Every finding on record at Meadow Lakes

Based on interview and record review, the facility failed to ensure education in-services were completed for nursing staff for specific treatment care needs for 1 of 5 residents reviewed. (Resident B)Finding includes:The clinical record for Resident B was reviewed on 6/29/26 at 9:50 a.m. The diagnoses included, but were not limited to, quadriplegia (a form of paralysis affecting all four limbs and the torso) and central cord syndrome at C4 (cervical vertebrae 4) of the cervical spinal cord. A Physician's Order, with a start date of 4/15/26 indicated, Transanal Irrigation [a water-based bowel management tool for bowel dysfunction] Special Instructions: Instill between 500 mL [milliliters] and 1000 mL of lukewarm water per irrigation session, titrating the volume to res [resident] tolerance and clinical response. Inflate balloon catheter with 1-2 pumps of air for retention. Do Not exceed 4 pumps per session. Document irrigation volume, frequency, balloon inflation amount, and any complications and indicated it was to be done once daily. During an interview on 6/29/26 at 12:39 p.m., the Assistant Director of Nursing Services (ADNS), indicated that all staff members on the rehabilitation short stay hallway when Resident B admitted received in person education related to the physician's order for transanal irrigation. The ADNS further indicated all staff who would potentially be caring for the resident when Resident B moved to the long-term care section of the facility had all received in-person education and the same step-by-step instructions on paper and a video link. A binder at the nursing station with information regarding the usage of resident's specific transanal irrigation device had also been available upon admission and moved to the long-term nursing station when resident moved. The ADNS indicated documentation of these in-services could not be located.During an interview on 6/29/26 at 2:00 p.m., the Executive Director (ED) indicated the in-services for Resident B's transanal irrigation device could not be located. During an interview on 6/29/26 at 3:00 p.m., the ED indicated the facility did not have a specific policy regarding in-services. The ED indicated regular in-services were scheduled, and that in the instance of a specific care need such as Resident B's device, in-services would be given as determined by the facility assessment tool or new admission needs for an uncommon and specific type of medical device or treatment.This citation relates to Intake 3047767.

Based on interview and record review, the facility failed to ensure the MDS (Minimum Data Set) assessment accurately reflected a resident's status for 1 of 5 residents reviewed for unnecessary medications. (Resident 8)Findings include:On 5/21/26 at 2:31 p.m., Resident 8's clinical record was reviewed. The diagnoses included, but were not limited to, Parkinson's disease (a disorder of the nervous system that affects movement and gets worse over time), psychotic disorder (severe mental disorders that cause abnormal thinking and perceptions), and dementia (loss of memory, language, problem-solving and other thinking abilities). A Review of the notice of PASARR (Preadmission Screening and Resident Review), dated 2/2/22, indicated, .Level I Outcome: Dementia/MI Exclusion. Rationale: A PASRR Level II evaluation is not required at this time.The Annual MDS assessment, dated 7/1/25, indicated the resident had a current PASARR Level II.During an interview with the Social Services Director on 5/26/26 at 11:29 a.m., she indicated the resident did not have a PASARR Level II.During an interview with the MDS assistant on 5/26/26 at 11:30 a.m., she indicated section A1500 on the Annual MDS assessment, dated 7/1/25, was marked yes in error and indicated it should have been marked no for PASARR Level II. She indicated they followed the Resident Assessment Instrument (RAI) manual for coding the MDS assessment.During an interview with the Administrator on 5/27/26 at 11:08 a.m., he indicated the facility did not have an MDS policy, he stated they follow the RAI manual for coding the MDS assessment.On 5/27/26 at 11:10 a.m., a review of the RAI, Version 3.0 User's Manual, 10/2025, for section A1500 of MDS, . Review the Level I PASRR form to determine whether a Level II PASRR was required.Code 0, no:.if any of the following apply: PASRR Level I screening did not result in a referral for Level II screening.410 IAC (Indiana Administrative Code) 16.2-3.1-31(d)

Based on observation, interview, and record review, the facility failed to ensure a self-medication administration assessment was completed for 1 of 1 random observations of medications left at the bedside. (Resident 71) Findings include: On 3/11/25 at 10:30 a.m., a medication cup with 1 large white tablet was observed on the bedside table of Resident 71. Resident 71 indicated it was her stomach medication and the nurses always left it for her to take after she had finished her meal. Resident 71's clinical record was reviewed on 3/11/25 at 11:30 a.m. The diagnosis included, but was not limited to, gastroesophageal reflux disease. The clinical record lacked documentation of a self-medication administration assessment. Current physician orders, dated 3/1/25 through 3/17/25, indicated Resident 71's medications included, but were not limited to, simethicone (for gas) tablet 125 milligrams 4 times a day. During an interview on 3/17/25 at 10:25 a.m., the Director of Nursing Services (DNS) indicated there had not been a self-medication administration assessment completed for Resident 71, however, the medication was just a gas pill and the resident would get sick if she took it before her meal so they let her keep it with her until after she ate. On 3/18/25 at 10:43 a.m., the DNS provided the facility's policy, Medication Administration-Medication Pass Procedure with a revised date of 7/2023, and indicated it was the policy currently being used by the facility. A review of the policy indicated, . 11. Observed taking medications-not left at bedside . 3.1-11(a)

Based on interview and record review, the facility failed to ensure the accuracy of the Minimum Data Set assessment for a resident determined to have a Level II PASARR and a serious mental illness for 1 of 1 resident reviewed for Resident Assessment. (Resident 62) Findings include: Resident 62's clinical record was reviewed on 3/18/25 at 11:00 a.m. The diagnoses included, but were not limited to, anxiety, psychotic disorder with delusions and anorexia nervosa. A Level II PASARR (Preadmission Screening and Resident Review) was completed in January 2023, and indicated the resident had a serious mental illness. The Significant Change Minimum Data Set (MDS) assessment, dated 2/23/25, indicated No to Resident 62 having a Level II PASARR and no to the resident having a serious mental illness. During an interview on 3/18/25 at 10:35 a.m., the Social Services Assistant indicated the Significant Change MDS assessment, dated 2/23/25, for Resident 62 should have been coded Yes to having a Level II PASARR and Yes to the resident having a serious mental illness. On 3/18/25 at 1:20 p.m., the facility provided a copy of the RAI Version 3.0 Manual, page 5, dated October 2023, and indicated it was the policy currently being used by the facility. A review of the RAI manual did not indicate coding of the Level II PASARR. 3.1-31(d)

Based on observation and interview, the facility failed to ensure staff revised the comprehensive care plan for a resident with significant weight loss for 1 of 4 residents reviewed for nutrition. (Resident 47) Findings include: On 3/11/25 from 9:20 a.m. to 9:45 a.m.,. Resident 47 was observed in bed with breakfast on her tray and no food eaten. No staff were present with the resident. On 3/14/25 from 9:25 a.m. to 9:50 a.m., Resident 47 was observed in bed with breakfast on her tray and no food eaten. No staff were present with the resident. On 3/11/25 at 10:10 a.m. Resident 47's clinical record was reviewed. The diagnoses included, but were not limited to, hemiplegia, adult failure to thrive, and unspecified protein-calorie malnutrition. The Quarterly MDS (Minimum Data Set) assessment, dated 3/10/25, indicated the resident had a five percent or more weight loss in the last month or weight loss of ten percent or more in the last 6 months. The Functional Assessment, dated 3/10/25, indicated the resident required supervision or touching assistance for eating. The Follow Up Nutrition Review, dated 3/11/25, indicated the resident had a five percent or more weight loss in the last month or weight loss of ten percent or more in the last six months, was not on a physician prescribed weight loss program, and the care plan had been reviewed and updated. A Nutrition Care Plan, reviewed on 3/11/25, indicated no nutritional care plan interventions since 8/1/23. - On 9/4/24, the resident weighed 154 lbs (pounds) - On 10/3/24, the resident weighed 146 lbs, which was a 5.19 percent weight loss in one month. - On 10/9/24, the resident weighed 152 lbs - On 11/4/24, the resident weighed 144 lbs, which was a 5.26 percent weight loss in one month. - On 3/3/25, the resident weighed 123 lbs, which was a 20.13 percent weight loss in six months. On 3/14/25 at 2:25 p.m., the DON provided the Resident Weight Monitoring policy with a revised date of, 9/2024, and indicated this was the current weight monitoring policy used by the facility. A review of the policy indicated, .any significant unexplained weight loss is considered a change in condition and must be addressed by the Interdisciplinary Team . During an interview on 3/17/25 at 10:30 a.m., the DON indicated the resident had significant weight loss and new interventions had not been updated on the nutrition care plan. 3.1-35(d)(2)(B)

Based on observation, interview, and record review, the facility failed to provide ADL's (Activities of Daily Living) for a dependent resident for 1 of 1 residents reviewed for ADL's. A resident was not shaved. (Resident 48) Findings include: On 3/11/25 at 10:19 a.m., Resident 48 was observed in her room with approximately half inch long whiskers on her chin. On 3/13/25 at 2:50 p.m., Resident 48 was observed in her room with approximately half inch long whiskers on her chin. At that time, Resident 48 wept and indicated having chin whiskers made her sad. She indicated staff used to shave her whiskers and she wished they did this more often, as it made her feel bad to have them on her chin. During an interview on 3/14/25 at 11:40 a.m., RN 1 indicated the resident needed her chin whiskers shaved. On 3/11/25 at 10:10 a.m., Resident 47's clinical record was reviewed. The diagnoses included, but were not limited to, hemiplegia, adult failure to thrive, and unspecified protein-calorie malnutrition. The Functional Assessment, dated 3/10/25, indicated the resident required substantial or maximal assistance to maintain personal hygiene, including shaving. A current Activity of Daily Living care plan, with a start date of 7/28/23 indicated the resident was to receive assistance with grooming and hygiene. 3.1-38(a)(3)(D)

Based on interview and record review, the facility failed to ensure a resident received adequate assistance to prevent a fall for 1 of 3 residents reviewed for accidents. (CNA in Training 1, Resident C) Finding includes: During an interview on 12/11/24 at 11:30 a.m., Resident E indicated on 11/28/24 at approximately 10:30 a.m., she observed a new CNA in Training (CNA in Training 1) attempting to transfer her roommate, Resident C, from her wheelchair to her bed. Resident E told CNA in Training 1 Resident C required 2 staff to transfer her. CNA in Training 1 told her she could transfer Resident C by herself. CNA in Training 1 attempted to move Resident C from Resident C's wheelchair but was unable to support her, and they both slid to the floor. CNA in Training 1 left the room and brought other staff to the room to help lift Resident C to her bed. She had not seen CNA in Training 1 since the incident. On 12/11/24 at 11:55 a.m., Resident E's clinical record was reviewed. The Admission Minimum Data Set (MDS) assessment, dated 10/13/24, indicated the Resident E had no cognitive impairment. During an interview on 12/12/24 at 9:45 a.m., Resident C indicated on 11/28/24 at approximately 10:30 a.m., CNA in Training 1 attempted to transfer her from her wheelchair to her bed with no other staff helping. CNA in Training 1 could not support Resident C and they both slid to the floor. Resident C indicated she was supposed be assisted by two staff members due to having little to no use of her left side extremities. Resident C indicated she was not injured during the incident. She had not seen CNA in training 1 since the incident. On 12/12/24 at 10:05 a.m., Resident C's clinical record was reviewed. The diagnoses included, but were not limited to, cerebral infarction and hemiparesis. The Quarterly MDS assessment, dated 11/18/24, indicated Resident C had no cognitive impairment, had impaired upper and lower extremities on one side, and required extensive assistance of two people for support and transfers from one surface to another. A Fall Event Record, dated 11/28/24 at 10:38 a.m., indicated prior to the fall the resident was in her wheelchair, and following the fall the resident was on the floor by the bed. A Fall Care Plan intervention, with a start date of 11/5/21, indicated the resident required two staff for transfers. During an interview on 12/12/24 at 10:45 a.m., LPN 1 indicated on 11/28/24 at approximately 10:30 a.m., CNA in Training 1 reported to LPN 1 that Resident C had been lowered to the floor after CNA in Training 1 attempted to transfer her from her wheelchair to her bed. Resident C was only to be transferred with assistance of two staff due to impairment to her left extremities as well as a contracture of the left arm. This citation relates to Complaint IN00448649. 3.1-45(a)(2)

Based on interview and record review, the facility failed to ensure the written notification required for a transfer and discharge was provided to the resident and the resident representative for 4 of 10 residents reviewed for hospitalization . (Resident 20, Resident 90, Resident 93, Resident 74) Findings include: 1. On 6/4/24 at 11:30 a.m., Resident 20's clinical record was reviewed. The diagnoses included, but were not limited to, nontraumatic intracerebral hemorrhage and dementia. Resident 20's progress notes indicated the resident was sent to the hospital on 3/13/24. The clinical record lacked documentation of written notification of the Notice of Transfer and Discharge forms having been provided to the resident representative. 50647 2. On 5/29/24 at 11:50 a.m., Resident 90's clinical record was reviewed. The diagnoses included, but were not limited to, sepsis and vascular dementia. Resident 90's progress notes indicated the resident was sent to the hospital on 5/5/24. The clinical record lacked documentation of written notification of the Notice of Transfer and Discharge forms having been provided to the resident representative. 3. On 5/29/24 at 2:57 p.m., Resident 93's clinical record was reviewed. The diagnoses included, but were not limited to, congestive heart failure and unspecified dementia. Resident 93's progress notes indicated the resident was sent to the hospital on 4/12/24. The clinical record lacked documentation of written notification of the Notice of Transfer and Discharge forms having been provided to the resident and the resident representative. 36912 4. On 6/4/24 at 11:15 a.m., Resident 74's clinical record was reviewed. The diagnoses included, but were not limited to, Alzheimer's disease and depression. The resident was transferred to the hospital on 3/4/24, 3/28/24, and 3/31/24. The clinical record lacked documentation to indicate the resident and the resident's representative were provided the written notification of the Notice of Transfer and Discharge forms. During an interview on 6/5/24 at 10:42 p.m., the Director of Nursing Services (DNS) indicated there had been no documentation of the Notice of Transfer or Discharge forms having been provided to the resident and the resident representative in writing. She indicated the facility contacted the representative by phone but did not send anything in writing. On 6/5/24 at 1:20 p.m., DNS provided the facility policy, Discharge/Transfer, dated 11/2015, and indicated this was the policy currently being used by the facility. A review of the policy indicated, Procedure: 1. A copy of the discharge or transfer in writing must be included in the resident's clinical record . and sent to the resident and responsible party, a family member of the resident . 3.1-12(a)(6)(A)(i) 3.1-12(a)(6)(A)(iii)

Based on observation, interview, and record review, the facility failed to ensure a urinary drainage bag was positioned off the floor to prevent infections for 1 of 2 residents reviewed for urinary catheters. (Resident 81) Findings include: On 5/29/24 at 10:43 a.m., Resident 81 was observed asleep in bed. A urinary drainage bag was observed to be touching the floor. On 5/30/24 at 9:59 a.m., Resident 81 was observed asleep in bed. A urinary drainage bag was observed to be touching the floor. On 5/31/24 at 10:45 a.m., Resident 81 was observed asleep in bed. A urinary drainage bag was observed to be touching the floor. On 6/3/24 at 9:43 a.m., Resident 81 was observed asleep in bed. A urinary drainage bag was observed to be touching the floor. On 6/3/24 at 11:02 a.m., Resident 81 was observed asleep in bed. A urinary drainage bag was observed to be touching the floor. Resident 81's clinical record was reviewed on 6/3/24 at 11:15 a.m. The diagnosis included, but was not limited to, obstructive and reflux uropathy due to neurogenic bladder. Physician orders, dated 5/5/24 through 6/5/24, for Resident 81 indicated . Cath [catheter] orders: Foley catheter Size: 14, Fr [french] 14 ml [millimeters] bulb . A care plan, initiated on 10/23/23, and current through target date 7/4/25, for Resident 81 indicated, . Problem: Resident requires an indwelling urinary catheter . Goal: Resident will have catheter care managed appropriately as evidenced by not exhibiting signs of urinary tract infection . Do not allow tubing or any part of the drainage system to touch the floor . During an interview on 6/4/24 at 11:06 a.m., Certified Nursing Assistant (CNA) 1 indicated the urinary drainage bag should be positioned off the floor. On 6/5/24 at 1:20 p.m., the Director of Nursing Services provided the facility's policy,Indwelling Urinary Catheter Care, Emptying Drainage Bag and Catheter Removal with a review date of 12/2012, and indicated it was the policy currently being used by the facility. A review of the policy did not indicate to keep drainage bag off the floor. 3.1-18(b)(1)

Based on observation, interview, and record review, the facility failed to ensure services were provided to residents with dementia to prevent resident-to-resident altercations for 2 of 3 residents reviewed for dementia. (Resident C, Resident D) This deficient practice resulted in Resident D experiencing a fall and sustaining an acute fracture of the right upper arm bone with moderate displacement and rotation. Finding includes: During an interview on 1/9/24 at 10:30 a.m., the Director of Nursing (DON) and Executive Director indicated a physical altercation occurred on 1/5/24 between Resident D and Resident C on a secured unit. The DON indicated a stop sign was positioned across the threshold to the bedroom of Resident C and usually was effective to prevent Resident D from entering the room. The DON indicated Resident D, the victim, entered the bedroom of Resident C by traveling underneath the stop sign. The DON indicated Resident C was pulling on the right upper arm of Resident D to get Resident D out of her room when a physical therapist walked by and told Resident C not to pull on the arm of Resident D. The DON indicated Resident C let go of Resident D and Resident D fell to the floor. The DON indicated Resident D was sent to the hospital and a right arm fracture was identified; however, surgery was not performed because Resident D was receiving hospice services. During an interview on 1/10/24 at 9:50 a.m., a family friend of Resident D indicated she was aware of the altercation between the two women. The resident was observed sleeping, at that time, and had her right arm folded up against her chest with no splint in place. The friend indicated it was unlike the resident to be so lethargic. She indicated the resident's daughters were flying in today to see their mother because she believed the fracture would cause a more rapid decline in her health and death would be soon. During an interview on 1/10/24 at 11:57 a.m., PT 1 indicated he was walking up towards the nurses station when he heard someone yelling, Don't! Stop it! He looked around and happened to be right outside of Resident C's room and saw her actively pulling Resident D onto the floor. She was pulling at her by her waist area which caused Resident D to fall between the bed and the front of the wheelchair. Resident C continued to yell at the patient while she was on the floor. He further indicated that he did know through communication with staff that Resident C had a tendency to wander and he knew to approach Resident C carefully because she can be foul-tempered. 1 On 1/9/24 at 11:30 a.m., Resident C's clinical record was reviewed. The diagnoses included, but were not limited to, Alzheimer's disease, dementia with agitation, dementia with psychotic disturbance, dementia with mood disturbance, unspecified dementia with psychotic disturbance, psychotic disorder with delusions, mood disorder, pseudobulbar affect, unspecified dementia with behavioral disturbance, and cognitive communication deficit. The Annual Minimum Data Set (MDS) assessment, dated 8/25/23, indicated the resident was severely cognitively impaired and had Alzheimer's disease and psychotic disorder. The assessment indicated there were no physical behaviors during the assessment period. The most current care plan for agitation, dated 9/25/23, indicated Resident C exhibited aggressive behaviors when other residents entered her bedroom without permission and included the following interventions: -staff will do rounds on the unit to ensure all of the residents are in the correct rooms and beds to assist residents not becoming agitated when peers enter into the wrong room, -staff to check resident's room often to ensure peers are not wandering into her room, -a stop sign is to be placed on the resident doorway to prevent others from entering into her room, -the resident was moved to a room closer to the nursing station to increase supervision, and -the resident preferred her door to be closed at all times and this would deter peers from entering her room. The Quarterly MDS assessment, dated 11/18/23, indicated the resident was severely cognitively impaired, utilized a wheelchair for locomotion, and had Alzheimer's disease, dementia, and psychotic disorder. The assessment indicated there were no physical behaviors during the assessment period. Resident C's progress notes, dated from 6/30/23 through 1/3/24, indicated Resident C was the perpetrator in three resident-to-resident altercations. A nursing progress note, dated 1/3/24 at 9:37 a.m., indicated the stop sign did not effectively prevent an unknown resident from entering the room of Resident C without permission, a resident-to-resident verbal altercation occurred, and Resident C attempted to make physical contact with the arm of the unknown resident. The progress note did not include documentation to show new, effective interventions were implemented to prevent further resident-to-resident altercations. A nursing progress note, dated 1/5/24 at 3:59 p.m., indicated the stop sign did not effectively prevent Resident D from entering the room of Resident C without permission, Resident C perpetrated a resident-to-resident physical altercation with Resident D that resulted in Resident D falling to the floor and sustaining a right upper arm fracture with dislocation and rotation. The progress note did not include documentation to show new, effective interventions were implemented to prevent further resident-to-resident altercations. The progress notes and plans of care, dated between 1/5/24 and 1/7/24 at 4:27 p.m., did not include documentation to show new, effective interventions were implemented to prevent further resident-to-resident altercations. 2. On 1/9/24 at 11:25 a.m., Resident D was observed sleeping in her bed with her right arm folded up and over her chest. On 1/9/23 at 11:32 a.m., Resident D's clinical record was reviewed. The diagnoses included, but were not limited to, Alzheimer's disease, displaced fracture of upper end of right humerus (bone in the upper arm), severe unspecified dementia, low back pain, unspecified pain, and cognitive communication deficit. A Significant Changed MDS assessment, dated 9/20/23, indicated severe cognitive impairment to make decisions regarding tasks of daily life, had wandering behaviors 1-3 days during the assessment period that significantly intruded on the privacy of others, and the resident had 1 fall with no injuries since the prior assessment. A Quarterly MDS assessment, dated 12/13/23, indicated Resident D experienced severe cognitive impairment to make decisions regarding tasks of daily life, utilized a wheelchair for locomotion, and had 1 fall since the prior assessment with no injury. A Facility Observation Detail List Report, dated 1/6/24 at 4:37 p.m., indicated the resident was transferred to the emergency room due to having a fracture of the head of the humerus. A Radiology Report, dated 1/6/24, indicated there was an acute fracture involving the neck of the right humerus with moderate displacement of greater than 1 cm (centimeter), with humeral head rotation. The boney structures appear osteopenia. On 1/10/24 at 2:45 p.m., the DON provided the facility policy, Fall Management, revised 8/2022, and indicated it was the policy currently being used. A review of the policy included, but was not limited to, it is the policy that residents residing within the facility receive adequate supervision. On 1/10/24 at 2:45 p.m., the DON provided the facility policy, Resident Rights, updated on 3/15/17, and indicated it was the policy currently being used. A review of the policy indicated, . Safe Environment . You have the right to a safe . environment . including but not limited to receiving treatment for daily living safely . This citation relates to Complaint IN00425646. 3.1-37(a)

Based on interview and record review, the facility failed to provide services in accordance with professional standards for 1 of 3 residents reviewed. Staff administered another resident's medication without a physician's order. (Resident E) Findings include: During an interview on 1/9/24 at 11:28 A.M., the Director of Nursing (DON) indicated on 1/8/24 around 3:00 A.M., Registered Nurse 1 (RN 1) accidentally administered an oral dose of morphine concentrate to Resident E, who was not prescribed the medication. RN 1 was placed on suspension pending the results of the investigation. On 1/9/24 at 11:30 A.M., Resident E's clinical record was reviewed. The diagnoses included, but were not limited to, senile degeneration of brain and Alzheimer's disease with late onset. The resident began hospice care on 1/4/24 for senile degeneration of the brain. The January 2024, Medication Administration Record (MAR) did not indicate the resident was administered morphine. During an interview on 1/9/24 at 3:06 P.M., the DON indicated a physician's order for a one-time administration of a 10 milligram (mg) dosage of morphine concentrate solution was obtained after it was discovered RN 1 had administered the medication to Resident E. The resident was not prescribed morphine prior to the accidental administration of the medication. During an interview on 1/10/24 at 12:35 P.M., RN 1 indicated Resident E was on hospice care. She was getting out of bed a lot and complained of pain. RN 1 indicated most residents on hospice care were ordered both Ativan and morphine, so she gave the resident Ativan, and around 3:00 A.M. gave her morphine without checking to verify if the resident was prescribed morphine. The morphine was in the medication drawer but it did not have Resident E's name on it. It was an accident and she should have checked to see if the resident had an order for the morphine. She normally charted when a medication was administered in the MAR on the computer. However, she had become busy and forgot to chart the medication administration. Around 11:00 A.M., the DON called her to tell her Resident E did not have an order for the morphine and should not have received it. She did not intend to give a medication that was not prescribed but was concerned with the resident's comfort and did not check to see if the resident was prescribed morphine. On 1/10/24 at 2:45 P.M., the DON provided the facility's Medication Administration Medication Pass Procedure, with the original date of 2/2010 and a revised date of 7/2023 and indicated this was the procedure currently utilized by the facility. A review of the procedure indicated, .Nursing Skills Competency .verify order with label .Perform the 5 rights of medication: Right Resident, Right Medication, Right Dose, Right Route, Right Time .Medication administration will be recorded on the MAR [Medication Administration Record]/EMAR [Electronic Medication Administration Record] or TAR [Treatment Administration Record] .Administration and inventory of controlled substances were documented according to facility policy . On 1/10/24 at 2:46 P.M., the DON provided RN 1's training and in-service transcript. A review of the transcript indicated RN 1 successfully completed the Oral Medication Administration course on 11/3/23 at 10:24 P.M. and successfully completed the facility in-service on charting on 11/21/23. This citation relates to Complaint IN00425771. 3.1-35(g)(1)

Based on interview and record review, the facility failed to ensure residents were showered per their preference for 2 of 6 residents reviewed for choices. (Resident 20, Resident 26) Findings include: 1. During an interview on 8/15/2022 at 10:52 a.m., Resident 20 indicated she had not had a shower nor her hair washed in over a week. Her scheduled days were Tuesday and Friday but she had not received any showers the prior week. On 8/17/2022 at 2:30 p.m., Resident 20's clinical record was reviewed. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set (MDS) assessment, dated 6/4/2022, indicated Resident 20 had moderately cognitive impairment and required extensive assistance of one with personal hygiene. A care plan, initiated on 9/14/2016, and current through target date 9/6/2022, for Resident 20 indicated, . Problem: Resident requires assistance with ADL's [activities of daily living] . related to: DX [diagnosis] of right [CONDITION(S)] secondary to [CONDITION(S)] [cerebral vascular accident] . Goal: Resident will not further decline in current functional abilities . Approach: Offer shower two times per week in the AM or PM, partial bath in between . A review of preferences for Resident 20 indicated, . How important is it for you to choose between a tub bath, shower, bed bath/sponge bath? Very important . Do you have a preference as to what time or how often you bathe? More than twice per week in the PM . What type of bathing are you used to? Shower . A review on 8/19/2022 at 2:15 p.m., of Resident 20's Shower Report indicated the following: -8/5/2022-shower provided. -8/16/2022-shower provided. -undated-shower provided. The Shower Report lacked documentation of Resident 20 having had a shower from 8/5/2022 through 8/16/2022. During an interview on 8/19/2022 at 2:45 p.m., the Director of Nursing Services indicated there were no shower sheets or documentation to indicate Resident 20 had a shower between 8/5/2022 and 8/16/2022. 2. During an interview on 8/14/22 at 12:44 p.m., Resident 26 indicated she was not getting bed baths per her preference. During an interview on 8/17/22 at 1:58 p.m Resident 26 indicated she was to have a bed bath on 8/16/22, but she did not receive it on 8/16/22. On 8/19/22 at 11:33 a.m., Resident 26's clinical record was reviewed. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly MDS assessment, dated 6/7/22, indicated Resident 26 was cognitively intact and was totally dependent on one staff for the bathing. The Preferences for Customary Routine and Activities, dated 6/9/22 at 11:06 a.m., indicated it was very important for her to choose between tub bath, shower, or bed bath/sponge bath and to have more than twice per week in the AM. A care plan, initiated on 6/21/19 and current through target date 9/9/22, indicated Resident 26 required assistance with activities of daily living (ADLs) and to assist with bathing as needed per resident preference. The 100 Back Hall Shower and Linen Change Schedule indicated Resident 26's shower schedule was on Tuesday and Friday evenings. Resident 26's Shower Reports lacked documentation of bed baths given from 8/7/22-8/13/22. During an interview on 8/18/22 at 10:43 a.m., Qualified Medication Aide (QMA) indicated Resident 26's preference has been bed baths instead of showers. She was to receive them twice a week in the evenings. During an interview on 8/19/22 at 2:45 p.m., the Director of Nursing Services (DNS) indicated the clinical record lacked documentation of Resident 26 receiving a bed bath or shower for the week of 8/7/22-8/13/22. On 8/14/22 at 2:00 p.m., the Administrator provided the facility's policy, Resident Rights, revised date 1/2022, and indicated it was the policy being used by the facility. A review of the policy indicated, .A resident has the right to: Choose activities, schedules, and health care consistent with his or her interests, assessments, and plans of care . 3.1-3(u)(1)

Based on observation, interview, and record review, the facility failed to ensure a resident who was diagnosed with dementia, received the appropriate treatment and services to attain or maintain their highest practicable physical, mental, and psychosocial well-being for 1 of 4 resident reviewed for dementia care. (Resident 34) Findings include: During a continuous observation on 8/15/22 from 11:25 a.m. to 11:48 a.m., the following was observed. Resident 34 was observed to go the exit door adjacent to the TV room and wiggle the handle in an attempt to open the door. Resident 34 appeared frustrated and then propelled herself back down the hallway. Resident 34 returned to the exit door and hit the handle three times. The resident appeared staff. No staff were observed to redirect the resident. Resident 34 propelled herself back down the hall towards the dining room. Resident 34 then returned to the exit door and aggressively shook the handle. Resident 34 was observed to be breathing heavily. Multiple staff members were observed to be within sight of Resident 34 but were not observed to redirect the resident. Resident 34 was then observed to propel herself away from the door and back down the hallway. On 8/17/22 at 10:45 a.m., the resident was observed self-propelling herself up and down the halls with her eyes closed. During a continuous observation on 8/18/22 from 11:19 a.m. to 11:29 a.m., the following was observed: Resident 34 was self-propelling herself throughout the unit in her wheelchair. She went up to the exit door and aggressively shook the door handle three times. The resident sat in front of the door for a few minutes before she propelled back down throughout the unit. No staff members were observed to redirect her. Resident 34 returned to the exit door and aggressively shook the door handle two times. She sat in front of the door for a few minutes before she propelled back through the unit. No staff members were observed to redirect her. Resident 34 returned to the exit door and aggressively shook the door handle two times. The resident sat in front of the door for a few minutes before she returned to propelling throughout the unit. Multiple staff members were observed to be nearby and did not redirect the resident. During a continuous observation on 8/18/22 from 11:29 a.m. to 11:47 a.m., the following was observed: Resident 34 was observed to be propelling herself throughout the unit in her wheelchair. She went up to the exit door and aggressively shook the door handle three times. The resident sat in front of the door for a few minutes before she propelled away. Multiple staff were present and did not redirect the resident. The resident returned to the exit door and aggressively shook the door handle three times. Resident 34 sat in front of the door for a few minutes before she propelled away. A CNA came up to the resident and asked her if she was hungry. Resident 34 responded that she was. The CNA was observed to assist the resident to the dining table. No food was observed to be given to the resident. Resident 34 propelled herself away from the dining table and down the hall. She returned to the exit door and aggressively shook the door handle three times. The resident sat in front of the exit door for a few minutes before she propelled away. Multiple staff members were nearby and were not observed to redirect the resident. Resident 34 returned to the exit door and aggressively shook the door handle three times. She was observed to sit in front of the exit door for a few minutes before she propelled way. During a continuous observation on 8/19/22 from 10:23 a.m. to 10:47 a.m., the following was observed: Resident 34 was observed self-propelling throughout the unit. She went up to the exit door rand aggressively shook the door handle two times. She sat in front of the door for a few minutes. Resident 34 then returned to propelling throughout the unit. Multiple staff members were nearby and were not observed to redirect the resident. Resident 34 returned to the exit door and aggressively shook the door handle three times. She sat in front of the door for a few minutes before she propelled away. Multiple staff members were observed to be nearby and did not redirect the resident. Resident 34 returned to the exit door and aggressively shook the door handle three times. She sat in front of the door for a few minutes before she propelled away. Multiple staff members were present and were not observed to redirect the resident. On 8/16/22 at 10:30 a.m., Resident 34's clinical record was reviewed. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A care plan, dated 11/19/22 with a target date of 9/22/22, indicated the resident was at risk for elopement as evidenced by exit seeking. The interventions included, but were not limited to, provide 1 on 1 attention and conversation as needed and redirect to activities of interest such as bingo, penny pitch or coffee hour. The Progress Notes included, but were not limited to: -On 6/16/22 at 8:31 a.m., a quarterly assessment indicated .One important aspect of the resident's life story: Resident loves to garden . -On 6/22/22 at 8:48 p.m., the resident was ambulating the unit via her wheelchair. -On 7/20/22 at 8:19 p.m., the resident was ambulating in wheelchair around the unit. -On 7/28/22 at 9:56 a.m., the resident was frequently self-propelling in her wheelchair throughout the unit. -On 8/2/22 at 5:45 a.m., the resident was up ambulating in wheelchair during the night shift. During an interview on 8/18/22 at 10:00 a.m., CNA 3 indicated the resident was always self-propelling around the unit and she usually had her eyes closed. During an interview on 8/18/22 at 10:15 a.m., CNA 4 indicated the residents do not get to stay outside very long because most of them want to come back in before some of the others. There are some residents on the unit who would love to sit outside all day long. During an interview on 8/18/22 at 10:30 a.m., the unit manager indicated the resident was always on the move about the unit. She indicated the resident liked sweets so she'll offer her cookies. During an interview on 8/19/22 at 2:45 p.m., the Director of Health Services indicated the facility did not have policy for managing wandering residents. 3.1-37(a)

Based on observation, interview, and record review, the facility failed to ensure a resident's menu choice and required texture were met for 1 of 8 residents reviewed for food. (Resident 70). Findings include: During an interview on 8/15/22 at 12:18 P.M., Resident 70 indicated the meals brought to him in his room were frequently not what he requested and were of a texture he was unable to consume. He was to be served a mechanical soft diet due to not being able to chew solid foods. During an interview on 8/16/22 at 12:35 P.M., Resident 70 indicated for that day's lunch he ordered a mechanical soft ground hamburger with cheese sauce, chopped steamed broccoli, cooked soft, pureed wedge fries, ice cream, and 2 servings of diced peaches. On 8/16/22 at 12:46 P.M., the resident's lunch tray was observed to contain a whole baked chicken breast, chopped steamed broccoli, 2 servings of diced pears, and ice cream. There was not a mechanical soft ground hamburger with cheese sauce, diced peaches, or pureed wedge fries. On 8/16/22 at 12:48 P.M., the lunch menu order card dated 8/16/22 was observed on the resident's lunch tray and indicated the resident ordered a mechanical soft ground hamburger with cheese sauce, chopped steamed broccoli, cooked soft, pureed wedge fries, ice cream, and 2 servings of diced peaches. On 8/16/22 at 2:20 P.M., Resident 70's clinical record was reviewed. The diagnoses included, but were not limited to, heart failure and dysphasia, oral phase (a condition in which an individual had difficulties using the mouth, lips and tongue to control food or liquid). A dietary order, dated 8/2/22 and open ended, indicated the resident was to receive .regular, mechanical, ground meat . A Speech - Language Pathologist Altered Diet Consistency Acknowledgement, dated 7/15/22, indicated, .recommended diet mechanical soft . During an interview on 8/17/22 at 11:45 A.M., the Dietary Manager indicated each resident had a tray card from which they choose their meal requests, and this told staff what to serve the resident for meals. 3.1-21(a)(3)

Based on observation, interview, and record review, the facility failed to ensure residents were transferred with a mechanical lift and assistance of 2 staff members for 3 of 3 residents reviewed for accidents (Resident C, Resident E, and Resident F). Finding include: 1. On 11/4/21 at 10:30 a.m., Resident C was observed to be sitting in a wheelchair, with transfer pad positioned under her, in the dining room. On 11/5/21 at 11:45 a.m., Resident C's clinical record was reviewed. The diagnoses included, but were not limited to, right-sided [CONDITION(S)] (paralysis of one side of the body), stroke, and dementia. The annual Minimum Data Set (MDS) assessment, dated 8/31/21, indicated Resident C had severe cognitive impairment, required extensive assistance of two or more staff members with transfers, and had upper and lower extremity impairment on one side. A care plan, initiated on 10/22/15 and current through target date 1/20/22, for Resident C indicated: Problem: .Resident is at risk for fall due to: [CONDITION(S)] [[CONDITION(S)] (stroke)] with right side [CONDITION(S)] [weakness] .dementia .Hx [history] of falls, lack of understanding with cognitive impairment .Goal: .Resident fall risk factors will be reduced in an attempt to avoid significant fall related injury Approach Hoyer [mechanical] lift for transfers x 2 [times 2] staff . Physician orders, dated 10/1/21 through 10/31/21, for Resident C indicated, .Transfer with Hoyer [mechanical] lift with assistance of 2 staff members .(start date 3/17/21). Resident C's progress notes indicated the following: -On 10/7/21 at 8:15 a.m., Resident C had a black/purple discoloration to her skin on her right arm, her right breast, and her right back. The measurements to her right arm were 6 centimeter (cm) by 5 cm; her right back were 10 cm by 9.5 cm; and her right breast were 6.5 cm by 3 cm. She had complaints of pain to the area on her right back. The clinical record lacked documentation of root cause of black/purple discoloration to her skin. During an interview, on 11/5/21 at 10:45 a.m., PCA 1 indicated Resident C required mechanical lift and 2 staff members with transfers. She had worked day shift on 10/6/21 with CNA 2. CNA 2 assisted Resident C into her chair without the mechanical lift. CNA 2 did not ask for assistance with transferring Resident C. She observed CNA 2 lock Resident C's wheel chair and transfer Resident C into bed by lifting her under her arms. During an interview, on 11/4/21 at 3:50 p.m., Licensed Practical Nurse (LPN) 1 indicated she worked day shift on 10/6/21. PCA 1 indicated CNA 2 did not utilize the mechanical lift to transfer Resident C. CNA 2 did not ask LPN 1 for assistance with transferring Resident C. During an interview, on 11/4/21 at 4:00 p.m., CNA 3 indicated she worked day shift on 10/6/21. CNA 2 worked day shift on 10/6/21. CNA 2 indicated to her he transferred Resident C without using a mechanical lift. During an interview, on 11/4/21 at 4:05 p.m., CNA 4 indicated he worked day shift on 10/6/21. Resident C required a mechanical lift and 2 assist with transfers. CNA 2 did not ask CNA 4 for assistance with transferring C. During an interview, on 11/4/21 at 11:43 a.m., Certified Nursing Assistant (CNA) 1 indicated Resident C required 2 staff members and mechanical lift for transfers. In October 2021, Resident C had bruises on her right arm, right back, and right breast from not being transferred with a mechanical lift and 2 staff members. During an interview, on 11/4/21 at 12:35 p.m., Unit Manager (UM) indicated Resident C required 2 staff members and mechanical lift for transfers. In October 2021, Resident C had bruises to her right arm, right back, and right breast. The root cause of the bruising was CNA 2 transferred her without a mechanical lift and 2 staff members. On 11/5/21 at 1:40 p.m., the Director of Nursing (DON) provided the facility's policy, Mechanical Lift, dated 3/2012, and indicated it was the policy currently being used by the facility. A review of the policy indicated, .NOTE: Two (2) staff is required at all times when using a mechanical lift . 2. On 11/4/21 at 10:30 a.m., Resident E was observed to be sitting in a wheelchair in the dining room. On 11/5/21 at 11:55 a.m., Resident E's clinical record was reviewed. The diagnoses included, but were not limited to, pain and dementia. The quarterly Minimum Data Set (MDS) assessment, dated 7/27/21, indicated Resident E had severe cognitive impairment and required extensive assistance of two or more staff members with transfers. A care plan, initiated on 1/8/14 and current through target date 1/22/22, for Resident E indicated: Problem: .Self care deficit .transfers .dementia with cognition deficits, lower body weakness .Goal: .Resident will not further decline in current adl [Activities of Daily Living] ability .Approach: .hoyer [mechanical] lift for transfers and leave hoyer pad under resident when in wheelchair . Physician orders, dated 10/1/21 through 10/31/21, for Resident E indicated, Transfer with mechanical left with assistance of 2 staff members - leave hoyer pad under resident when in wheelchair . (start date 2/13/20). During an interview, on 11/5/21 at 10:45 a.m., PCA 1 indicated Resident E required mechanical lift and 2 staff members with transfers. She worked day shift on 10/6/21 with CNA 2. CNA 2 assisted Resident E into her chair without the mechanical lift. CNA 2 did not ask for assistance with transferring Resident E. During an interview, on 11/4/21 at 11:43 a.m., Certified Nursing Assistant (CNA) 1 indicated Resident E required a mechanical lift and 2 staff members for transfers. During an interview, on 11/4/21 at 3:50 p.m., Licensed Practical Nurse (LPN) 1 indicated she worked day shift on 10/6/21. PCA 1 indicated CNA 2 did not utilize the mechanical lift to transfer Resident E. CNA 2 did not ask LPN 1 for assistance with transferring Resident E. On 11/5/21 at 1:40 p.m., the Director of Nursing (DON) provided the facility's policy, Mechanical Lift, dated 3/2012, and indicated it was the policy currently being used by the facility. A review of the policy indicated, .NOTE: Two (2) staff is required at all times when using a mechanical lift . 3. During an interview, on 11/5/21 at 10:45 a.m., PCA 1 indicated Resident F required mechanical lift and 2 staff members with transfers. She worked day shift on 10/6/21 with CNA 2. CNA 2 assisted Resident F into her chair without the mechanical lift. CNA 2 did not ask for assistance with transferring Resident F. On 11/5/21 at 12:00 p.m., Resident F's clinical record was reviewed. The diagnoses included, but were not limited to, dementia and weakness. The quarterly Minimum Data Set (MDS) assessment, dated 10/4/21, indicated Resident F had severe cognitive impairment and required extensive assistance of two or more staff members with transfers. A care plan, initiated on 11/25/20 and current through target date 1/5/22, for Resident F indicated: Problem: .Resident is at risk for falls due to: weakness and debility, alteration in cognition related to dementia, hx [history] of falls resident requires staff assist with safe transfers .Goal: .Resident fall risk factors will be reduced in an attempt to avoid significant fall related injury Approach hoyer [mechanical] lift assist of 2 . Physician orders, dated 10/1/21 through 10/31/21, for Resident F indicated, .Transfer with mechanical hoyer lift with assistance of 2 staff members .(start date 5/28/21). During an interview, on 11/5/21 at 10:45 a.m., PCA 1 indicated Resident F required mechanical lift and 2 staff members with transfers. She worked day shift on 10/6/21 with CNA 2. CNA 2 assisted Resident F into her chair without the mechanical lift. CNA 2 did not ask for assistance with transferring Resident F. On 11/5/21 at 1:40 p.m., the Director of Nursing (DON) provided the facility's policy, Mechanical Lift, dated 3/2012, and indicated it was the policy currently being used by the facility. A review of the policy indicated, .NOTE: Two (2) staff is required at all times when using a mechanical lift . This Federal tag relates to Complaint IN 967. 3.1-45(a)(2)

Based on observation, interview, and record review, the facility failed to ensure supervision to prevent repeated falls for residents assessed to be a high risk for falls and who wandered resulting in unwitnessed falls that resulted in rib fractures, lacerations, and skin tears for 2 of 5 residents reviewed for accidents. (Resident O and Resident N) Findings include: 1. On 5/11/2021 from 1:05 p.m. to 1:15 p.m., Resident O was observed to be self propelling around Unit 300 in her wheelchair. She had a yellow colored bruise and a nickel sized scabbed area under her right eye. Staff were not observed to be near the resident nor supervising. On 5/11/2021 from 3:00 p.m. to 3:05 p.m., Resident O was observed to be self propelling around Unit 300 in her wheelchair. Staff were not observed to be near the resident nor supervising. On 5/12/2021 at 10:36 a.m., Resident O's clinical record was reviewed. Diagnoses included, but were not limited to dementia and repeated falls. The Quarterly Minimum Data Set assessment, dated 4/2/2021, indicated Resident O was not interviewable, required limited assistance of 1 for locomotion on the unit, was not steady from a seated to standing position, required a wheelchair for mobility, had 2 falls with injury since admission, and had a behavior of wandering. A review of the Fall Risk Assessments for Resident O indicated the following: -On 7/7/2020 at 1:00 p.m., Resident O was assessed as a high fall risk due to age, fall history, elimination, medications, mobility and cognition. -On 9/29/2020 at 10:20 a.m., Resident O was assessed as a high fall risk due to age, fall history, elimination and cognition. -On 1/1/2021 at 12:51 p.m., Resident O was assessed as a moderate fall risk due to age, fall history, elimination, mobility and cognition. -On 3/26/2021 at 8:28 a.m., Resident O was assessed as a high fall risk due to age, fall history, elimination, medications, mobility and cognition. -On 4/9/2021 at 2:40 p.m., Resident O was assessed as a moderate fall risk due to age, fall history, elimination and cognition. A care plan, initiated on 6/28/2018 and current through target date 7/21/2021, for Resident O indicated, . Problem: Resident is at risk for falls due to: hx [history] of left hip fx [fracture] repair, hx of falls, poor balance, debility/weakness, dementia, poor safety awareness, drug regimen, advanced age, resident has hx of removing adaptive equipment when put in place for safety measures, lack of understanding, impulsive, poor safety awareness, recent fall with rib fractures, Resident has DX [diagnosis] of osteopenia. Per observation, resident propels self in WC [wheelchair] looking down at the floor . Goal: Resident fall risk factors will be reduced in an attempt to avoid significant fall related injury . Approach: Non skid footwear. Start 6/28/2018. Therapy screen. Start 7/5/2018. Personal items in reach. Start 7/5/2018. Environmental changes. Start 7/5/2018. Call light in reach. Start 7/5/2018. Staff to assist resident to meals. Start 7/9/2018. Wheelchair with brake extenders and anti-rollbacks. Start 3/4/2019. Nonskid strips next to bed. Start 3/4/2019. Bolster mattress. Start 3/8/2019. Maintenance to adjust anti-rollbacks. Start 3/15/2019. Wheelchair lock extensions. Start 3/19/2019. Therapy to eval [evaluate] wheelchair. Start 1/24/2020. Dycem wheelchair cushion top and bottom of cushion. Start 3/23/2020. Therapy to eval WC for tipping. Start 8/19/2020. Touch pad call light clipped on bed close to the bed side table. 12/17/2020. Bed to be in lowest position when in bed. Start 1/29/2021. Repair wheelchair. Start 3/14/2021. Therapy to dump wheelchair seat. Start 3/17/2021. Toilet every 2 hours. Start 4/6/2021. Signs in room/bathroom to remind resident to call for assist to help. Start 4/7/2021. Therapy to eval for proper wheelchair. Start 5/3/2021. Give resident baby doll to hold. Start 5/11/2021. Replace adaptive equipment when resident removes as resident allows [eg. brake extenders and lateral supports]. Start 5/12/2021 . The care plan for Resident O lacked documentation of implementation of an intervention for staff supervision to prevent a reoccurrence of falls. A review of the 8 Fall Event Reports for Resident O indicated the following: -On 8/19/2020 at 7:07 p.m., . resident was found in her old room after yelling 'help' on the floor. Resident fell face forward out of wheelchair hitting left side of face resulting in heavy blood loss. Resident sent to ER [emergency room ] for evaluation. Right knee swelled and there is a deep gash on left side of eyebrow. Fall was not witnessed [was not observed by the staff] . Hospital ER Report, dated 8/19/2021 at 7:19 p.m., for Resident O indicated, . [resident name] with a history of dementia who presents via EMS [emergency medical services] after an unwitnessed fall . Staff went to check on another patient and heard patient fall. She has a laceration to her left forehead. She also has abrasions to both knees . left forehead laceration closed with 6 prolene [sutures] x 6 simple [sutures] . -On 12/17/2020 at 4:23 p.m., . staff entering room to find res [resident] laying on floor. Resident noted to attempt to transfer from bed to wheelchair. Slight abrasion to back. Fall was not witnessed . -On 1/28/2021 at 2:45 a.m., . heard resident yelling 'hey.' Upon entering room resident sitting on buttocks next to bed, next to wheelchair with feet facing closet. 3 cm [centimeter] skin tear note to rue [right upper extremity]. Fall was not witnessed . The Fall Event Report for Resident O dated, 1/28/2021 at 2:45 a.m., indicated an intervention of, close monitoring. -On 3/13/2021 at 10:28 p.m., . nurse called to resident room by QMA [Qualified Medication Aide]. Resident had an unwitnessed fall. Upon entering room, resident was sitting on floor leaning on left arm on floor next to bed. Resident with a skin tear to L [left] forearm and R [right] shin. Fall was not witnessed . -On 4/4/2021 at 3:12 a.m., . resident had an unwitnessed fall. Resident was found on floor under bed by staff . -On 4/6/2021 at 11:03 a.m., . resident had an unwitnessed fall in the bathroom. Found sitting on bottom in front of the toilet. Red, swollen area to right side flank [upper abdomen to back] area measuring approximately 5 cm x 5 cm. Stat x-ray of right flank area ordered . Radiology Report, dated, 4/8/2021 at 5:02 p.m., indicated, . Multiple fracturest [sic] felt to be acute lateral fifth through seventh ribs. Osteopenia. [CONDITION(S)] change. Soft tissues unremarkable. Conclusion: Multiple left rib fractures not evident prior exam . -On 5/1/2021 at 9:20 p.m., . writer notified that resident had fallen. Fall was unwitnessed. Resident has an abrasion on her right eye with purple red bruising and a small cut. Skin tear on right elbow . -On 5/10/2021 at 8:36 p.m., . res had unwitnessed fall in MDR [main dining room]. Found laying on right side in front of WC. Resident with new skin tear to R elbow measuring 3 cm x 0.5 cm, scant amount of blood noted . During an interview, on 5/10/2021 at 2:28 p.m., Licensed Practical Nurse (LPN) 1 indicated Resident O had multiple falls with injuries including rib fractures and there was not enough staff on Unit 300 to supervise her at all times, due to providing personal care to the other residents. During an interview, on 5/10/2021 at 3:30 p.m., QMA 1 indicated Resident O had multiple falls with injury and there was not enough staff to supervise her at all times, due to providing care to the other residents. During an interview, on 5/11/2021 at 12:50 p.m., LPN 2 indicated Resident O liked to wander all the time. She propelled herself in the wheelchair. There were times when staff were too busy to keep an eye on her, due to providing care to the other residents. During an interview on 5/11/2021 at 1:15 p.m., the Assistant Director of Nursing (ADON) indicated Resident O wandered the hallway in her wheelchair. Staff should be keeping an eye on her when she was up wandering. During an interview, on 5/12/2021 at 10:25 a.m., LPN 3 indicated Resident O wandered the halls in her wheelchair. She liked to lean forward in her chair and sometimes falls over head first. She required supervision at all times due to being a fall risk, but they did not have the staff to be able to do that. During an interview, on 5/12/2021 at 10:45 a.m., LPN 4 indicated she was working the evening Resident O fell on [DATE] at 8:36 p.m. The resident was rolling around in her wheelchair when LPN 4 heard a loud noise. She did not witness the fall. Resident O should be supervised at all times, but it was difficult when they were short staffed. During an interview, on 5/12/2021 at 11:05 a.m., QMA 2 indicated Resident O liked to wander. She was supposed to be checked on often, but at times they were too busy and unable to watch her. 2. On 5/11/2021 from 3:00 p.m. to 3:05 p.m., Resident N was observed to be in her room, with the door closed, and walking around the room. Staff were not observed to be near the resident nor supervising. On 5/12/21 at 12:30 p.m., Resident N's clinical record was reviewed. Diagnoses included, but were not limited to dementia, history of falling, difficulty in walking, and muscle weakness. The significant change Minimum Data Set (MDS) assessment, dated 6/4/20, indicated Resident N had cognitive impairment; required limited assistance of one for transfer, required extensive assistance of one for walking in corridor, room, locomotion on the unit, and toileting; had 2 or more falls with no injury; and had 2 or more falls with injury. The quarterly Minimum Data Set (MDS) assessment, dated 2/20/21, indicated Resident N was not interviewable; required extensive assistance of one for transfer, walking in corridor, room, locomotion on the unit, and toileting; had 2 or more falls with no injury; and had 2 or more falls with injury. A care plan, initiated on 3/29/20 and current through target date 5/22/21, for Resident N indicated: .Problem .Resident is at risk for falls due to: weakness and debility, cognitive deficits, advanced age, hx [history] of falls, current drug regiment, impulsive, unsteady gait and urgency .Goal: Resident fall risk factors will be reduced in an attempt to avoid significant fall related injury .Approach .lab work as ordered .refer to eye doctor for glasses .Bolster mattress .high toilet seat with side bars .nonskid strips by bedside and toilet .nonskid socks on at all times .therapy to eval [evaluation] . neon sign reminder to have walker while resident is up .assist to toilet after meals .staff to assist resident to dining area for each meal .toilet every 2 hrs [hours] .frequent checks when resident is in her room .resident to be dressed in clothing per preference .call light in reach .personal items in reach .observe for unsafe actions and intervene as needed . The fall care plan lacked an intervention for supervision to prevent recurrence of falls. Resident N's Fall Risk Assessment Tool indicated the following: -On 3/27/20 at 9:10 p.m., Resident N had one fall within the previous 6 months, had unsteady gait, and was a moderate fall risk. -On 8/31/20 at 11:14 a.m., Resident N had one fall within the previous 6 months, had incontinence of bowel and bladder, on 2 or more high fall risk drugs, unsteady gait, cognition limitations, and was a high fall risk. -On 10/29/20 at 12:42 p.m., Resident N had one fall within the previous 6 months, had incontinence of bowel and bladder, on 2 or more high risk drugs, required assistance or supervision with mobility, transfer, or ambulation, was impulsive, and was a high fall risk. -On 1/22/21 at 2:07 p.m., Resident N had one fall within the previous 6 months, had incontinence of bowel and bladder, on 2 or more high risk drugs, and was a high fall risk. -On 4/20/21 at 1:21 p.m., Resident N had one fall within the previous 6 months, on 2 or more high fall risk drugs, and was a high fall risk. Resident N's 18 Fall Events indicated the following: -On 5/11/20 at 5:15 a.m., Resident N was found on the floor with her head on a pillow. Resident N had a laceration (cut) on the back of her head. The fall was not witnessed (Staff did not see the fall occur). -On 5/15/20 at 5:34 a.m., Resident N was found on the floor with no injury. The fall was not witnessed. -On 5/16/20 at 9:30 p.m., Resident N was found on the floor with no injury. The fall was not witnessed. -On 6/20/20 at 11:55 a.m., Resident N was found on the floor in her room with a skin tear to her right elbow. The fall was not witnessed. -On 6/21/20 at 3:30 a.m., Resident N was found in the bathroom on the floor next to the toilet with no injury. The fall was not witnessed. -On 8/31/20 at 10:23 p.m., Resident N was found on the floor in the bathroom with no injury. The fall was not witnessed. -On 9/8/20 at 12:29 p.m., Resident N was found on the floor in the hallway with a swollen area on the back of her head and a skin tear on her left elbow. The fall was not witnessed. Resident N was sent to the emergency room . The emergency room report, dated 5/13/21 at 12:41 p.m., indicated a mid occipital hematoma (collection of blood on the back of head). -On 9/13/20 at 6:10 a.m., Resident N was found on the floor in her room with a skin tear on her right elbow. The fall was not witnessed. -On 9/17/20 at 1:35 p.m., Resident N was found on the floor in her room with a skin tear on her right forearm. The fall was not witnessed. -On 10/24/20 at 10:20 a.m., Resident N was found on the floor in her bathroom with no injury. The fall was not witnessed. -On 11/14/20 at 9:28 p.m., Resident N was found on the floor in hallway with no injury. The fall was not witnessed. -On 11/17/20 at 9:16 a.m., Resident N was found on the floor in front of her toilet with a skin tear to her right elbow. The fall was not witnessed. -On 12/7/20 at 3:30 a.m., Resident N was found on the floor in next to her toilet with no injury. The fall was not witnessed. -On 12/14/20 at 9:31 a.m., Resident N was found on the floor in front of her bed with a swollen area on the back of her head. The fall was not witnessed. -On 2/17/21 at 9:11 a.m., Resident N was found on the floor in front of her toilet with no injury. The fall was not witnessed. -On 2/27/21 at 7:11 p.m., Resident N was found on the floor in a doorway with no injury. The fall was not witnessed. -On 3/14/21 at 9:34 a.m., Resident N was found lying on her back with her head on the floor with an abrasion on the right side of her head. The fall was not witnessed. -On 3/26/21 at 5:08 p.m., Resident N was found on the floor in her doorway with a laceration to her left elbow. The fall was not witnessed. During an interview, on 5/12/21 at 10:25 a.m., Licensed Practical Nurse (LPN) 3 indicated Resident N had frequent falls with injuries like skin tears, bruises, and had hit the back of her head. Her fall interventions were to toilet every 2 hours, redirection to use walker, and to provide supervision at all times. During an interview, on 5/12/21 at 10:45 a.m., LPN 4 indicated Resident N had frequent falls. Her fall interventions were to have an entry light on in the bathroom, to toilet every 2 hours, and to provide supervision at all times. During an interview, on 5/12/21 at 11:05 a.m., Qualified Medication Aide (QMA) indicated Resident N had frequent falls. She had numerous attempts to ambulate without supervision. She has had numerous falls in the bathroom from attempting to take herself to the bathroom without supervision. Her fall interventions were to toilet every 2 hours and to provide supervision at all times. On 5/12/2021 at 1:00 p.m., the Director of Nursing provided the facility's policy, Fall Management Program with a revised date of 11/2017, and indicated this was the policy currently being used by the facility. A review of the policy indicated, . It is the policy of [facility corporation name] to ensure residents residing within the facility receive adequate supervision and or assistance to prevent injury related to falls . This Federal tag relates to Complaint IN 218. 3.1-45(a)(2)

Based on observation, interview, and record review, the facility failed to provide sufficient staffing on the Memory Care Unit in order to provide adequate supervision to prevent falls which resulted in injury for 2 of 6 residents reviewed for accidents. (Resident O and Resident N) Findings include: 1. On 5/11/2021 from 1:05 p.m. to 1:15 p.m., Resident O was observed to be self propelling around Unit 300 in her wheelchair. She had a yellow colored bruise and a nickel sized scabbed area under her right eye. Staff were not observed to be near the resident nor supervising. On 5/11/2021 from 3:00 p.m. to 3:05 p.m., Resident O was observed to be self propelling around Unit 300 in her wheelchair. Staff were not observed to be near the resident nor supervising. On 5/12/2021 at 10:36 a.m., Resident O's clinical record was reviewed. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set assessment, dated 4/2/2021, indicated Resident O was not interviewable, required limited assistance of 1 for locomotion on the unit, was not steady from a seated to standing position, required a wheelchair for mobility, had 2 falls with injury since admission, and had a behavior of wandering. A review of the Fall Risk Assessments for Resident O indicated the following: -On 7/7/2020 at 1:00 p.m., Resident O was assessed as a high fall risk due to age, fall history, elimination, medications, mobility and cognition. -On 9/29/2020 at 10:20 a.m., Resident O was assessed as a high fall risk due to age, fall history, elimination and cognition. -On 1/1/2021 at 12:51 p.m., Resident O was assessed as a moderate fall risk due to age, fall history, elimination, mobility and cognition. -On 3/26/2021 at 8:28 a.m., Resident O was assessed as a high fall risk due to age, fall history, elimination, medications, mobility and cognition. -On 4/9/2021 at 2:40 p.m., Resident O was assessed as a moderate fall risk due to age, fall history, elimination and cognition. A care plan, initiated on 6/28/2018 and current through target date 7/21/2021, for Resident O indicated, . Problem: Resident is at risk for falls due to: hx [history] of left hip fx [fracture] repair, hx of falls, poor balance, debility/weakness, dementia, poor safety awareness, drug regimen, advanced age, resident has hx of removing adaptive equipment when put in place for safety measures, lack of understanding, impulsive, poor safety awareness, recent fall with rib fractures, Resident has DX [diagnosis] of osteopenia. Per observation, resident propels self in WC [wheelchair] looking down at the floor . Goal: Resident fall risk factors will be reduced in an attempt to avoid significant fall related injury . Approach: Non skid footwear. Start 6/28/2018. Therapy screen. Start 7/5/2018. Personal items in reach. Start 7/5/2018. Environmental changes. Start 7/5/2018. Call light in reach. Start 7/5/2018. Staff to assist resident to meals. Start 7/9/2018. Wheelchair with brake extenders and anti-rollbacks. Start 3/4/2019. Nonskid strips next to bed. Start 3/4/2019. Bolster mattress. Start 3/8/2019. Maintenance to adjust anti-rollbacks. Start 3/15/2019. Wheelchair lock extensions. Start 3/19/2019. Therapy to eval [evaluate] wheelchair. Start 1/24/2020. Dycem wheelchair cushion top and bottom of cushion. Start 3/23/2020. Therapy to eval WC for tipping. Start 8/19/2020. Touch pad call light clipped on bed close to the bed side table. 12/17/2020. Bed to be in lowest position when in bed. Start 1/29/2021. Repair wheelchair. Start 3/14/2021. Therapy to dump wheelchair seat. Start 3/17/2021. Toilet every 2 hours. Start 4/6/2021. Signs in room/bathroom to remind resident to call for assist to help. Start 4/7/2021. Therapy to eval for proper wheelchair. Start 5/3/2021. Give resident baby doll to hold. Start 5/11/2021. Replace adaptive equipment when resident removes as resident allows [eg. brake extenders and lateral supports]. Start 5/12/2021 . The care plan for Resident O lacked documentation of implementation of an intervention for staff supervision to prevent a reoccurrence of falls. A review of the 8 Fall Event Reports for Resident O indicated the following: -On 8/19/2020 at 7:07 p.m., . resident was found in her old room after yelling 'help' on the floor. Resident fell face forward out of wheelchair hitting left side of face resulting in heavy blood loss. Resident sent to ER [emergency room ] for evaluation. Right knee swelled and there is a deep gash on left side of eyebrow. Fall was not witnessed [was not observed by the staff] . Hospital ER Report, dated 8/19/2021 at 7:19 p.m., for Resident O indicated, . [resident name] with a history of dementia who presents via EMS [emergency medical services] after an unwitnessed fall . Staff went to check on another patient and heard patient fall. She has a laceration to her left forehead. She also has abrasions to both knees . left forehead laceration closed with 6 prolene [sutures] x 6 simple [sutures] . -On 12/17/2020 at 4:23 p.m., . staff entering room to find res [resident] laying on floor. Resident noted to attempt to transfer from bed to wheelchair. Slight abrasion to back. Fall was not witnessed . -On 1/28/2021 at 2:45 a.m., . heard resident yelling 'hey.' Upon entering room resident sitting on buttocks next to bed, next to wheelchair with feet facing closet. 3 cm [centimeter] skin tear note to rue [right upper extremity]. Fall was not witnessed . The Fall Event Report for Resident O dated, 1/28/2021 at 2:45 a.m., indicated an intervention of, close monitoring. -On 3/13/2021 at 10:28 p.m., . nurse called to resident room by QMA [Qualified Medication Aide]. Resident had an unwitnessed fall. Upon entering room, resident was sitting on floor leaning on left arm on floor next to bed. Resident with a skin tear to L [left] forearm and R [right] shin. Fall was not witnessed . -On 4/4/2021 at 3:12 a.m., . resident had an unwitnessed fall. Resident was found on floor under bed by staff . -On 4/6/2021 at 11:03 a.m., . resident had an unwitnessed fall in the bathroom. Found sitting on bottom in front of the toilet. Red, swollen area to right side flank [upper abdomen to back] area measuring approximately 5 cm x 5 cm. Stat x-ray of right flank area ordered . Radiology Report, dated, 4/8/2021 at 5:02 p.m., indicated, . Multiple fracturest [sic] felt to be acute lateral fifth through seventh ribs. Osteopenia. [CONDITION(S)] change. Soft tissues unremarkable. Conclusion: Multiple left rib fractures not evident prior exam . -On 5/1/2021 at 9:20 p.m., . writer notified that resident had fallen. Fall was unwitnessed. Resident has an abrasion on her right eye with purple red bruising and a small cut. Skin tear on right elbow . -On 5/10/2021 at 8:36 p.m., . res had unwitnessed fall in MDR [main dining room]. Found laying on right side in front of WC. Resident with new skin tear to R elbow measuring 3 cm x 0.5 cm, scant amount of blood noted . On 5/10/2021 at 2:15 p.m., the Director of Nursing (DON) provided the evening staffing schedule for 5/10/2021. Unit 300, where Resident O resided and where she sustained injuries. A review of the schedule indicated on 5/10/2021, 1 nurse worked from 2:00 p.m. to 6:30 p.m., 1 nurse worked from 6:00 p.m., to 10:30 p.m., and 1 CNA (certified nursing aide) worked from 2:00 p.m. to 10:00 p.m., with a 2:00 p.m. shift open. The night staffing schedule for 5/10/2021 for Unit 300 indicated, 1 nurse worked from 10:00 p.m. to 6:30 a.m., on 5/11/2021. One CNA worked from 10:00 p.m. to 6:00 a.m., on 5/11/2021. The schedule did not indicate if a staff member had called in sick or was sent to another unit. Unit 300 had a census of 18 residents during the survey period and was a a secured memory care unit. The most current MDS reviews indicated 7 residents on Unit 1 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] During an interview, on 5/10/2021 at 3:30 p.m., QMA 1 indicated Resident O had multiple falls with injury and there was not enough staff to supervise her at all times. She often worked the unit by herself. She did not have a CNA. Many residents needed toileting and when helping with toileting care, that left them with no staff on the unit watching the residents who wander. During an interview, on 5/11/2021 at 12:50 p.m., Licensed Practical Nurse (LPN) 2 indicated Resident O liked to wander all the time. She propelled herself in the wheelchair. There were times when staff was unable to keep an eye on her due to providing care to other residents. During an interview, on 5/11/2021 at 1:15 p.m., the Assistant Director of Nursing (ADON) indicated Resident O wandered the hallway in her wheelchair. Staff should keep an eye on her when she was up wandering. During an interview, on 5/12/2021 at 10:25 a.m., LPN 3 indicated Resident O wandered the halls in her wheelchair. She liked to lean forward in her chair and sometimes falls over head first. She required supervision at all times, but they did not have the staff to be able to do that. She often worked Unit 300 by herself. She had to give residents showers and toilet them so that would leave the unit with no staff to supervise the residents who wander. There were 7 residents who wandered and 18 who were incontinent. During an interview, on 5/12/2021 at 10:45 a.m., LPN 4 indicated she was working the evening Resident O fell on [DATE] at 8:36 p.m. The resident was rolling around in her wheelchair when LPN 4 heard a loud noise. She did not witness the fall. Resident O should be supervised at all times, but it was difficult when they were short staffed. There were times she would be required to work Unit 300 by herself. She has also had to work Unit 300 and 600 at the same time leaving only a CNA on Unit 300 caring for the residents. During an interview, on 5/12/2021 at 11:05 a.m., QMA 2 indicated Resident O liked to wander. She was supposed to be checked on often, but at times they were too busy and unable to watch her. They often worked Unit 300 short staffed. Many shifts there was 1 nurse and 1 CNA, but if the nurse was also working the 600 hall, she would be on the Unit 300 by herself. Many residents are to be checked, turned and repositioned every 2 hours, but it was impossible to do that when she was working by herself. 2. On 5/11/2021 from 3:00 p.m. to 3:05 p.m., Resident N was observed to be in her room, with the door closed, and walking around the room. Staff were not observed to be near the resident nor supervising. On 5/12/21 at 12:30 p.m., Resident N's clinical record was reviewed. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The significant change Minimum Data Set (MDS) assessment, dated 6/4/20, indicated Resident N had cognitive impairment; required limited assistance of one for transfer, required extensive assistance of one for walking in corridor, room, locomotion on the unit, and toileting; had 2 or more falls with no injury; and had 2 or more falls with injury. The quarterly Minimum Data Set (MDS) assessment, dated 2/20/21, indicated Resident N was not interviewable; required extensive assistance of one for transfer, walking in corridor, room, locomotion on the unit, and toileting; had 2 or more falls with no injury; and had 2 or more falls with injury. A care plan, initiated on 3/29/20 and current through target date 5/22/21, for Resident N indicated: .Problem .Resident is at risk for falls due to: weakness and debility, cognitive deficits, advanced age, hx [history] of falls, current drug regiment, impulsive, unsteady gait and urgency .Goal: Resident fall risk factors will be reduced in an attempt to avoid significant fall related injury .Approach .lab work as ordered .refer to eye doctor for glasses .Bolster mattress .high toilet seat with side bars .nonskid strips by bedside and toilet .nonskid socks on at all times .therapy to eval [evaluation] . neon sign reminder to have walker while resident is up .assist to toilet after meals .staff to assist resident to dining area for each meal .toilet every 2 hrs [hours] .frequent checks when resident is in her room .resident to be dressed in clothing per preference .call light in reach .personal items in reach .observe for unsafe actions and intervene as needed . The fall care plan lacked an intervention for supervision to prevent recurrence of falls. Resident N's Fall Risk Assessment Tool indicated the following: -On 3/27/20 at 9:10 p.m., Resident N had one fall within the previous 6 months, had unsteady gait, and was a moderate fall risk. -On 8/31/20 at 11:14 a.m., Resident N had one fall within the previous 6 months, had incontinence of bowel and bladder, on 2 or more high fall risk drugs, unsteady gait, cognition limitations, and was a high fall risk. -On 10/29/20 at 12:42 p.m., Resident N had one fall within the previous 6 months, had incontinence of bowel and bladder, on 2 or more high risk drugs, required assistance or supervision with mobility, transfer, or ambulation, was impulsive, and was a high fall risk. -On 1/22/21 at 2:07 p.m., Resident N had one fall within the previous 6 months, had incontinence of bowel and bladder, on 2 or more high risk drugs, and was a high fall risk. -On 4/20/21 at 1:21 p.m., Resident N had one fall within the previous 6 months, on 2 or more high fall risk drugs, and was a high fall risk. Resident N's 18 Fall Events indicated the following: -On 5/11/20 at 5:15 a.m., Resident N was found on the floor with her head on a pillow. Resident N had a laceration (cut) on the back of her head. The fall was not witnessed (Staff did not see the fall occur). -On 5/15/20 at 5:34 a.m., Resident N was found on the floor with no injury. The fall was not witnessed. -On 5/16/20 at 9:30 p.m., Resident N was found on the floor with no injury. The fall was not witnessed. -On 6/20/20 at 11:55 a.m., Resident N was found on the floor in her room with a skin tear to her right elbow. The fall was not witnessed. -On 6/21/20 at 3:30 a.m., Resident N was found in the bathroom on the floor next to the toilet with no injury. The fall was not witnessed. -On 8/31/20 at 10:23 p.m., Resident N was found on the floor in the bathroom with no injury. The fall was not witnessed. -On 9/8/20 at 12:29 p.m., Resident N was found on the floor in the hallway with a swollen area on the back of her head and a skin tear on her left elbow. The fall was not witnessed. Resident N was sent to the emergency room . The emergency room report, dated 5/13/21 at 12:41 p.m., indicated a mid occipital hematoma (collection of blood on the back of head). -On 9/13/20 at 6:10 a.m., Resident N was found on the floor in her room with a skin tear on her right elbow. The fall was not witnessed. -On 9/17/20 at 1:35 p.m., Resident N was found on the floor in her room with a skin tear on her right forearm. The fall was not witnessed. -On 10/24/20 at 10:20 a.m., Resident N was found on the floor in her bathroom with no injury. The fall was not witnessed. -On 11/14/20 at 9:28 p.m., Resident N was found on the floor in hallway with no injury. The fall was not witnessed. -On 11/17/20 at 9:16 a.m., Resident N was found on the floor in front of her toilet with a skin tear to her right elbow. The fall was not witnessed. -On 12/7/20 at 3:30 a.m., Resident N was found on the floor in next to her toilet with no injury. The fall was not witnessed. -On 12/14/20 at 9:31 a.m., Resident N was found on the floor in front of her bed with a swollen area on the back of her head. The fall was not witnessed. -On 2/17/21 at 9:11 a.m., Resident N was found on the floor in front of her toilet with no injury. The fall was not witnessed. -On 2/27/21 at 7:11 p.m., Resident N was found on the floor in a doorway with no injury. The fall was not witnessed. -On 3/14/21 at 9:34 a.m., Resident N was found lying on her back with her head on the floor with an abrasion on the right side of her head. The fall was not witnessed. -On 3/26/21 at 5:08 p.m., Resident N was found on the floor in her doorway with a laceration to her left elbow. The fall was not witnessed. During an interview, on 5/12/21 at 10:25 a.m., Licensed Practical Nurse (LPN) 3 indicated Resident N had frequent falls with injuries like skin tears, bruises, and had hit the back of her head. Her fall interventions were to toilet every 2 hours, redirection to use walker, and to provide supervision at all times. There is not enough staff on the memory care unit to provide supervision at all times. During an interview, on 5/12/21 at 10:45 a.m., LPN 4 indicated Resident N had frequent falls. Her fall interventions were to have an entry light on in the bathroom, to toilet every 2 hours, and to provide supervision at all times. There is not enough staff on the memory care unit to provide supervision at all times. During an interview, on 5/12/21 at 11:05 a.m., Qualified Medication Aide (QMA) indicated Resident N had frequent falls. She had numerous attempts to ambulate without supervision. She has had numerous falls in the bathroom from attempting to take herself to the bathroom without supervision. Her fall interventions were to toilet every 2 hours, and to provide supervision at all times. There is not enough staff to toilet her every 2 hours and to provide supervision at all times. On 5/12/2021 at 1:00 p.m., the DON provided the facility's policy, Staffing with a revised date of 9/2018, and indicated this was the policy currently being used by the facility. A review of the policy did not indicate providing sufficient staffing in order to provide supervision to prevent falls. This Federal tag relates to Complaint IN 218. 3.1-17(a)

Based on interview and record review, the facility failed to ensure an assessment of a surgical wound upon admission, wound care orders were implemented from date of admission, and refusal of antibiotic medication prescribed for wound care was acted upon by staff for 1 of 3 residents reviewed for wound care. (Resident B) Findings include: Resident B's clinical record was reviewed on 8/4/2020 at 11:30 a.m. [DIAGNOSES REDACTED]. The resident admitted to the facility on [DATE]. a. The nursing Admission assessment dated , 3/27/2020, for Resident B lacked documentation of a wound assessment being completed. The first wound assessment for Resident B was dated 3/30/2020. Interview, on 8/4/2020 at 11:30 a.m., the Wound Care Nurse indicated Resident B came in late on 3/27/2020, and did not get a wound assessment until 3/30/2020. b. The hospital Discharge Summary dated, 3/27/2020, for Resident B indicated, . Wound Care . patient is to have right foot wound dressing changed q (every) 48 hours with 1/2 [MEDICATION NAME] packing, gauze 4x4, ABD, kerlix and ACE bandage. If dressings become wet or detached they are to be replaced ASAP (as soon as possible) . Resident B's physician's orders [REDACTED]. cleanse right foot surgical wound with normal saline, pat dry, pack with [MEDICATION NAME] packing, cover with 4x4 gauze then ABD pad, then wrap with kerlix, cover with ACE wrap, change every other day . The start date of the order was 3/30/2020. The Treatment Administration Record (TAR) dated, 3/27/2020 through 4/14/2020, indicated Resident B's treatment to his right foot wound was initiated on 3/30/2020. Interview, on 8/4/2020 at 11:30 a.m., the Wound Care Nurse indicated Resident B came in late on 3/27/2020. She did not know the resident had wound care orders until she called the doctor on 3/30/2020. She was unaware of the Discharge Summary from the hospital dated, 3/27/2020, which included wound care orders. Interview, on 8/6/2020 at 2:25 p.m., Unit Manager (UM) 1 indicated the discharge summary from the hospital is the documentation the admitting nurse would use as orders when a resident is newly admitted . The wound care orders should have been put in the computer and wound care started as ordered. On 8/6/2020 at 3:26 p.m., the Administrator provided the facility's policy, Physician order [REDACTED]. A review of the policy indicated, . all new orders will be entered into (computer program name) Physician order [REDACTED]. c. Resident B's physician's orders [REDACTED]. meropenem (an antibiotic) 0.9% sodium chloride piggyback; 1 gram/50 ml (milliliters). Amount to administer: 1000 mg (milligrams) intravenous (IV) . A review of the Event Report dated 4/10/2020 at 7:58 a.m., indicated, . Monitor and Document refusal of care-non compliance . Review of Nursing Progress Notes indicated the following: - 4/13/2020 at 3:18 a.m., . patient refusing IV medication at this time d/t (due to) what he feels like is an allergic reaction (lethargy/confusion) . - 4/13/2020 at 1:45 p.m., . resident refused IV ATB (antibiotic) TX (treatment) resident stated medication had him feel funny (sic) . - 4/12/2020 at 1:32 p.m., . cont. (continues) to refuse ATB . - 4/12/2020 at 11:55 a.m., . res (resident) continues to refuse ATB . - 4/11/2020 at 1:48 p.m., . on call with (physician name) aware of refusal of IV ATB . - 4/11/2020 at 1:08 p.m., . refusing IV at this time . The clinical record for Resident B lacked documentation which indicated the facility responded to the refusal of ATB therapy. The resident discharged to the hospital on [DATE]. Interview, on 8/6/2020 at 12:11 p.m., the Administrator indicated there was no documentation in the resident's clinical record to indicate a staff response for the resident having refused the ATB therapy. This Federal tag relates to Complaint IN 573. 3.1-37(a)

Based on interview and record review, the facility failed to ensure physician prescribed insulin was available for 1 of 3 residents reviewed for pharmacy services (Resident B). Findings include: On 8/5/20 at 2:30 p.m., Resident B's clinical record was reviewed. The [DIAGNOSES REDACTED]. Resident B's, April 2020, physician orders [REDACTED]. -[MEDICATION NAME] R (insulin) inject 55 units SQ three times a day. Resident B's progress notes indicated the following: -4/5/20 at 7:55 a.m., [MEDICATION NAME] r unavailable, pharm (pharmacy) to stat (send immediately) out. md (medical doctor) aware. awaiting new orders -4/5/20 at 8:20 a.m. res (resident) wife bringing in insulin at this time. administered. md aware. During an interview, on 8/4/20 at 3:00 P.M., the resident's spouse indicated on the morning of 4/5/20, the facility informed her they did not have the resident's [MEDICATION NAME]on hand. During an interview, on 8/5/20 at 3:20 P.M., LPN (Licensed Practical Nurse) 1 indicated on the morning of 4/5/20 the resident's [MEDICATION NAME] was not available to administer the prescribed dosage to the resident. A stat order for the resident's [MEDICATION NAME] R 100 unit/ML was placed with Omincare of Indianapolis. She notified the physician, pharmacy and the resident's wife. The wife brought a bottle of the [MEDICATION NAME] R in. A delivery receipt from Omnicare of Indianapolis indicated the resident's [MEDICATION NAME] R 100 Unit/ML was ordered on [DATE] at 10:17 A.M. On 8/6/20 at 3:20 P.M., the facility Administrator provided the facility's Medication Shortages/Unavailable Medications policy, revised date 1/1/13. A review of the policy indicated, A licensed Facility nurse should obtain the ordered medication from the Emergency Medication Supply. If the ordered medication is not available in the Emergency Medication Supply, the licensed Facility nurse should call Pharmacy's emergency answering service and request to speak with the registered pharmacist on duty to manage the plan of action . This Federal tag relates to Complaint IN 573. 3.1-25(a)

Based on interview and record review, the facility failed to ensure a resident received adequate supervision and assistance to prevent a fall during transfer care which in a diagnosed sprained knee/leg for 1 of 3 residents reviewed for accidents (Resident B). Findings include: Interview, on 8/7/19 at 4:00 p.m., Resident B's family member indicated the resident fell , on 7/27/19, and sustained a sprained knee. The fall should not have happened. All you have to do is get (Resident B's name) wheelchair next to her bed. She can pull herself up with the transfer pole and use her leg to help her pivot into the wheelchair. From what I was told, she had to walk all the way over to her chair and she can't do that. On 8/7/19 at 11:30 A.M., Resident B's clinical record was reviewed. [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS) assessment, dated 7/7/19, indicated the resident was cognitively intact. Functional status indicated the resident required extensive assistance with 2 person physical assist for transfers between surfaces, including to or from bed, chair, wheelchair, standing position. Care plan, with a problem start date 2/17/11 and remained current, indicated, .resident is at risk for fall due [MEDICAL CONDITION](stroke) with left [MEDICAL CONDITION], unsteady balance and functional transfers An approach, with a start date of 12/22/17, indicated .2 person assist with transfers . Resident B's July, 2019, progress notes indicated the following: -7/27/19 at 11:43 a.m., CNA (certified nursing assistant) came to get writer and said that res (resident) had fallen. CNA stated that res was getting weak and she tried to assist her to the floor. Res lying on her back side next to her bed. L (left) knee/leg appears swollen with possible break. Res with c/o (complaints of) pain to area . N.O. (new order) to send res to ER (emergency room ) to evaluate and treat . -7/27/19 at 4:56 p.m., Res (resident) returned to facility from hospital. Res with sprain to L (left) knee/leg. Res to ice the affected area for 20-30 minutes at a time as needed, and to take Tylenol q (every) 4-6h (hours) as needed for pain. -7/29/19 at 11:02 a.m., IDT (interdisciplinary team) FALL REVIEW: Resident had a witnessed fall on 7/27/19 at 11:54 a.m. Resident fell during a transfer. Resident fell landing on her buttocks . Resident became weak and fell according to the CNA (certified nursing assistant). Resident had a complaint of left leg pain with swelling (and) decreased range of motion . IDT determines root cause of fall to be weakness. IDT recommends placing anti-roll backs to the wheelchair . Interview, on 8/7/19 at 4:12 p.m., the Director of Nursing indicated it was reported to her, on 7/27/19, that NA (Nurse Aide) 1 was transferring Resident B alone and without a gait belt. The wheelchair was at the foot of the bed and not locked, which contributed to resident's fall. Interview, on 8/8/19 at 10:30 a.m., CNA 1 indicated, on 7/27/19, she advised NA 1 not to get Resident B out of bed on her own, because she did not feel NA 1 was adequately trained to do so. After the fall, around 11:50 a.m., CNA 1 went to the resident's room and observed the resident on the floor with the wheelchair pushed far away from the bed and no gait belt on the resident. Interview, on 8/8/19 at 11:10 a.m., Resident B indicated, on 7/27/19, NA 1 came to transfer her from her bed to the wheelchair. Resident B was concerned because her wheelchair was near the foot of the bed and told NA 1 the wheelchair was too far away for her. She indicated she normally pulls herself up with the transfer pole, gets her balance, then can spin around into the wheelchair. I can actually do some stuff on my own. After the resident stood upright with the use of the transfer pole, NA 1 took the resident by the arm to guide her to the wheelchair as she walked down toward the foot of the bed. Resident B made it to the wheelchair, however, the wheelchair moved as she sat down, due to the right wheel brake was not being locked. This caused her to she slip off of the seat. At some point, her left leg twisted underneath her, made a pop sound and began to swell. Interview, on 8/8/19 at 12:15 p.m., LPN 1 indicated she went to Resident B's room after the fall, on 7/27/19, and assessed the resident. Swelling and pain to the left knee/leg and a bump on the back of her head were noted. On 8/8/19 at 1:15 p.m., the Director of Nursing provided the facility policy, Transfer to Wheelchair, reviewed on April, 2012, and indicated this was the policy currently used. A review of the policy indicated, . place wheelchair near the head of the bed . lock wheelchair wheels .place gait belt around resident's waist . This Federal tag relates to Complaint IN 305. 3.1-45(a)(2)

Based on interview and record review, the facility failed to ensure a shower chair's wheels were locked causing a resident to fall and sustain a skin laceration that required sutures for wound closure for 1 of 3 residents reviewed for falls. (Resident B) Findings include: Resident B's clinical record was reviewed on 5/09/18 at 1:30 p.m. [DIAGNOSES REDACTED]. The current Minimum Data Set Assessment (MDS), dated [DATE], indicated Resident B was moderately cognitively impaired, needed supervision when walking, and required the physical assistance of one staff while bathing due to being at risk for falls and having an unsteady balance. Review on 5/09/2018 at 12:15 p.m., of a facility reported incident, dated 4/28/2018 at 9:18 a.m., indicated after Resident B's shower was completed CNA 1 turned around to remove some wet towels. While CNA 1 was turned around Resident B attempted to stand. The shower chair wheels were not locked. The shower chair moved backwards and Resident B lost his balance, fell to the floor, and struck his right elbow on the shower floor drain which caused a laceration (cut in skin). Afterwards, Resident B complained of pain in their right elbow. First aid was provided by the nurse, the doctor was notified, and an order was obtained to send Resident B to the ER (emergency room ) for further evaluation and treatment. Review, on 05/09/18 at 1:30 p.m., of Resident B's emergency room visit, dated 4/28/2018, no time noted, Resident B received eight sutures to his right elbow. The sutures were to be removed in 10 days. Interview with Resident B, on 5/9/2018 at 2:34 p.m., indicated staff used a shower chair to assist him to take a shower. He was being assisted by CNA 1. CNA 1 bent down to get wet towels off of the floor. Resident B then stood up, had not realized the wheels on the shower chair were not locked, and he fell out of the shower chair and hit his right elbow on the floor drain. The resident indicated the nurse was called to check on me and I noticed I had a skin tear on my right elbow. Interview with CNA 1, on 5/9/2018 at 2:59 p.m., indicated she turned around to pick up some wet towels off of the floor when Resident B stood up. The shower chair slid out from underneath him, which caused Resident B to slip out of the shower chair and land on his right elbow. A laceration was noted and was taken care of by the nurse who came into the shower room. On 5/10/2018 a 10:45 a.m., the Executive Director provided an orientation check off sheet used for re-turn demonstrations by new employees, and indicated there was no separate policy related to shower chairs, and indicated it was the sheet used during orientation. Review of the check of sheet indicated under number 9, Transfer to or place shower chair into position, lock wheels. This Federal tag relates to Complaint IN 019. 3.1-45(a)(2)