) and to administer antibiotic as ordered. physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] During an interview, on 10/3/22 at 12:02 p.m., the Infection Preventionist (IP) indicated Resident 49 had a hospitalization recently related to Tracheitis (bacterial infection of the windpipe). The resident's equipment had dates from the previous week. There was a concern if staff were not changing the equipment which could cause a spread of infections or cause an infection in Resident 49. Nursing staff are responsible for changing equipment. During an interview, on 10/4/22 at 8:20 a.m., Registered Nurse (RN) 14 indicated it was hard to tell whether a resident was raised to a 30-45 degree angle. His legs were elevated, his middle was creased and his head was elevated the same as his feet, more like a 10 degree angle. A thick air loss mattress was used. She had not checked on the resident yet this morning. There were concerns his [CONDITION(S)] had yellow/green colored dried mucous on the cannula with water pooling in the tube and the filter appeared dirty. All equipment should be labeled. During an interview, on 10/4/22 at 1:35 p.m., the DON indicated nursing staff should be labeling patient equipment items as needed. Resident 49 was to be properly positioned with his humidified air mask positioned over his [CONDITION(S)]. Not having the humidified air on could dry up secretions for Resident 49 and he could be at risk for of infection if the resident equipment was not stored, changed and labeled. 3. During the initial tour of the facility, on 9/30/22 at 9:55 a.m., Resident 67's [CONDITION(S)] machine was observed on the bedside table with the nose piece laying on the bedside table surface uncovered and not bagged. During a random observation, on 10/3/22 at 10:34 a.m., Resident 67's [CONDITION(S)] machine was observed on the bedside table. The nose piece was not bagged or covered. The record for Resident 67 was reviewed on 10/3/22 at 10:21 a.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A progress note, dated 10/2/22 at 4:30 p.m. indicated Resident uses Bi-Pap or C-Pap. Resident 67 had no care plans for the use of a [CONDITION(S)] machine. There was no order for a [CONDITION(S)] or any orders for cleaning or maintenance for the machine. There was no documentation of times the [CONDITION(S)] was applied or removed. During an interview, on 9/30/22 at 10:15 a.m., Agency Nurse (AN) 8 indicated she did not know if Resident 67 used a [CONDITION(S)] or not, there was no order in the electronic record. A current policy, titled [CONDITION(S)] Therapy, undated and provided by the Director of Nursing on 10/4/22 at 2:21 p.m., indicated .Procedure: Verify doctor's orders .Cleaning the Machine: gently wash .rinse .air dry .clean and inspect .Filter maintenance .two filters 3.1-47(a)(6)

Based on observation, interview and record review, the facility failed to ensure a resident who required assistance with activities of daily living (ADL) by two staff members received adequate supervision and assistance to prevent accidents during a transfer from a wheelchair to the bed for 1 of 3 residents reviewed for accidents. (Resident B) This resulted in Resident B receiving a fractured femur. Finding includes: During tour of the facility, on October 12, 2021 at 11:21 a.m., Resident B was observed in the therapy room seated in a high back wheelchair. An immobilizer was on the resident's right leg and the wheelchair foot pedals were up. The resident was working with her left hand placing pegs in a board. Her right hand sat idle on the arm rest of the chair. The sides of a lift pad were observed from under the resident. The record for Resident B was reviewed on October 12, 2021 at 1:23 p.m. Diagnoses included, but were not limited to, [CONDITION(S)] and [CONDITION(S)] (paralysis) of the dominate right side, diabetes mellitus, hypertension, [CONDITION(S)] (weak, brittle bones), osteopenia (low bone mass or density), unsteadiness on feet, repeated falls, abnormal posture and muscle weakness. A review of the resident's MDS (minimum data set) assessment, section G, titled Functional Status, dated 07/04/2021 indicated the resident required extensive assistance of two + [plus] persons physical assist for the task of transfers from the bed to a chair, wheelchair or a standing position. Resident B's fall risk assessment, dated 07/08/2021, utilizing the [NAME] Hopkins Fall Risk Assessment Tool, indicated the resident was a high risk for falls due to having a history of one or more falls within the previous six months, being incontinent and on 2 or more high fall risk drugs. A physical therapy plan of care, dated 07/08/2021, indicated .Precautions: Low endurance - needs frequent rests. Balance precautions include Right [CONDITION(S)] .Resident depends on staff for bathing, toileting, transfers and dressing due to physical deficits from her stroke. Resident requires maximal assist for transfers to wheelchair and at times staff has been using a Hoyer lift and maximum assist for wheelchair mobility due to her right [CONDITION(S)] . Resident B's current level of functioning indicated .Mobility .Chair/bed to chair transfer .Helper does ALL of the effort. Resident does none of the effort to complete the activity. Or the assistance of 2 or more helpers is required for the resident to complete the activity . A review of Resident B's progress notes indicated: On 07/19/2021 at 1:45 p.m., the resident was being transferred to her bed when she stepped on the CNA's (certified nursing assistant) foot causing her to lose her balance and resident was then lowered to floor for safety. The resident was assisted off the floor and into the bed. The resident was fully dressed with non-skid shoes in place at time of the fall. Her blood pressure was elevated. The NP (nurse practitioner) was notified with no new orders. The resident denied pain or discomfort. ROM (range of motion) was WNL (within normal limits). On 07/20/2021 at 11:35 a.m., the IDT (interdisciplinary team) reviewed the fall and indicated Resident B was being transferred back to bed and stepped on the CNA's foot causing the CNA to lose her balance and resident had to be lowered to the ground. No injuries were noted. It was determined the root cause of the fall was improper placement of her feet during a transfer. The intervention put into place to address the root cause of the fall was to ensure the resident's feet were properly placed when transferring. On 07/21/2021 at 6:40 a.m., the resident's right lower extremity had 3+ [CONDITION(S)] (swelling) from her hip to her toes, most severe around the knee. The resident was unable to straighten her knee. Her leg was externally rotated and she yelled out in pain when attempts were made to move the leg. The resident indicated on Monday (July 19, 2021) a staff member wearing white was transferring her without a gait belt and dropped her on the floor. On 07/21/2021 at 6:00 p.m., Resident B left the facility via emergent ambulance due to a recent fracture to the right trochanter (the bony prominence of the end of the thigh bone commonly known as the femur). The facility's investigative notes regarding the event indicated: 1. CNA 1 received Employee Coaching & Counseling due to on 07/19/2021, CNA 1 transferred a resident without a gait belt. Education was provided on utilizing a gait belt with all resident transfers. This counseling was signed and dated on 7/22/21 by the previous Director of Nursing Services. 2. A written statement from CNA 1, dated 07/22/2021, indicated on 7/19 CNA 1 was assisting Resident B from her wheelchair to the bed. During the pivot from the wheelchair to the bed Resident B ended up stepping CNA 1's foot. Resident B was leaning and both the resident and the CNA were getting ready to fall. CNA 1 held onto Resident B tightly and went behind her to lower her easily and safely. Resident B sat on CNA 1's left leg. CNA 1 turned on the call light for help. Resident B indicated she was not hurt. 3. A radiology report, dated 7/21/2021 at 2:23 p.m., indicated views of the right hip demonstrated an acute subtrochanteric fracture. 4. A copy of the resident plan of care, with a start date of 01/12/2011, indicated Resident B had a problem of being at risk for falls due to impaired balance, daily use of [CONDITION(S)] medications, [CONDITION(S)], aphagia, hypertension, [CONDITION(S)], a history of falls, incontinence, age and altered awareness of immediate physical environment. The goal was Resident B would not have injuries related to falls through the next review. The approaches to the goal were updated 07/20/2021 and indicated to ensure the resident's feet were properly placed before transferring. A review of the plan of care was not observed to include the manner by which the resident was to be transferred or how many staff were required to safely transfer the resident wheelchair to the bed. During an interview, on 10/13/2021 at 11:32 a.m., the Executive Director (ED) indicated the CNA present on 07/19/2021, when the resident was lowered to the floor during a transfer, was no longer employed at the facility due to a no call, no show. During an interview, with the Corporate Support Nurse and Director of Nursing Services (DNS), on 10/13/2021 at 2:34 p.m., the DNS indicated staff were informed of resident care requirements through assignment sheets generated each morning. The corporate nurse indicated these forms were not saved from day to day. A current facility policy, titled Fall Management Program, dated 11/2017 and provided by the Executive Director on 10/13/2021 at 1:49 p.m., indicated .4. All residents with a score greater than 0 are considered at risk for falls .5. Residents who are categorized as moderate to high risk should have fall interventions implemented .6. The resident specific care requirements will be communicated to the assigned caregiver utilizing resident profile or CNA assignment sheet This Federal Tag relates to Complaints IN 252 and IN 398. 3.1-45(a)(1) 3.1-45(a)(2)

Based on observation, interview, and record review, the facility failed to supervise a dementia resident at risk for falls when she was left alone in the shower room sitting on a shower chair which resulted in a fractured left hip for 1 of 3 residents reviewed for accidents (Resident D). The facility failed to supervise a resident with a history of falls, dementia, and impulsive behavior while sitting in the dining room in a Broda (type of positioning chair) for 1 of 3 residents reviewed for accidents (Resident H). Findings include: 1. An Indiana State Department of Health Survey Report System Incident report, dated 10/24/19, indicated on the evening of 10/1/19, Resident D fell in the shower room after receiving a shower by Certified Nursing Assistant (CNA) 4. She was assessed at the time of the fall with no injuries. The next morning while being seen by therapy, she was complaining of left hip pain when her leg was moved. A left hip X-ray was ordered and the resident was sent to the hospital for treatment of [REDACTED]. The preventative measures were to ensure the floor was dry after showering residents and staff education was completed on shower room safety. CNA 4 was given written disciplinary action. The record review for Resident D was completed on 10/24/19 at 2:02 p.m. [DIAGNOSES REDACTED]. A Care Plan, dated 2/28/17, indicated she was at risk for falls due to impaired balance, altered awareness of immediate physical environment, unsteady gait, impulsive, lack of understanding of one's physical, cognitive limitations, and she had a history of [REDACTED]. A physician order, dated 6/9/19, indicated foot stop drop to wheelchair every shift. The resident had a Care plan, dated 2/28/17, indicated she required assistance with ADL's (Activities of Daily Living) including, but not limited to, transfers, toileting, and eating. The resident had a Care Plan, dated 1/31/19, which indicated she was at risk for impaired vision. She was unable to participate with vision screening. The approaches included, but were not limited to, the following: .1/31/19--Assure the floor is free of flare, liquids, foreign objects, 1/31/19--Keep call light in reach at all times .1/31/19--Provide an environment free of clutter . The following progress notes were reviewed in Resident D's record and indicated the following: Nursing progress note, dated 8/15/19 at 7:44 a.m., indicated, Resident quarterly MDS (Minimum Data Set) completed. Per interview with resident on 8/15/19 resident was noted to not respond to direct questions .Resident is rarely/never understood and rarely/never understands others .When asked to squeeze hand on 8/15/19, Resident was unable to follow that direction .Resident presents as having a poor appetite; on 8/8-8/10 it is noted that her meal intakes were less than 50%, per intake logs .Resident has a Guardian Nursing progress note, dated 10/1/19 at 10:29 p.m., was marked Invalid on 10/2/19 at 10:53 AM Reason: Incorrect data wrong writer, writer forgot to log off matrix (computer system for documenting resident records). --INVALID--Resident in shower room after shower. CNA (Name of CNA) left resident to get assistance and patient fell on the floor unobserved. No injuries noted On 10/2/19 at 9:34 a.m., IDT (Interdisciplinary Team) met to discuss the fall that occurred on 10/1/19 at 10:19 p.m. The Resident was sitting in a shower chair in the shower room prior to the fall. While CNA was out of the room finding someone to assist her, the resident fell out of the chair. Resident was dressed in a gown with no socks on. Resident was found lying on the ground next to the shower chair .Root cause: Resident has poor safety awareness and is dependent on all transfers .IDT recommendation: Staff education on shower room safety and therapy screen Nursing progress note, dated 10/2/19 at 10:17 a.m., indicated, Resident with noted increase in pain in left hip, new order for STAT (immediately) x-ray Nursing progress note, dated 10/2/19 at 2:00 p.m., Resident x-ray report received, notified NP (Nurse Practitioner) and DNS (Director of Nursing Services), resident to be sent to ER (emergency room ) for eval (evaluation) and treatment, NP to notify resident guardian. A Discharge Report from (Name of Hospital) dated 10/4/19, included, but were not limited to, the following orders: .Activity: other, Up to chair/wheelchair if pain will allow it .Discharge Diagnosis: [REDACTED]. During an interview on 10/24/19 at 4:00 p.m., the Director of Nursing (DON) indicated Resident D fell in the shower room when she was left unattended. CNA 4 showered the resident, then left the shower room to get assistance to take her back to her room and put her to bed and the resident fell while she was gone. During an interview on 10/24/19 at 4:23 p.m., CNA 4 indicated she and CNA 8 took Resident D to the shower room on 10/1/19 at approximately 8:30 p.m., and she helped him place the resident on the shower chair. Resident D was on CNA 8's assignment for the evening. CNA 8 left the shower room to get a bath blanket for the resident, but he never came back to the shower room. After she gave the resident her shower she stuck her head out the shower door to see if she could find CNA 8, so he could take her to her room. She saw CNA 8 at the nurses' station talking to the nurses, so she told him he needed to come into the shower room and push Resident D back to her room. At that time, she observed him leave the nurses' station and walk towards the shower room. He was approximately four feet away from the shower door when she exited the shower room and went to answer a bathroom call light. When she came out of the unidentified resident's bathroom, she was told to get a Hoyer lift and go to the shower room because Resident D fell out of her shower chair. She approximated the time she was out of the shower room as five to six minutes while she was assisting her resident off the toilet. The resident was sitting on the shower chair by the door when she left the shower room. A document titled, Employee Communication Form, dated 10/9/19, provided by the DON on 10/24/19 at 4:40 p.m., indicated on 10/1/19, CNA 4 violated the following policy/procedure, which was she left a resident alone while in the shower room. Details of the incident: Resident was given a shower. CNA left shower room before ensuring that another staff member was present in the room. She was given a final written warning dated 10/9/19. During a phone interview on 10/25/19 at 2:47 p.m., Licensed Practical Nurse (LPN) 5 indicated on 10/1/19 between approximately 10:40 to 10:45 p.m., she and LPN 9 were charting at the nurses' station and CNA 8 was standing at the nurses' station talking with LPN 9. Approximately five minutes prior to Resident D falling, CNA 4 walked out past the nurses' station toward her assigned part of the hallway addressing CNA 8 when she indicated she was done providing care for Resident D and CAN 8 need to attend to her. CNA 8 continued to stand there in front of LPN 9 talking. Approximately five to six minutes later all three of them at the nurses' station heard a big crash which came from the direction of the shower room. All three of them ran to the shower room. Resident D was found lying on her left side with her head close to the bathroom wall by the sink and most of her body was under the sink. The shower chair was nowhere near her. There was no wheelchair in the shower room. When CNA 4 came into the shower room, after the resident fell , LPN 5 found out she showered the resident, and then left her in the shower because she thought CNA 8 heard her as she was walking by the nurses' station. During a phone interview on 10/29/19 at 8:05 p.m., LPN 9 indicated she was the nurse responsible for Resident D's care on 10/1/19 when she fell in the shower room. She overheard CNA 4 and CNA 8 discussing giving Resident D's shower. CNA 4 transported Resident C to the shower room herself on the shower chair. CNA 8 was not available at the time. CNA 4 stuck her head out the shower room door and told CNA 8 to come get Resident C because she was finished with her shower. LPN 9 and LPN 5 were sitting at the nurses' station trying to finish their shift charting when they heard a loud bang. Both nurses ran to the shower room where Resident C was visualized alone in the shower room, laying on the bare shower room floor with a resident gown on and without socks on. The shower chair had rolled back towards the opposite wall from the wall the resident was lying next to. Her head was toward the wall facing the nurses' station and her body was lying in a straight line out from where her head was at. She asked CNA 4 why she left the resident alone in the shower room, but CNA 4 did not answer her question. A current document titled Skills Validation-CNA Shower originally dated 02/2010, with a reviewed date 04/2012, provided by the DON on 10/24/19 at 6:15 p.m., contained the following, Procedure Steps: 10. Stay with resident during entire procedure .16. Unlock shower chair wheels and roll resident out of shower .22. return resident to room 2. During an interview on 10/23/19 at 4:06 p.m., LPN 3 indicated Resident H's last fall was in the dining room. She scooted herself out of her Broda (type of positioning chair) onto the floor landing under the dining room table. She had a previous fall prior to this one where she scooted herself out of her chair and received a laceration to the back of her head, so the intervention after the last fall in the dining room was the resident was not to be taken to the dining room until her meal tray was being served. She was supposed to be the last resident brought into the dining room and the first one taken out of the dining room. She was to be kept in the common areas, so she could be supervised by staff and she liked to watch the TV in the lounge. At that time, the resident was observed sitting in the hallway by the nurses' station in front of the lounge with her Broda chair laid back. On 10/24/19 at 11:42 a.m., with the DON was in attendance, Resident H was observed sitting in an upright position in her Broda chair in the Hall 1 dining room at a white crescent shaped dining table. There was no staff member in the line of site of the resident to supervise her during that time. There was a Hall 1 nurses' station, but a wall was in front of the dining room between the two doorways. The DON indicated there was no staff member in the resident's line of site supervising her and the nurses at the nurses' station would not be able to supervise her while she sat at the dining room table with the back of the her Broda chair towards them. The DON asked CNA 20 to take Resident H out of the dining room until her tray had been served. CNA 20 indicated, at the time she came to get the resident to take her out of the dining room, I don't know who put her there anyway. She's not supposed to be in her until meal time because she slides out of her Broda chair. As she was wheeling her out of the dining room she stopped and placed her Broda chair into the laying position indicating she would have less of a chance to slide out of her chair than if she was in a sitting upright position. The record review was completed for Resident H on 10/24/19 at 2:58 p.m. [DIAGNOSES REDACTED]. A Physician Order, dated 6/20/19, indicated Patient (pt) to have 1:1 supervision with all meals to slow pt's rate of self feeding. A fall event, dated 8/9/19 at 8:30 a.m., indicated there was a witnessed fall while eating breakfast. The resident was found sitting on the floor in front of her wheelchair. She was fully dressed in the dining room. She slid herself out of her wheelchair onto the floor in front of her chair. The new intervention was to place hipsters on her. A progress note, dated 8/9/19 at 3:22 p.m., indicated Resident in dining room eating breakfast this am. Resident very anxious and repetitive with movements and statements. Staff assisted resident with re-positioning in wheelchair and went to assist another resident while she continued to feed herself oatmeal, staff turned back around and witnessed resident scooting herself out of chair and onto the floor. Resident unable explain what she was trying to do. No injuries noted. able to move all extremities. Did not hit head. Not incontinent at time. Assisted back into wheelchair. NP aware of incident. New order for hipsters at all times A progress note, dated 8/12/19 at 2:56 p.m., indicated the IDT met to discuss the resident's fall on 8/9/19. The resident was in the dining room prior to her fall sitting in her Broda chair. She was witnessed scooting herself out of her Broda chair while sitting at the dining room table. She was fully dressed with shoes on. The root cause was [MEDICAL CONDITION] with dementia causing poor safety awareness. The immediate intervention was hipsters at all times except during hygiene. IDT recommendations was a therapy screen. A fall event, dated 8/24/19 at 8:12 a.m., indicated an unwitnessed fall in the dining room. The resident was found lying on her back. Prior to the fall she was sitting in the dining room. She was fully clothed with non-skid socks on. The new intervention to prevent another fall was the resident was to stay at the nurses' station until the trays arrived. A progress noted, dated 8/26/19 at 10:25 a.m., indicated the IDT met to discuss her fall, which occurred on 8/24/19 during breakfast. She was in the dining room sitting in her Broda chair waiting for her breakfast at the table when staff seen her out of her Broda chair lying on her back, on the floor with a laceration to the back of her head. She was fully dressed with non-skid socks. The root cause of the fall was [MEDICAL CONDITION] with dementia causing poor safety awareness. The immediate intervention was to have Resident H stay at the nurses' station until the trays arrive. IDT recommendations were to have the resident be the last resident in the dining room for meals and be the first resident out of the dining room after meals. An IDT Weekly Update Skin Event--(Name of Company) Non-Ulcer Skin Event, dated 8/26/19 at 1:58 p.m., indicated the resident had a laceration to the back of her head, which was a new area. The measurements were 2.0 x 0.1 x 0.1 cm (centimeters). The wound was a scabbed dark purple color. A fall event, dated 9/25/19 at 7:20 a.m., indicated an unwitnessed fall in Hall 1 dining room. The resident was sitting in her Broda chair prior to the fall. She was found lying on her back. The intervention put into place to prevent another fall was staff education. A progress note, dated 9/25/19 at 7:42 a.m., the nursing staff was notified by the CNA the resident was on the floor in the dining room on 9/25/19 at 7:20 a.m. The resident was found lying on her back beside her Broda chair and it appeared as if she climbed out of her chair. She was assisted back into her chair by three staff members. The staff was educated that Resident H was to stay at the nursing station until her meal tray was ready to be served to her. A progress note, dated 9/26/19 at 11:56 a.m., indicated IDT met to discuss the fall on 9/25/19 at 7:20 a.m. The resident was in the dining room in her Broda chair prior to the fall. She was found lying on her back near her Broda chair. Root cause was [MEDICAL CONDITION] causing poor safety awareness. IDT recommended staff education on not leaving the resident alone in the dining room until the trays were passed. A Care Plan, dated 6/24/19, which addressed the problem the resident was at risk for falls due to impaired balance, history of falls, impulsiveness, and dementia. The approaches included, but were not limited to, the following: 8/24/19--Encourage resident to remain at nurses station until trays arrive A current document titled ,Fall Management Program, originally dated 07/2001 with a revised date of 11/2017, provided by the DON on 10/24/19 at 6:15 p.m., contained the following, Policy: It is the policy of (Name of Company) to ensure residents residing within the facility receive adequate supervision and or assistance to prevent injury related to falls. A Fall refers to unintentionally coming to rest on the ground, floor, or other lower level. An episode where a resident lost his/her balance and would have fallen, if not for another person or if he or she had not caught him/herself, is considered a fall. A fall without injury is still a fall. Unless there is evidence suggesting otherwise, when a resident is found on the floor, a fall is considered to have occurred. Facilities must implement comprehensive, resident-centered fall prevention plans for each resident for falls or with a history of falls. Procedure: Fall risk: 5. Residents who are categorized as moderate to high risk should have fall interventions implemented based on resident specific risk factors .7. The interdisciplinary team will discuss new residents on the 1st business day after admission in the clinical meeting. Fall risk will be discussed at this time, including appropriate interventions. Post Fall: 5. A fall event will be initiated as soon as the resident has been assessed and cared for. The report must be completed in full in order to identify possible root causes of the fall and provide immediate interventions. 6. All falls will be discussed by the interdisciplinary team at the 1st IDT meeting after the fall to determine root cause and other possible interventions to prevent future falls. The fall event will be reviewed by the team. IDT note will be written. The care plan will be reviewed and updated, as necessary. This Federal tag relates to Complaints IN 818 and IN 924. 3.1-45(a)(2)

Based on observation, interview, and record review, the facility failed to have new pressure interventions in place to prevent worsening of a pressure ulcer from a Stage 2 to an unstageable ulcer (Resident C) and failed and ensure to ensure infection control procedures were followed to prevent the possibility for an infection for 1 of 3 residents. (Resident #137) Findings include: 1. On 4/09/2015 at 2:34 p.m., the record review was completed for Resident C. [DIAGNOSES REDACTED]. The admission nursing assessment dated [DATE], indicated the resident had a skin tear below right knee, many scratch marks on the lower right and left extremity and stomach and a scar on left knee. He had three open [MEDICAL CONDITION] (damage to skin), two [MEDICAL CONDITION] above the right ankle, one lesion on the right hip. The physician's orders dated 8/25/14, indicated Roho cushion to the wheelchair and Roho overlay to the bed to promote wound healing. The physician's order dated 9/11/14, indicated daily multivitamin for 60 days for wounds. The nursing notes indicated, .1/2/15 10:06 p.m. Requested order for reddened area on left buttock .1/3/15 a staff from physician's office called back with regards to elevated lab .call with any other concerns .1/4/15 2:13 a.m .reddened area on left glute blanches .1/5/15 2:45 p.m .resident to have an open area to left gluteal fold, area is completely yellow slough (dead tissue separated from the surrounding living tissue)., measured 4 centimeters x 3.5 cm x 0.1 cm, resident has a ROHO overlay on bed and a ROHO cushion in his chair, staff has been using barrier cream .1/6/15 10:27 a.m .Will continue Santyl (ordered on [DATE]) with foam to resident's gluteal fold and resident is to be in bed between meals The wound events documentation indicated on 1/2/15 at 9:56 p.m., . a reddened 1.5 centimeter(cm) spot on left buttock At that time it measured 1.5 cm x 1.0 cm and was a reddened area. The box was marked that the Physician, Nurse Practitioner and family were notified via fax at 10:40 p.m. On 4/13/15 at 10:20 a.m., the Executive Director provided a copy of the fax sent to the physician by LPN #1. The document was dated 1/2/14 and indicated, May we use [MEDICATION NAME] (an ointment used to provide a physical moisture barrier keeping feces, urine and wound drainage from intact and injured skin) on 1.5 x 1.0 cm reddened area on left buttock The fax send report indicated the fax was sent 11:49 p.m., on 1/2/15. The Physician's orders dated 1/2/15, indicated, .Chest x ray due to increased congestion, [MEDICATION NAME] (a diuretic which rids body of excess water) 60 milligrams (mg) twice daily for lung congestion and [MEDICATION NAME] 40 milligrams (anti swelling agent) for three days, 30 milligrams daily for three days and then 20 milligrams daily for three days and then 10 milligrams daily for three days and then discontinue The Physician's orders dated 1/3/15 indicated, . 20 milligrams of [MEDICATION NAME] daily starting 1/5/15 and BNP (a lab to indicate heart failure There was no order found regarding [MEDICATION NAME] cream. The Physician's orders dated 1/5/15, . Clarification : discontinue [MEDICATION NAME] 20 milligrams daily Resident to resume [MEDICATION NAME] 40 milligrams twice daily for heart. Cleanse left gluteal fold with normal saline (NS), pat dry, apply Santyl (a wound debridement ointment that removed dead skin tissue) and cover with foam dressing change every day The wound events documentation indicated on 1/5/15, the resident had a left gluteal fold unstageable area that was existing and originally noted on 1/2/15, was unstageable and the most severe tissue type was slough. The area measured 3.5 x 4 cm x 0.1 cm. The wound was not cultured. The wound treatment order was Santyl covered with foam dressing daily for the treatment. The Physician's order indicated, . 1/5/15 Cleanse left gluteal fold with NS, pat dry, apply Santyl and cover with foam dressing daily The order was discontinued 1/5/15 and restarted 1/6/15 and went through 1/27/15. During an interview on 4/13/2015 at 12:07 p.m., Nurse Practitioner (NP) #5 indicated, on 1/2/15, in her notes the resident was taking thin liquids and she had given orders to increase [MEDICATION NAME]. No other communication was noted from the facility at that time. She indicated that if she had seen the resident, there would be facility documentation in the physician progress notes [REDACTED]. She indicated there was no documentation in her notes regarding any skin concerns until 1/5/15. During an interview on 4/13/2015 11:10 a.m., The Executive Director (ED) indicated there was no documentation that the barrier creme was applied from 1/2/15 through 1/5/15. The ED indicated there was no physician's order for [MEDICATION NAME] and they could not find any other documentation of any other new interventions put into place after reddened area was noted on 1/2/15. 2. Resident #137's record was reviewed on 4/10/15 at 9:32 a.m. [DIAGNOSES REDACTED]. A Pressure Wound Skin Evaluation Report dated 4/6/15, indicated the resident had a pressure ulcer to her right buttock, which was an existing wound present on admission. The wound was originally noted on 4/4/15. The wound was unstageable. The most severe type of tissue was slough (yellow or white tissue that adhered to the ulcer bed). The wound measured 3.0 x 1.5 x 0.1 cm (centimeters). The wound bed color was yellow slough. The wound had a scant amount of serosanguineous drainage. The periwound was pink scar tissue. On 4/10/15 at 10:47 a.m., LPN #3 was observed changing Resident #137's right buttock pressure ulcer dressing. RN #4 was observed assisting LPN #3 by holding the resident onto her left side during the dressing change. LPN #3 washed the bedside table with a sani-wipe, was observed washing her hands for 7 seconds, then donned clean gloves. RN #4 donned clean gloves without washing her hands. RN #4 and LPN #3 was observed assisting the resident to lay onto her left side and RN #4 assisted the resident to stay on her left side during the dressing change. LPN #3 removed her gloves, washed her hands for 7 seconds, then donned clean gloves. LPN #3 removed the old dressing dated 4/9/15. She removed her gloves and washed her hands for 4 seconds. LPN #3 prepared her dressing supplies, then donned clean gloves. She cleansed the wound and removed her gloves. She washed her hands for 5 seconds, then donned clean gloves. LPN #3 finished the rest of the dressing change. During an interview on 4/10/15 at 12:06 p.m., LPN #3 indicated she should have washed her hands for 15 seconds. She indicated she thought she had washed her hands for 15 seconds. At that time, the DNS indicated the facility policy and procedure indicated the staff was to wash their hands for 15 seconds. On 4/13/15 at 10:19 a.m., a Glove and Dressing Change skills validation was provided by the DNS. A skill validation for Dressing Change (Incision or Wound) dated 1/2010 and revised 9/2012, provided by the DNS on 4/13/13 at 10:19 a.m., indicated .4. Wash hands . 6. Put on gloves .8. Remove gloves and discard 9. Perform hand hygiene 10. Put on gloves .13. Remove gloves and discard 14. Perform hand hygiene 15. Put on gloves . 18. Remove gloves and discard . 20. Wash hands . 23. Wash hands 3.1-40(a)(1)