Every finding on record at Miller's Merry Manor

Based on observation, interview, and record review, the facility failed to implement infection control practices for 1 of 2 residents reviewed for urinary catheters. The urinary catheter bag was on the floor.(Resident 54) Findings include: On 12/17/24 at 11:02 a.m., Resident 54 was observed to be sitting in her wheelchair with a urinary catheter drainage bag in a privacy bag placed under the wheelchair. The privacy bag was dragging the floor as the staff was pushing her in the wheelchair. On 12/17/24 11:13 a.m., Resident 54 was observed to be sitting in her wheelchair with a urinary catheter drainage bag in a privacy bag placed under the wheelchair. The privacy bag was dragging the floor as the staff was pushing her in the wheelchair. On 12/18/24 at 11:02 a.m., Resident 54's clinical record was reviewed. The diagnoses included, but were not limited to, chronic kidney disease and neuromuscular dysfunction of the bladder (lack of bladder control due to brain, spinal cord, or nerve problem). Resident 54's December 2024 Physician Order, indicated 16 French (size of catheter) catheter with a 10 milliliters balloon. Resident 54's care plan, dated 7/2/24, indicated she had a catheter for urinary retention and neuromuscular dysfunction of the bladder. The care plan lacked documentation of placement of catheter bag under wheel chair to assist with keeping drainage bag off the floor. During an interview on 12/20/24 at 11:55 a.m., CNA 1 indicated when drainage bag and cover were placed under the wheelchair, it should not touch or drag the floor. On 12/20/24 at 12:30 p.m., the Director of Nursing (DON) provided the facility's policy, Foley Catheter Care & Maintenance, dated 8/30/07, and indicated it was the policy currently being used by the facility. A review of the policy indicated, .1. When in bed or wheel chair: .b. Place in catheter cover bag underneath wheelchair . c. Ensure bag or tubing is not touching floor . 3.1-18(b)(1)

Based on observation, interview, and record review, the facility failed to ensure a resident's wheelchair was clean for 1 of 1 residents reviewed for feeding tubes. (Resident 19) Findings include: During a family interview on 2/20/24 at 11:39 a.m., Resident 19's wife indicated when she comes to visit, Resident 19 was always covered in sticky tube feeding solution. She indicated it's all over his clothes, his wheelchair, and on the bedroom floor. She wished the facility would be more careful to make sure the tube feeding did not get all over the place. During an observation at that time, a light-brown substance on various spots on the seat and the wheels of his wheelchair was observed. On 2/20/24 at 11:50 a.m., Resident 19's clinical record was reviewed. The diagnoses included, but were not limited to, cerebral infarction (stroke), dominant-sided hemiplegia, and acute respiratory failure with hypoxia (an absence of enough oxygen in the tissues to sustain bodily functions). An Annual Minimum Data Set (MDS) assessment, dated 1/17/24, indicated the Resident 19 had impairment on one side for upper and lower extremities. He was dependent (helper does all of the effort and the resident does none of the effort to complete the activity) on staff with dressing and personal hygiene. A Brief Interview for Mental Status (BIMS) was not conducted because the resident was rarely/never understood. A physician's order, dated 1/15/24, indicated the resident was prescribed continuous administration of Jevity 1.2 (a nutritional tube feeding solution) at 50 milliliters per hour. On 2/22/24 at 3:04 p.m., Resident 19's wheelchair was observed with multiple light-brown substance spots on the seat and wheels. On 2/23/24 at 10:58 a.m., Resident 19's wheelchair was observed with multiple light-brown substance spots on the seat and wheels. During an interview on 2/23/24 at 2:30 p.m., the DON indicated Resident 19's wheelchair had splotches of brown substance on its wheels, seat, handles, and armrests and was in need of cleaning. She believed the substance was related to the placement of the tube feeding solution which had caused the spills. On 2/23/24 at 3:00 p.m., the Administrator provided the policy, Resident Rights, dated 11/17/17, and indicated it was the policy currently being used. A review of the policy indicated, . (i) Safe environment. The resident has a right to a safe, clean, comfortable and homelike environment . The facility must provide -- (1) A safe clean comfortable, and homelike environment . 3.1-19(f)

Based on record review and interview, the facility failed to ensure information regarding the administration of insulin was correctly entered in the Minimum Data Set assessment for 1 of 4 residents reviewed for unnecessary medications. (Resident 12) Finding includes: On 2/23/24 at 11:25 p.m., Resident 12's clinical record was reviewed. The diagnoses included, but were not limited to, chronic atrial fibrillation and diabetes. The Quarterly Minimum Data Set assessment (MDS), dated [DATE], indicated the resident had received 7 insulin injections within the past 7 days. A physician's order with a start date of 4/20/23 indicated the resident had been prescribed a 100 unit Humalog (insulin) solution injection on a sliding scale. The order was discontinued on 10/4/23. During an interview on 4/23/24 at 1:10 p.m., the MDS Coordinator indicated the MDS assessment information had been incorrectly entered, as the insulin order had been discontinued on 10/4/23. 3.1-31(d)

Based on interview and record review, the facility failed to ensure residents were free from significant medication errors for 1 of 3 residents reviewed. (Resident B) Finding includes: On 8/2/23 at 11:00 a.m., the clinical record for Resident B was reviewed. The diagnoses included, but were not limited to, cerebral vascular accident (CVA) and hypertension. A review of the admission home health orders, dated 6/29/23, included, but were not limited to: - Chlorthalidone (a diuretic medication) 25 mg (milligrams), give one half tablet daily, dated 6/29/23. A review of the signed orders physician's orders included, but were not limited to: Chlorthalidone 25 mg, one tablet daily, initiated 7/19/23 Resident B's MAR (Medication Administration Record), dated 7/1/2023 through 7/31/2023, indicated Resident B received Chlorthalidone 25 mg daily while in the facility. On 8/2/23 at 12:56 p.m., the DON (Director of Nursing) indicated Resident B was to receive Chlorthalidone 25 mg, one half tablet daily. After Resident B was discharged to home, it was discovered Resident B was given a whole tablet of Chlorthalidone 25 mg daily. She indicated when the nursing staff received the orders from the home health agency, they entered it into the computer and sent it to the physician for verification. The DON indicated the staff should have reviewed the medications put into the computer, but they did not. On 8/2/23 at 1:35 p.m., the DON provided the facility Physician Order Transcription Policy, revised 6/15/10, and indicated it was the policy currently in use. The policy indicated if orders were entered directly into the PCC (point click care software) just add the new orders. This Federal tag relates to Complaint IN00414135. 3.1-48(c)(2)

Based on interview and record review, the facility failed to ensure an accurate record of dispensing for a narcotic pain medication. The nurse failed to have a second nurse verify a narcotic pain medication was disposed before preparing and administering a second dose of the medication. (Resident B, LPN 1) Finding includes: During an interview on 2/15/23 at 9:50 a.m., the Administrator indicated an investigation was completed when LPN 1 (Licensed Practical Nurse) dropped an oxycodone (narcotic pain medication) 5 mg (milligram) tablet on the floor. She prepared another dose for Resident B without having a second nurse verify the first pill was wasted. The clinical record for Resident B was reviewed on 2/15/23 at 10:04 a.m. The diagnoses included, but were not limited to, chronic obstructive pulmonary disease and pain. An Admission MDS (Minimum Data Set) assessment, dated 1/27/23, indicated Resident B was cognitively intact. Physician's orders included, but was not limited to, oxycodone 5 mg by mouth every 8 hours as needed for pain, initiated 1/20/23. The February 2023 Medication Administration Record indicated Resident B was assessed for effectiveness of oxycodone 5 mg, on 2/7/23 at 12:42 p.m. and 9:50 p.m. The Controlled Medication Record Sheet, dated 2/7/23, indicated LPN 1 administered oxycodone 5 mg to Resident B on 2/7/23 at 11:00 a.m., 6:30 p.m. The Drug Diversion Investigation Worksheet: Reasonable suspicion of a Crime, dated 2/9/23 at 2:04 p.m., indicated medication was signed out as administered but Resident B stated she did not receive the medication. During an interview on 2/15/23 at 10:58 a.m. LPN 1 indicated she gave oxycodone 5 mg to Resident B two times, on 2/7/23 at 11:00 a.m. and 6:30 p.m. She prepared one oxycodone 5 mg tablet for the 6:30 p.m. dose but dropped it on the floor. She prepared a second dose of oxycodone 5 mg and administered it to Resident B. She wrote dropped on the controlled medication record sheet but did not have a second nurse verify the oxycodone tablet was wasted. She should have had a second nurse verify the oxycodone tablet was wasted before she administered the second oxycodone tablet to Resident B. On 2/15/23 at 1:00 p.m., the Administrator provided a copy of a facility policy, titled Counting and Disposing of Schedule 2 Narcotics, dated 1/29/16, and indicated this was the current policy used by the facility. A review of the policy indicated if a dose of scheduled 2 narcotic is removed from the container but refused by the resident or not given for any reason, it will be destroyed in the presence of 2 licensed nurses. The disposal will be documented on the narcotic count sheet and or drug disposition record. 3.1-25(s)(8)

Based on observation, interview, and record review, the facility failed to identify and respond to an assessed weight loss and failed to implement interventions for 1 of 1 resident reviewed for nutrition. (Resident 217) Finding includes: During an interview on 1/12/23 at 1:59 p.m., Resident 217 indicated she had lost weight since her admission to the facility but she hadn't had much of an appetite since being in the hospital and hadn't been eating very much. She did drink an Ensure at times. Resident 217's clinical record was reviewed on 1/17/23 at 2:00 p.m. The diagnoses included, but were not limited to, diverticulitis of the small intestine with perforation and abscess without bleeding and ileostomy (an opening in the abdominal wall). The resident admitted to the facility on [DATE]. Physician orders, dated 1/18/23, for Resident 217 indicated, . Diet: regular, low fiber and Ensure 257 ml [milliliters] with meals for poor appetite. The start date of the Ensure was 1/7/2023 . A care plan, initiated on 1/4/23, with a target date of 4/4/23, for Resident 217 indicated, . FOCUS: Nutritional risk. I am at nutritional risk related to: BMI [body mass index], I do not drink a minimum of 1500 ml fluids daily. Potential for weight fluctuations related to fluid shifts. I eat only 2 meals a day most of time at home. I am particular about what I eat. Varied intakes of meals. Edema in lower extremities. Potential for weight fluctuations related to fluid shifts . GOAL: I will consume meals of foods and beverages that I select to maintain weight. I will have no significant weight loss of 5% or greater in 1 month . INTERVENTIONS: . Diet is served as ordered, snacks are available to me between meals upon request, offer replacement for foods not consumed . monitor weights and intakes . oral pharmaceutical supplements as ordered . provide with bedtime snack . monitor labs . notify physician and resident representative of significant weight changes . Resident 217's weights indicated the following: - On 1/4/23, the resident weighed 162 pounds. - On 1/12/23, the resident weighed 140 pounds. - On 1/15/23, the resident weighed 139.2 pounds. This was an assessed 14.07% severe weight loss in 11 days. The Dietary Full Review, dated, 1/11/23 at 3:59 p.m., for Resident 217 indicated . Does resident receive dietary provided nutritional supplements, No . Weight changes . new admission and no weight trend identified yet . Goal: I will have no significant weight loss of 5% or greater in 1 month . Recommendations, No . The clinical record for Resident 217 lacked documentation of an assessment or implementation of a nutritional intervention after the residents was noted to have a significant weight loss since admission. During an observation on 1/17/23 at 12:27 p.m., Resident 217 was observed to have a bowl of mashed potatoes and gravy and a bowl of yogurt. Resident indicated at that time she couldn't eat anything else on the menu that day and no one had offered her a substitute. She thought she might try a hamburger. During an interview on 1/17/23 at 12:30 p.m., Licensed Practical Nurse (LPN) 1 indicated she would order Resident 217 a hamburger. During an interview on 1/17/23 at 2:31 p.m., Resident 217 indicated she ate 3/4 of the hamburger and it was really good. During an interview on 1/18/23 at 10:10 a.m., the Dietician indicated she relies on the facility to let her know when a resident has lost weight because she doesn't look at the weights everyday. The Interdisciplinary Team (IDT) should have met on 1/13/2023, and would have discussed Resident 217's weight loss but they did not meet that day due to the Department of Health being in the facility. The resident was ordered Ensure on 1/7/23, and she does drink it. During an interview on 1/18/23 at 10:25 a.m., the Director of Nursing (DON) indicated they weigh new admissions weekly for four weeks to establish a baseline. After 1 month they will address any weight loss in the IDT meeting. They run a report once a month before the meeting. Resident 217 would not have triggered in the weekly meeting because it had not been a month since she had been admitted . On 1/18/23 at 10:34 a.m., the Director of Nursing provided the facility's policy, Weight Management Program dated, 12/13/19, and indicated it was the policy currently being used by the facility. A review of the policy indicated, . A. New Admissions will be weighed weekly X 4 weeks to establish a baseline weight . G. Resident experiencing unplanned weight change will be assessed for interventions . 3.1-46(a)(1)

Based on observation, interview, and record review, the facility failed to ensure treatment was provided to prevent the development of pressure ulcers which resulted in the development of a facility acquired stage 2 pressure ulcer (Resident 9) and an unstageable and infected pressure ulcer (Resident 7) for 2 of 5 residents reviewed for pressure ulcers. Findings include: 1. During an interview on 1/12/23 at 11:52 a.m., Resident 7 was sitting in his wheelchair and indicated he had recently developed a pressure ulcer on his bottom. He indicated the staff wanted him to lay in the bed to get him off of his bottom, however, lying in the bed hurt his right leg which he could not move or bear any weight. Since he had no side rails, he could not easily move around in bed. He further indicated staff did not reposition him every 2 to 3 hours, rather in bed or up in his wheelchair. No side rails were observed to the resident's bed. On 1/13/23 at 10:17 a.m., Resident 7's clinical record was reviewed. The diagnoses included, but were not limited to, neuromuscular dysfunction of bladder, difficulty in walking, muscle weakness, incomplete paraplegia, arthropathy (joint disease), and peripheral vascular disease. On 1/7/23 the resident weighed 244 pounds, and was 6 foot and 2 inches tall. A Quarterly MDS (Minimum Data Set) assessment, dated 11/7/22, indicated the resident had moderately impaired cognition, the resident required limited assistance of one staff with transfers, and he had lower extremity impairment on both sides. During the assessment look-behind period, the MDS indicated the resident was unsteady and only able to stabilize with human assistance with surface-to-surface transfers, and when moving on and off of the toilet. The resident's wound assessments indicated the following: - On 12/21/22, the resident developed an in-house stage 2 pressure ulcer which resulted from shearing. The wound measured 8 centimeters (cm) in length, 5 cm. in width, and had a depth of 0.1 cm. The assessment identified the resident was chairfast (the ability to walk was severely limited or non-existent) and he could not bear own weight and/or must be assisted into chair or wheelchair. The resident required moderate to maximum assistance in moving, complete lifting without sliding against sheets was impossible, and he frequently slid down in the bed or chair and required frequent repositioning with maximum assistance. - On 12/27/22, the wound measured 9.5 cm in length, 6.5 cm in width, and had a depth of 0.1 cm. The wound was now a stage 3, with 25% slough, and had a foul odor. - On 1/3/23, the wound measured 13 cm in length, 6.5 cm in width, and had a depth of 0.1 cm. - On 1/10/23, the wound measured 11 cm in length, 5 cm in width, and had a depth of 0 cm. The wound was now unstageable, with 100% slough. - On 1/17/23, the wound measured 10 cm in length, 6 cm in width, and had a depth of 0.1 cm. - On 1/17/23, the resident developed 3 new, in-house, pressure ulcers on his left upper thigh. The first fluid-filled blister measured 2 cm in length, 2 cm. in width, and had no depth. The second fluid-filled blister measured 1 cm in length, 1 cm in width, and had no depth. The third fluid-filled blister measured 1.6 cm in length, 2.3 cm in width, and had no depth. The resident's progress notes indicated the following: - On 12/21/22 at 3:25 p.m., the resident developed an in-house pressure ulcer to his right buttocks. The facility was to obtain a slider sheet since the resident frequently needed to be pulled up higher in the bed due to sliding down in the bed. - On 12/28/22 at 4:37 p.m., a new order for Clindamycin 300 milligrams (mg) was placed due to the buttocks wound. - On 1/3/23 at 10:51 a.m., the resident's pressure ulcer was not healing. - On 1/10/23 at 10:09 a.m., the resident's pressure ulcer was not healing. The resident's physician orders indicated the following: - On 12/21/22 at 1:30 p.m., the pressure wound treatment was to clean buttocks with normal saline, apply collagen powder, and cover with Mepilex (foam dressing that absorbs exudate and maintains a moist wound environment) every 2 days. The order was discontinued on 1/3/23. - On 12/28/22 at 1:15 p.m., the resident was ordered Clindamycin (an antibiotic medication) 300 mg, three times a day, for 7 days, for the buttocks wound. - On 1/3/23 11:15 a.m., the pressure wound treatment was to clean buttocks with normal saline, apply Exufiber (an absorbent sterile dressing), cover with dry dressing, and change every 2 days. - On 1/18/23 at 11:15 a.m., the pressure wound treatment was changed add collagen powder to the Exufiber dressing changes. The order was now for daily dressing changes. The resident's care plan's indicated the following: - On 10/10/22, the resident was identified to be at risk for pressure ulcers. He required up to extensive assistance with bed mobility due to weakness related to his diagnosis of incomplete paralysis of lower limbs. An intervention included for staff to document any encouraged/assisted to turn/reposition every 2-3 hour to prevent pressure ulcers. - On 10/11/22, the resident was identified to be at risk for falls. He required up to extensive staff assistance with transfers related to his diagnosis of incomplete paralysis of bilateral lower extremities (BLE). The interventions did not identify how the resident should be transferred. - On 10/11/22 the resident was identified as needing assistance with ADLs (activities of daily living). He required up to total assistance with ADL's (including bed mobility and transfers) due to his diagnosis of incomplete paralysis of BLE and muscle weakness. The interventions did not identify how the resident should be transferred. - On 12/21/22, the resident developed a pressure ulcer on his right buttocks. He needed to be pulled up in the bed often from sliding down, and he could not lift body weight to assist staff. The resident was encouraged to turn and reposition every 2 hours. The resident's December through January turn sheets indicated staff documented on turning/repositioning every shift (three times a day). There was no other documentation related to staff turning or repositioning the resident. During an observation on 1/18/23 at 10:15 a.m., CNA (Certified Nurse Aide) 1 and BNA (Basic Nurse Aide) 1 were observed mid transfer of the resident from his bed. The CNAs instructed the resident to help with the transfer, however, the resident was screaming loudly in pain and indicated he could not help with the transfer. After a rapid drop to the bed, the resident was observed laying with half of his bottom off of the side of the bed, he was breathing heavily, and showed signs of distress. His pants were below his briefs, exposing his supra pubic catheter and tubing, 3 dark purple fluid-filled blisters to his upper thigh, and his catheter site entrance had bright red blood around the naval tubing. The CNAs indicated they needed extra help, and CNA 1 was observed to leave the room to get additional staff. The resident indicated he could not do the transfer because he could not use his legs. BNA 1 indicated she did not know what caused the blisters and thought it might have been due to his catheter tubing position on his leg. On 1/18/23 at 10:21 a.m., a large, irregular-shaped, tunneling wound with slough (necrotic tissue that needs to be removed from the wound for healing to take place) was observed on the resident's right buttock. The left buttock was observed to be reddened. RN 1 indicated the wound was not improving. During an interview on 1/18/23 at 11:23 a.m., CNA 1 indicated she did not know if he was normally a manual transfer because she did not normally work that hall. He should be turned or repositioned every 2 hours. During an interview on 1/18/23 at 12:08 p.m., the resident indicated frustration with how staff transfer him. Last night he was dropped in his bed during a manual transfer. He indicated that staff would sometimes use the mechanical lift with him, but not often. He would like to try a slide-board for transfers since he could not use his legs. During an interview on 1/18/23 at 10:38 a.m. the Director of Nursing (DON) indicated she was the wound nurse for the facility. The resident's buttocks wound now had tunneling and it developed due to shearing when staff transferred him. She was still investigating the incident related to the resident's transfer last night. 36912 2. On 1/12/23 from 9:30 a.m. until 12:07 p.m., Resident 9 was observed lying on his back in his bed with the head of his bed raised at an approximate angle of 45 degrees. His lower body was in full contact with the mattress. During an interview at 11:47 a.m., the resident indicated he had been lying in the same position as long as he could recall. He wished to reposition off of his bottom, but when he tried to do so himself he slid on the wound on his left buttock. He would have used his call light button, but staff took too long to get to him. On 1/13/22 from 9:40 a.m. until 12:16 p.m., Resident 9 was observed lying on his back in his bed with the head of the bed raised at an approximate angle of 45 degrees. His lower body was in full contact with the mattress. Certified Nurse Aide (CNA) 2 was observed entering the room at 10:40 a.m. to attend to the resident's roommate until 10:45 a.m. There was no interaction between CNA 2 and Resident 9. During an interview at 10:48 a.m., the resident indicated staff repositioned him that morning around 8:30 a.m. but had not come in to do so for a long time. He could not wait for them because of the pain he had in his left hip and he tried to move himself in the bed, sliding on the wound on his left buttock. He believed the dressing they put on his wound came off whenever he moved himself in bed. On 1/17/23 from 9:10 a.m. until 11:20 a.m., Resident 9 was observed lying on his back in his bed with the head of the bed raised at an approximate angle of 45 degrees. His lower body was in full contact with the mattress. On 1/17/23 at 11:32 a.m., the Director of Nursing (DON) was observed performing a dressing change for a pressure ulcer on the left buttock of the resident. There was no prior dressing on the wound to remove during the observation. The skin at the resident's coccyx (a small triangular bone at the base of the spinal column) area was intact and appeared reddened in color. During an interview at that time, the DON indicated the previous dressing may have come off when the resident attempted to reposition himself. During an interview on 1/18/23 at 10:43 a.m., CNA 1 indicated staff were to encourage or assist residents at risk for pressure sores every 2 to 3 hours. They documented this was done each shift, but not necessarily each individual time the resident was repositioned. During an interview on 1/18/23 at 11:52 p.m., The DON indicated the resident was able to move himself in his bed and did not always wait or call for assistance to be repositioned. Residents at risk for pressure ulcers were to be repositioned every 2 to 3 hours. On 1/17/23 at 11:50 a.m., Resident 9's clinical record was reviewed. The diagnoses included, but were not limited to, chronic obstructive pulmonary disease, anxiety disorder, insomnia, and muscle weakness. The Quarterly MDS assessment, dated 11/16/22, indicated the resident was cognitively intact, at risk for developing pressure ulcers, and required the extensive physical assistance of 1 person for bed mobility. A pressure injury assessment, dated 1/5/23, indicated the resident had developed a stage 2 pressure ulcer measuring 1.8 cm long by 1.2 cm wide, and 0.1 cm deep on his left buttock while a resident of the facility. A physician's order, dated 1/5/23 indicated the resident's wound was to be treated every 2 days by cleaning the left buttock with normal saline, applying collagen powder and covering with mepitel one (a see thru dressing). A skin risk care plan, initiated on 5/10/22 indicated, Document encouraged/assisted to turn/reposition every 2-3 hr to prevent pressure injuries. On 1/18/23 at 12:35 p.m., the DON provided the policy, Skin Management Program, dated 8/14/14, and indicated it was the policy currently being used by the facility. A review of the policy indicated, . E. REPOSITIONING FOR THE PREVENTION OF PRESSURE ULCERS: . II . In general, every 2 hours will be the minimum for repositioning the resident. III . If the resident is not responding as expected to the repositioning schedule, reconsider the frequency and method of repositioning. IV. Lift - don't drag the resident when repositioning. 3.1-40(a)(1)

Based on observation, interview, and record review, the facility failed to assess and monitor a resident for 72 hours after a fall for 1 of 3 residents reviewed for accidents. (Resident 10) Finding includes: During an interview on 1/12/23 at 10:30 a.m., Resident 10's family member indicated about a month ago Resident 10 fell and hit her head. On 1/13/23 at 10:51 a.m., Resident 10 was observed to be sitting up in her bed with her feet resting in her wheelchair. On 1/17/23 at 11:35 a.m., Resident 10 was observed to be sitting in her bed with her shoes on. On 1/17/23 at 10:44 a.m., Resident 10's clinical record was reviewed. The diagnoses included, but were not limited to, vascular dementia, Alzheimer's disease, repeated falls, and anxiety. The Significant Change Minimum Data Set (MDS) assessment, dated 12/13/22, indicated Resident 10 had severe impaired cognition and had one fall with no injury. The Nursing-Occurrence Initial Assessment, dated 12/18/22 at 3:04 a.m., indicated Resident 10 was found lying on the floor next to her bed. She indicated she was trying to empty her trash and slid off her bed onto the floor hitting her head. She had a small abrasion to her right eyebrow. The Nursing-Occurrence Follow-Up Assessment, dated 12/22/22 at 1:15 a.m., indicated neurological and head to toe assessments were completed. The clinical record lacked Nursing-Occurrence Follow-Up documentation being completed every shift for 12/19/22, 12/20/22, or 12/21/22. The December 2022 progress notes lacked documentation of fall follow up. The Neurological Checklist dated 12/18/22 through 12/26/22 lacked documentation of vital signs and neurological assessments being completed on 12/18/22 at 1:15 p.m., 12/18/22 at 3:15 p.m., 12/18/22 at 5:15 p.m., 12/18/22 at 9:15 p.m., 12/19/22 at 1:15 a.m., 12/19/22 at 5:15 a.m., 12/20/22 at 9:15 a.m., and 12/20/22 at 5:15 p.m. During an interview on 1/18/23 at 11:07 a.m., the Director of Nursing (DON) indicated a fall with injury was followed-up every shift for 72 hour on a Nursing-Occurrence Follow-up. During an interview on 1/18/23 at 11:32 a.m., the DON indicated Resident 10's clinical record lacked documentation of 72 hour fall follow-up. During an interview on 1/18/23 at 12:15 p.m., the DON indicated the Neurological Checklist lacked documentation on 12/18/22 at 1:15 p.m., 12/18/22 at 3:15 p.m., 12/18/22 at 5:15 p.m., 12/18/22 at 9:15 p.m., 12/19/22 at 1:15 a.m., 12/19/22 at 5:15 a.m., 12/20/22 at 9:15 a.m., and 12/20/22 at 5:15 p.m. On 1/18/23 at 12:45 p.m., the DON provided the facility's policy, Fall Management Procedure dated 3/18/22, and indicated this was the policy currently being used by the facility. A review of the policy did not provide how often fall follow-up should be completed. 3.1-37(a)

Based on interview, and record review, the facility failed to ensure residents was free from misappropriation of property for 1 of 4 residents reviewed. Controlled substances were unaccounted for. (Resident D) Finding includes: During an interview on 6/8/22 at 8:24 a.m., Resident D indicated he didn't think he had his anxiety medication last week, but he hadn't had any negative effects due to anxiety. The clinical record for Resident D was reviewed on 6/8/22 at 8:24 a.m. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission MDS (Minimum Data Set) assessment, dated 5/17/22, indicated Resident D had mild cognitive impairment. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The Medication Administration Record, [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 6/8/22 at 11:05 a.m., the Administrator indicated she was not able to substantiate if the [MEDICATION(S)] tablets were taken from the facility. The pharmacy manifest from 5/11/22 indicated that 8 [MEDICATION(S)] tablets were delivered that night for Resident D, but when LPN 2 (Licensed Practical Nurse) went to give him the [MEDICATION(S)], the medication card and count sheet were not on the cart. LPN 2 left a note on 5/13/22, letting them know the [MEDICATION(S)] and the count sheet were not in the cart. The pharmacist indicated the [MEDICATION(S)] was delivered because the narcotic/controlled substance pharmacist signed that it was in the tote for that delivery. The nurse working that night was LPN 2 and she had signed the manifest that indicated the 8 [MEDICATION(S)] tablets were delivered. LPN 2 stopped cooperating with the investigation when the facility notified the police and then she quit. The [MEDICATION(S)] was never found, so we immediately replaced the [MEDICATION(S)]. On 6/8/22 at 12:49 p.m., the Administrator provided a copy of the In Touch Pharmaceuticals manifest, dated 5/11/22. A review of the manifest indicated LPN 2 electronically signed for 8 [MEDICATION(S)] tablets on 5/11/22 at 11:13 p.m. On 6/8/22 at 11:00 a.m., the Administrator provided a copy of a facility policy, titled Pharmacy Delivery, dated 4/24/19, and indicated this was the current policy used by the facility. A review of the policy indicated .the pharmacy provides a method, such as a manifest, for both parties to confirm delivery and receipt of all items. The nurse receiving the delivery provides a written or electronic signature to the drivers as proof of delivery. This Federal tag relates to Complaint IN 448. 3.1-28(a)

Based on observation, interview, and record review, the facility failed to ensure residents were free from abuse for 1 of 3 residents reviewed for abuse. A resident cursed at and threw a plastic shower basin at another resident. (Resident B, Resident C) Finding includes: During an interview on 6/8/22 at 8:51 a.m., Resident B indicated she was in her room several days ago, and all of the sudden Resident C started cursing at her and called her a whore. Resident C threw a plastic basin at her and hit her arm. The staff took her out of the room, and Resident C remained in the room. She got scared when Resident C threw the plastic basin at her. Resident C had treated her like this on multiple occasions but Resident B was unable to remember exact details of each occasion. She didn't remember if she reported it to anyone because she thought the staff could hear Resident C cursing at her. Resident B indicated she became fearful of Resident C when Resident C threw something at her. The clinical record of Resident B was reviewed on 6/8/22 at 8:51 a.m. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Annual MDS (Minimum Data Set) assessment, dated 3/16/22, indicated Resident B was cognitively intact. A Nursing Occurrence Initial Assessment, dated 5/27/22 at 10:37 a.m., indicated Resident B's roommate threw an emesis basin at her striking Resident B in the upper left arm. The clinical record for Resident C was reviewed on 6/8/22 at 9:30 a.m. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Brief Interview for Mental Status, dated 5/26/22, indicated Resident C was cognitively intact. A progress note, dated 5/26/22 at 5:10 p.m., indicated Resident C was taken to the dining room. Resident C took silverware from a table and threw it almost hitting another resident. She then began to flip her middle finger and stated f*** you b******. Resident C was removed from the dining room and taken to Pioneer Hall lobby. In the lobby Resident C took a bedside table and pushed it to the ground. Resident C began yelling a name and pulled off her ostomy bag and threw it on the coffee table. The resident was provided one on one care to replace the ostomy bag and remained agitated. A progress note, dated 5/27/22 at 10:12 a.m., indicated Resident C was in bed. The resident began to hit the wall and yell for her sister. Staff attempted to redirect and resident stated, I just want to die, give me poison, take me to the hospital. Staff asked the resident was she needed at the hospital and the resident then took light string from bedside light and attempted to put around her neck in a strangling motion. Staff removed the string and placed it out of reach. Resident C grabbed the emisis basin from the bedside table and threw it at roommate striking her on the arm. Resident C's roommate was removed from room. Resident C remained in bed stating she wanted to die. Family was notified of Resident C's statements. Resident C was placed on 15 minute safety checks and the room was cleared of all potential self harm objects. Physician was notified and the resident was referred to inpatient psychicatric services. A Nursing Occurrence Initial Assessment, dated 5/27/22 at 10:29 a.m., indicated Resident C took an emesis bucket that was on the bedside table and threw it hitting her roommate in the arm. During an interview on 6/8/22 at 10:37 a.m., LPN 1 (Licensed Practical Nurse) indicated she had worked in the facility for almost three years. The day before Resident C threw the plastic basin at Resident B, she was in the dining room and threw silverware almost hitting another resident and yelled f*** you b****** at the residents sitting in the dining room. LPN 1 indiccated after Resident C's behavior she removed her from the dining room. The next day was when Resident C threw the plastic basin and cursed at Resident B. On 6/8/22 at 9:18 a.m., the Administrator provided a copy of a facility policy, titled Abuse Prohibition, Reporting, and Investigation, dated 12/2017, and indicated this was the current policy used by the facility. A review of the policy indicated It is the policy of Miller's Health Systems that all residents have the right to be free from verbal .physical abuse . This Federal tag relates to Complaint IN 741. 3.1-27(a)(1) 3.1-27(b)(4)

Based on interview and record review, the facility failed to ensure residents with pressure ulcers received necessary treatment and services to promote healing for 2 of 3 residents reviewed for pressure ulcers. (Resident B and Resident C) Findings include: 1. On 2/9/22 at 11:40 A.M., Resident B's clinical record was reviewed. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Pressure Injury Assessment, dated 11/25/21 indicated a new wound. The wound was an acquired in-house stage 3 pressure injury, measuring 4.5 centimeters by 4.6 centimeters with a depth of 0.1 centimeter on the resident's left buttock. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A Pressure Injury Assessment, dated 12/7/21, indicated the resident's pressure wound to the left buttock was unstageable and non-healing, measuring 5 centimeters by 5 centimeter with a depth of 0.1 centimeter. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A Pressure Injury Assessment, dated 1/18/22, indicated the pressure wound to the left buttock was unstageable and non-healing, measuring 5.7 centimeters by 5 centimeter with a depth of 0 centimeters. The treatment record, dated 11/1/21 through 11/30/21 indicated the resident's ordered treatment was not administered on 11/25/21. The treatment record for 1/1/22 through 1/31/22 indicated the ordered treatment was not administered on 1/6/22, 1/20/22, and 1/21/22. During an interview on 2/10/22 at 11:45 A.M., Licensed Practical Nurse 1 indicated Resident B had developed a stage 2 pressure sore on her left buttock that had progressed to a stage 3 and ultimately an unstageable pressure sore. During an interview on 2/10/22 at 2:50 P.M., the Director of Nursing indicated the clinical record lacked documentation to indicate the ordered treatment to the resident's pressure sore was performed on 11/25/21, 1/6/22, 1/20/22, and 1/21/22. 2. On 2/9/22 at 11:50 A.M., Resident C's clinical record was reviewed. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Significant Change MDS (Minimum Data Set) assessment, dated 5/5/21, indicated Resident C's had an unstagable pressure ulcer (damage within the ulcer cannot be confirmed because it is obscured by dead tissue). Resident C's Pressure Injury Assessment, dated 11/23/22, indicated a pressure ulcer was an acquired in-house stage 4 (the injury is very deep, reaching into muscle and bone and causing extensive damage) pressure injury, measuring 1.6 centimeters by 2.5 centimeters with a depth of 0.1 centimeter on the resident's right buttocks. The wound was originally identified on 4/9/21 as a stage 4. Resident C's current February 2022, physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident C's TAR (Treatment Administration Record), dated from 1/1/22 through 1/31/21, indicated the ordered treatment was not administered on 1/15/22 and 1/20/22. The TAR, dated from 2/1/22 through 2/10/22, indicated the ordered treatment was not administered on 2/3/22. During an interview on 2/10/22 at 2:50 P.M., the Director of Nursing indicated the clinical record lacked documentation to indicate the ordered treatment to Resident C's pressure ulcer was performed on 1/15/22, 1/20/22, and 2/3/22. On 2/10/22 at 3:15 P.M., the Administrator provided the policy, Skin Management Program, dated 8/14/14, and indicated this was the policy currently used by the facility. A review of the policy indicated, .interventions will be implemented .that will best .promote the most effective healing of existing areas . This Federal tag relates to Complaint IN 350. 3.1-40(a)(2)

Based on observation, interview, and record review, the facility failed to ensure staff placed a soft boot on a resident's amputated leg, as ordered by the physician, for 1 of 2 residents reviewed for quality of care. (Resident 26) Findings include: On the following dates and times, Resident 26 was observed in his bed with no soft boot on the stump (amputated area) of his right leg, which had been amputated below the knee: 11/16/21 from 2:30 P.M. to 3:15 P.M. 11/17/21 from 11:00 A.M. to 11:35 A.M. 11/18/21 from 2:10 P.M. to 2:50 P.M. 11/19/21 from 2:05 P.M. to 2:40 P.M. On 11/17/21 at 11:45 A.M., Resident 26's clinical record was reviewed. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The significant change Minimum Data Set assessment, dated, 9/8/21, indicated the resident was severely cognitively impaired and required extensive assistance of 2 people for transfers from his wheelchair to the bed, and extensive assistance of 2 people for bed mobility. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview, on 11/19/21 at 10/46 A.M., the resident's relative indicated she had visited everyday until late afternoon. When the resident was placed in bed by staff, no soft boot had been placed on his right stump, nor had any offer of the soft boot placement had been made by staff. During an interview, on 11/19/21 at 2:12 P.M., the resident indicated he could not recall a soft boot being placed on his right stump when he was in bed. During an interview, on 11/19/21 at 2:41 P.M. Licensed Practical Nurse 1 indicated the soft boot was on the shelf in the resident's closet. The resident sometimes refused to wear the soft boot or removed it after it was placed on him. She did not recall when the soft boot was last placed on the resident's right stump. During an interview, on 11/19/21 at 2:54 P.M., the Director of Nursing indicated the clinical record lacked documentation that the soft boot was placed on the resident's right stump or the resident refused to wear the soft boot on the aforementioned dates and times. 3.1-37(a)

Based on interview and record review the facility failed to ensure a Minimum Data Set (MDS) assessment was transmitted within 14 days of completion for 1 of 1 resident reviewed for resident assessment (Resident 1.) Findings include: On 11/19/21 at 2:48 p.m., Resident 1's clinical record was reviewed. A quarterly MDS, dated [DATE], had been exported but not accepted electronically to the CMS National Repository. During an interview, on 11/19/21 at 3:09 p.m., the corporate nurse consultant indicated Resident 1's quarterly MDS was late and it should have been transmitted by 10/26/21. She indicated the facility follows the RAI (Resident Assessment Instrument) manual and did not have a specific policy in regard to MDS transmissions. On 11/22/21 at 10:00 a.m., a review of the Centers for Medicare & Medicaid Services Long-Term Care Facility Resident Assessment Instrument, dated October 2017, indicated, . Assessment Management Requirements and Tips for Non-Comprehensive Assessments: . The MDS must be transmitted (submitted and accepted into the MDS database) electronically no later than 14 calendar days after the MDS completion date .

Based on interview and record review, the facility failed to ensure a careplan was updated following a fall for a resident with history of falls for 1 of 17 residents reviewed for care plan revision. (Resident 1) Findings include: On 11/16/21 at 3:15 p.m., Resident 1's clinical record was reviewed. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A quarterly Minimum Data Set assessment, dated 9/27/21, indicated Resident 1 required limited assistance of one staff member with toileting. A review of Resident 1's Fall Events indicated the following: -On 9/20/21 at 4:00 p.m., the resident had a fall related to standing up and not knowing why. A new intervention was implemented: taller wheelchair ordered to accommodate the resident's height. -On 9/15/21 at 4:00 a.m., the resident stated she was trying to get into her wheelchair. A new intervention was implemented: lip mattress (raised up on the sides to prevent rolling out of bed) to bed. -On 9/18/21 at 4:00 p.m., the resident was attempting to stand up without assistance fell to their bottom. A new intervention was implemented: educate resident to ask for assistance. -On 8/31/21 at 6:00 p.m., the resident was found on the floor in their bathroom laying on their side. The resident stated they were not sure what they were trying to do. A intervention was implemented: re-educate staff. -On 8/21/21 8:00 a.m., the resident was attempting to transfer self from the toilet to their wheelchair and fell . A intervention was implemented: educate staff to stay with resident in bathroom -On 6/20/2021 at 12:45 p.m., Resident was observed laying on right said with head laying in threshold of shower and feet facing toilet. Resident was sent to the hospital and was diagnosed with a right [CONDITION(S)]. A intervention was implemented: resident educated on using call light appropriately. -On 5/21/21 at 8:00 a.m., the resident was found on their buttocks next to the bed. Resident stated they were trying to get into their wheelchair and the wheelchair rolled away. A intervention was implemented: anti roll backs to wheelchair. Resident 1's care plan, initiated on 7/2/21 and current through 12/26/21, indicated, Fall Risk . Staff to stay with resident while on toilet. Date initiated: 8/23/21. Taller chair ordered to accommodate the resident's height. Date initiated: 9/21/21 . No new interventions were initiated on the care plan between 8/23/21 and 9/21/21. During an interview, on 11/19/21 at 10:03 a.m., CNA 1 indicated the resident does tell people to leave them alone while toilet, however, they are very unsteady on their feet and requires staff assistance of one with toileting. During an interview, on 11/19/21 at 2:39 p.m., the Director of Nursing indicated Resident 1's clinical care plan had not been updated to reflect an intervention following the 8/31/21 fall. 3.1-35(d)(2)(B)

Based on observation, interview, and record review, the facility failed to ensure new admission residents were placed on droplet isolation precautions (measures used to prevent the spread of diseases) upon admission to the facility for 2 of 3 residents reviewed for isolation precautions. (Resident 1 and Resident 2) Findings include: 1. On 6/10/20 at 9:58 a.m., during a tour of the facility with Registered Nurse (RN) 2, Resident 1 was observed from the hallway, in her private room, sitting on her bed and watching television. RN 2 indicated, Resident 1 was confined to her room for 14 days, because she was a new admission to the facility. No notification of isolation signage was observed on Resident 1's door, nor was an isolation cart (supplies of personal protective equipment) observed near Resident 1's room. On 6/10/20 at 12:10 p.m., the Executive Director (ED) indicated, Resident 1 was admitted to the facility on [DATE]. Because she was a new admission, Resident 1 was quarantined to her room for 14 days, but droplet isolation precautions were not in place for the resident, because the resident had not shown any signs or symptoms of a respiratory illness. On 6/10/20 at 12:22 p.m., Licensed Practical Nurse (LPN) 5 delivered a lunch tray to Resident 1 in her room. LPN 5 was wearing a mask, sanitized hands before entering the room, placed the tray on a bedside table, and sanitized hands, when she exited Resident 1's room. No notification of isolation signage was observed on Resident 1's door, nor was an isolation cart observed near Resident 1's room. On 6/10/20 at 3:59 p.m., Resident 1 was observed in her room with the door open, sitting on her bed, and watching television. No notification of isolation signage was observed on Resident 1's door, nor was an isolation cart observed near Resident 1's room. Resident 1's record was reviewed on 6/10/20 at 2:45 p.m. Resident 1 was admitted to the facility, from her home, on 6/8/20. Diagnoses, included but not limited to, acute [MEDICAL CONDITION] and [MEDICAL CONDITION]. physician's orders [REDACTED]. Notify physician of temperature greater than 100.0 degrees and symptomatic. A care plan, dated 6/10/20, indicated, Resident 1 was at risk for decline in psychosocial wellbeing related to changes in daily facility operations, related to COVID-19 threat and could possibly become sick. A goal for the resident was to remain free from distress related to changes in facility operations. Interventions on the care plan, included but were not limited to, daily assessments, including checking of temperature and symptoms, eat meals in room to reduce risk until further notice, and provide education to the resident of the importance of following the restrictions to maintain the safety and wellbeing of the resident. The care plan lacked documentation for interventions related to droplet isolation precautions to be implemented. 2. On 6/10/20 at 10:15 a.m., during a tour of the facility with Registered Nurse (RN) 2, Resident 2 was observed from the hallway, in his private room with the door opened, sitting in his wheelchair, while he watched the television. RN 2 indicated, Resident 2 was confined to his room for 14 days, because he was a new admission to the facility. No notification of isolation signage was observed on Resident 2's door, nor was an isolation cart (supplies of personal protective equipment) observed near Resident 2's room. On 6/10/20 at 12:15 p.m., the Executive Director (ED) indicated, Resident 2 was admitted to the facility on [DATE]. Because he was a new admission, Resident 2 was quarantined to his room for 14 days, but droplet isolation precautions were not in place for the resident, because Resident 2 had not shown any signs or symptoms of a respiratory illness. On 6/10/20 at 4:12 p.m., Resident 2 was observed wearing a face mask and propelling himself in a wheelchair down the hallway. Resident 2's room door was open. No notification of isolation signage was observed on Resident 2's door, nor was an isolation cart observed near Resident 2's room. On 6/11/20 at 9:45 a.m., Resident 2's record was reviewed. [DIAGNOSES REDACTED]. physician's orders [REDACTED]. Notify physician of temperature greater than 100.0 degrees and symptomatic. A care plan, dated 6/9/20, indicated, Resident 2 was at risk for decline in psychosocial wellbeing related to changes in daily facility operations, related to COVID-19 threat and could possibly become sick. A goal for the resident was to remain free from distress related to changes in facility operations. Interventions on the care plan, included but were not limited to, daily assessments, including checking of temperature and symptoms, and eat meals in room to reduce risk until further notice. The care plan lacked documentation for interventions related to droplet isolation precautions to be implemented. The Centers for Disease Control and Prevention (CDC), dated 4/28/20, indicated, for all Long Term Care Facilities to, .Create a plan for managing new admissions and readmissions whose COVID-19 status is unknown. Options may include placing the resident in a single-person room or in a separate observation area so the resident can be monitored for evidence of COVID-19. Residents could be transferred out of the observation area to the main facility if they remain afebrile (without fever) and without symptoms for 14 days after their exposure (or admission). Testing at the end of this period could be considered to increase certainty that the resident is not infected .All recommended PPE should be worn during care of residents under observation; this includes use of an N95 or higher-level respirator (or facemask if a respirator is not available), eye protection (i.e., goggles or a disposable face shield that covers the front and sides of the face), gloves, and gown 3.1-18(b)(1)

Based on observation, interview, and record review, the facility failed to ensure a severely cognitively impaired resident with a history of multiple falls was care planned and provided supervision to prevent recurrence of falls for 1 of 3 residents reviewed for falls. (Resident C) Findings Include: On 12/16/19 at 11:16 a.m., observed Resident C in her room finishing up with morning care. Resident C responded when spoken to, however she indicated she did not have the time to talk as she had things to do. Resident C was fully dressed and in a wheelchair with staff making Resident C's bed. On 12/16/19 at 12:00 p.m., observed Resident C sitting in the TV (television) room across from the nurses station, engaged in conversation with other residents. Two nurses sat in the nurses station working on the computers, approximately 9 feet and to the left of where Resident C was seated. On 12/17/19 at 11:00 a.m., Resident C was observed to be in the TV room with other residents, engaged in conversation with other residents. Two nurses were standing in nurses station conversing between themselves. On 12/16/19 at 10:45 a.m., Resident B's clinical record was reviewed. [DIAGNOSES REDACTED]. A Quarterly Minimum Data Set Assessment, dated 10/1/19, indicated Resident C had a severe cognitive impairment. She was wheelchair bound, required extensive assistance with activities of daily living, and had been determined to be a fall risk since admission, dated 06/04/19. On 12/17/19 at 12:30 p.m., the DON (Director of Nursing) provided the facilities post occurrence IDT (internal department team) and fall risk assessments of Resident C's falls dated from 06/09/2019 through 12/11/24/19. The assessments indicated 8 falls one with injury (skin tear) within a 6 month time period. Root causes of the falls were documented and IDT documented recommendations were completed. The assessments indicated 8 of 8 falls of the resident being found by staff after the fall: On 06/09/19 at 2:00 a.m., Resident was observed sitting upright on buttocks in lobby, previous to this res (resident) was laying in bed in room, w/c (wheelchair) was still in room, and resident had one slipper on and was fully dressed. No injury. Root cause: wanted up and changed. IDT recommendations were for staff to put pajamas on at bedtime. On 6/12/2019 at 7:00 a.m., resident was noted on the floor in her room. Resident stated she was trying to transfer self from bed to chair. No injury. Root cause: resident not sleeping at night, resident transfers self from bed to chair often thru the night. IDT recommendation was to notify md (medical doctor) for sleep aid. On 07/12/2019 at 11:30 p.m., res was attempting to transfer self to toilet when she ended up on setting (sic) on the floor in front of w/c in bathroom, res moves all extremities without difficulty or discomfort. No injury. Root cause: did not lock wheelchair, and chair rolled away. IDT recommendations anti-roll backs to wheelchair. On 07/31/2019 at 1:30 a.m., Resident was observed laying on floor next to bed on her left side, resident unable to say what she was attempting to do. Type of injury indicated a small laceration above left eye measuring skin tear noted just under left eye measuring 2 x 2. total skin flap loss. purple bruise around eye measures 3.5 x 6.2. left eye is swollen. Root cause:resident rolled out of bed. IDT recommendations low bed with mat. On 08/03.2019 at 2:30 p.m., Resident was noted by CNA laying on floor next to bed, resident did not hit head resident stated she rolled on to floor/mat next to bed. No injury. Root cause: rolled out of bed. IDT recommendations: lip mattress to bed, continue with low bed and mat. On 09/22/2019 at 04:45 a.m., resident was in wheelchair in bathroom entry, resident stood up from wheelchair to use bathroom and when looking for the light switch she fell . No injury. Root cause: unable to find the light switch and room was dark. IDT recommendations: night light to be placed in bathroom. On 11/05/2019 at 5:30 p.m., Resident sitting in room on floor, water on floor. No injury. Root cause: water pitcher not in reach due to floor mat. IDT recommendations: floor mat removed. On 11/24/2019 at 6:15 a.m., resident was sitting in wheelchair in hallway, fell out of wheelchair acquired skin tear on left elbow. Injury: skin tear on left elbow. Root case: resident fell asleep in her wheelchair. IDT recommendations: NP (nurse practitioner) to look at medications for sleep. Resident C's Fall Risk care plan, dated 06/14/19 through 01/01/20, indicated a goal of Resident C's fall risk factors will be reduced in an attempt to avoid significant injury related to falls. Interventions include, but are not limited to: call light within reach, reassess fall risk factors annually and whenever necessary, anti-roll backs on wheelchair, lip mattress, and analyze previous resident falls to determine whether pattern/trend can be addressed. Resident C's care plan did not indicate identified fall risk factors nor an intervention for supervision to prevent recurrence of falls. Physical therapy notes, dated 12/17/19 at 2:30 p.m. indicated . (name) will require maximum assistance ., to maintain balance on toilet commode, and to complete toileting hygiene. Also (name) with require minimal assistance to toilet/commode, and will require standby by assist in all aspects of toileting and all functional transfers. On 12/17/19 at 4:30 p.m., the Administrator provided the CNA (certified nursing assistant) assignment sheet for hall Resident C resided on. The assignment sheet included Resident C was a fall risk, toilet before and after meals, and arise and bedtime preferences. No supervision checks were noted. On 12/17/19 at 4:00 p.m., the Administrator provided the facilities Nursing Policy & Procedure manual indicating Fall Management Procedure, policy date 01/10/2019, and indicated the policy was the one currently being used by the facility. A review of the policy indicated, .a post fall intervention must be put in place to prevent reoccurrence . until the IDT can review the fall circumstances and complete the post fall investigation .and determine an appropriate fall prevention intervention/s . On 12/17/19 at 4:00 p.m., interview with the Administrator, indicated there was no facility policy in regard to resident supervision. This Federal tag relates to Complaint IN 289. 3.1-45(a)(2)

Based on observation, interview, and record review, the facility failed to ensure staff disposed of expired sour cream and potato chips by the best used by date and failed to ensure food was not stored under a water condenser line on which water had condensed and frozen. Findings include: 1.) On [DATE] at 10:10 A.M., the facility's walk in refrigerator was observed to contain one 5 pound container of sour cream with a use by date of [DATE]. 2.) On [DATE] at 10:15 A.M., the facility's dry storage room was observed to contain 3 twenty ounce bags of potato chips, each with a use by date of [DATE]. 3.) On [DATE] at 10:20 A.M., the facility's walk in freezer was observed to have an open 30 pound box of tortilla chips stored beneath a water line and condenser upon which water had frozen. Interview, on [DATE] at 10:25 A.M., the Dietary Manager indicated the sour cream and potato chips were past their use by dates and should have been discarded. The box of tortilla chips should not have been stored, opened, under the condenser and should have been discarded. The state Retail Food Establishment Sanitation Requirements manual was used to determine food storage procedure. On [DATE] at 10:40 A.M., a review of the state Retail Food Establishment Sanitation Requirements manual indicated, .food may not be stored as follows: under lines on which water has condensed . 3XXX,[DATE](i)(2) 3XXX,[DATE](i)(3)

Based on interview and record review, the facility failed to ensure the completion of a quarterly Minimum Data Set assessment by 14 calendar days of assessment reference date (ARD)/date due for 1 of 2 residents reviewed for Resident Assessment. (Resident 18) Findings include: On 7/12/19 at 10:39 a.m., Resident 18's clinical record was reviewed. [DIAGNOSES REDACTED]. The clinical record lacked documentation of quarterly MDS assessment, dated 6/24/19, being completed within 14 calendar days of the assessment reference date (ARD)/date due, which was (MONTH) 8, 2019. Interview, on 7/12/19 at 2:30 p.m., the MDS nurse indicated Resident 18's quarterly MDS assessment was not completed, and the quarterly MDS assessment was late. The Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, Version 1.16, (MONTH) (YEAR), indicated the quarterly MDS completion date (Item Z0500B) must be no later than 14 days after the ARD (ARD + 14 calendar days). On 7/12/19 at 3:05 p.m., the MDS nurse provided the Comprehensive Assessments (MDS): policy, dated 3/1/16, and indicated the policy was the one currently being used by the facility. A review of the policy did not indicate the time frame to complete a quarterly MDS assessment. 3.1.-31(d)(3)

Based on observation, interview, and record review, the facility failed to ensure staff administered medications under the direct observation of the person administering the medications for 1 of 1 randomly observed resident (Resident 38). Findings include: On 7/8/19 at 9:50 A.M., Resident 38 was observed in her room, sitting in her chair. On the bedside table was a cup of medications. The medications were identified as 81 milligrams (mg) of aspirin, 20 mg of [MEDICATION NAME], 50 mg of [MEDICATION NAME], 80 mg of [MEDICATION NAME], and 10 MilliEQuivalents Per Liter (mEQ) of potassium chloride. No facility staff were observed to be in the resident's room. Interview, on 7/8/19 at 9:53 A.M., Licensed Practical Nurse 1 indicated staff should have stayed in the room while the resident took the medications. She had taken the medications to the resident's room at approximately 9:50 A.M., then went to another resident's room to attend to another resident as she trained new staff. Medications were not to be left unattended in residents' rooms. On 7/12/19 at 2:30 P.M., the Director of Nursing provided the policy, Medication Administration Procedure, policy start date, 8/29/16, and indicated this was the policy currently used by the facility. A review of the policy indicated, .remain with the resident until each medication is swallowed. Never leave medication with the resident . 3.1-35(g)(1)

Based on interview and record review, the facility failed to lock/complete an admission Minimum Data Set (MDS) assessment within 14 days of the admitted for 1 of 21 residents reviewed for MDS. (Resident 155) Findings include: Resident 155's clinical record was reviewed on 7/12/2019 at 1:45 p.m. [DIAGNOSES REDACTED]. Resident 155 admitted to the facility on [DATE]. The clinical record lacked documentation of the admission Minimum Data Set (MDS) being locked/completed within 14 calendar days of the assessment reference date (ARD), which was (MONTH) 11, 2019. Interview, on 7/12/2019 at 2:30 p.m., the MDS nurse indicated Resident 155's admission MDS was late. A review of the Resident Assessment Instrument (RAI) Version 3.0 Manual, indicated, . Admission Assessment (A0310A=01) The Admission assessment is a comprehensive assessment for a new resident and, under some circumstances, a returning resident that must be completed by the end of day 14, counting the date of admission to the nursing home as day 1 . On 7/12/2019 at 3:05 p.m., the MDS nurse provided the policy titled, Comprehensive Assessments (MDS), dated [DATE], and indicated it was the policy currently being used by the facility. A review of the policy indicated, . A. 1. To assure that a comprehensive assessment of resident's needs is completed within 14 days of the admission . 3.1-31(d)(1)

Based on observation, interview, and record review, the facility failed to ensure residents were not neglected during changes in their conditions for 2 of 4 residents in a sample of 4 who were reviewed for neglect. (Resident #B and Resident #D) Findings include: 1). Resident #B's closed clinical record was reviewed on [DATE] at 6:10 a.m. and indicated the resident was admitted to the facility on [DATE] and re-admitted on [DATE]. The resident's [DIAGNOSES REDACTED]. difficile. Resident #B's care plan dated [DATE] with recent revision on [DATE] for Potential for exacerbation of : [MEDICAL CONDITION], CAD, HTN, [MEDICAL CONDITION] Fib and [MEDICAL CONDITION] indicated a goal of, "Will have s/s (signs/symptoms) of exacerbation recognized early." Interventions included, but were not limited to, "Notify MD as needed"; "Observe for changes in cardio/respiratory system and notify MD as needed"; and "Observe for s/s i.e. increased secretions, cough, SOB (shortness of breath) and notify MD for treatment." Electronic Nurse's Notes dated [DATE] at 2:30 a.m. by LPN #3 indicated the resident was alert and oriented to self, situation, place, and time, currently experiencing no pain, blood pressure ,[DATE], pulse 74, respirations 18, temperature 97.3 oxygen sats at 96%, shortness of breath when anxious, receives respiratory treatments, mucous membranes pink and moist, skin color pink, skin turgor good, and no cough present. The resident's lung sounds were absent or diminished. Electronic Nurse's Notes dated [DATE] at 9:05 a.m. indicated the medical doctor (MD) was notified and order received for transfer to hospital. The responsible party was notified of transfer, receiving facility was notified and given verbal report and the resident was transferred via ambulance. Vital signs at time of transfer were blood pressure ,[DATE], pulse 88, respirations 28, oxygen sats 92% and indicated in the notes was, "Res (Resident) having difficulty getting breath, warm to touch, sweaty." Interview with the Director of Nursing (DON) on [DATE] at 5:35 a.m. indicated the facility had terminated LPN #3 for sleeping on the job and for not checking on a resident (Resident #D) immediately after a fall. The DON was not aware of any other incidents with LPN #3. Interview with CNA #1 on [DATE] at 5:15 a.m. indicated LPN #3 works nights, sleeps during the shift, and plays on his phone. Employee #1 indicated LPN #3 told Resident #A he does not refill oxygen tanks until 4 a.m. Resident #A was observed at this time with 2 portable oxygen tanks on the back of her electric wheel chair. Interview with CNA #2 on [DATE] at 5:20 a.m. indicated she knew Resident #B and she was one of her favorite residents. CNA #2 indicated she got to work at 10 p.m. the night Resident #B went bad. CNA #2 indicated she was passing ice water and noticed Resident #B did not look good at all and was not her normal self. CNA #2 indicated she told LPN #3 about Resident #B and LPN #3 said it was just her anxiety. CNA #2 indicated Resident #B was pushing on her call light and later wanted to go to the hospital. CNA #2 indicated she told LPN #3 that the resident wanted to go to the hospital and he said it was just her anxiety and never went to check on Resident #B. CNA #2 indicated another aide - CNA #10 came into work and she had her look at Resident #B and CNA #10 said she looked like she was dying. CNA #2 indicated the resident was still pushing her call light and was still asking to go to the hospital and at 3:30 a.m. CNA #2 approached LPN #3 again and told him he needed to check on Resident #B and he finally got up and gave her a breathing treatment. Interview with RN #5 on [DATE] at 5:40 a.m. indicated she knew LPN #3 and indicated he was a nice person, caught him sleeping one time and nodding off, had concerns about medications and thought he might have passed meds only to alert and oriented residents, because he would get done so fast, and indicated when she followed him one time he did not do his dressing change as the old dressing was still on when she came on shift. RN #5 indicated she was not working the night Resident #B got bad, but heard about it from 3 different aides. RN #5 indicated one aide told her Resident #B was really different, not her normal self and employee #3 just ignored the situation. The other 2 aides had the same story that LPN #3 just ignored the resident and her condition. Interview with CNA #6 on [DATE] at 5:50 a.m. indicated she knew LPN #3, indicated he was very nice, corgal, took naps, and read a lot. CNA #6 indicated if she asked him for help, he would help her, but he would not answer call lights. Interview with CNA #10 on [DATE] at 9:27 a.m. indicated she came into work at 2 a.m. the night Resident #B went bad, and indicated Resident #B was unresponsive, very weak, very short of breath, clinching her chest, and wanted to go to the hospital. CNA #10 indicated Resident #B's stomach was trying to breathe, her respirations were 32 and her oxygen saturation was in the 90's, but she couldn't breath. CNA #10 indicated she informed LPN #3, three (3) times that Resident #B wanted to go to the hospital, but he ignored her. CNA #10 indicated LPN #3 finally got up from his nap at 3:30 a.m. and gave Resident #B a breathing treatment, but it didn't help at all and actually made her worse as it sometimes makes the resident more nervous and Resident #B's respirations went up to 36. CNA #10 indicated he still would not send Resident #B to the hospital, but day shift came in and finally sent her out that morning. Hospital records dated [DATE] indicated in emergency department notes the resident was awake, could follow commands, makes purposeful movements, does not verbalize answers, but makes sounds as what she wants. Right extremities contracted, positive for multiple discolored areas noted on bilateral upper extremities and right lower extremity. The resident's eyes open spontaneously, positive for labored breathing at rest noted. Positive for course crackles, rhonchi noted throughout. Skin hot to touch. Upon examination, the notes indicated the resident appeared cachactic and had a sickly appearance. Tachypnea was noted and notes indicated the resident was in respiratory distress. The resident had rhonchi and rales coarse throughout. Chest x-ray results from the hospital dated [DATE] indicated chronic upper lung interstitial infiltrates. Lab results indicated a blood Troponin T at 0.102 high (which is an indication of a [MEDICAL CONDITION]), red blood cell 3.56 low, hemoglobin 11.0 low, and hematocrit 33.0 low (indicators of [MEDICAL CONDITION] or blood loss). The clinical impression was dyspnea, aspiration pneumonitis, and cardiac ischemia. Discharge Summary Notes dated [DATE] indicated date of death as [DATE]. The notes indicated the resident was admitted with cough and congestion with increased need for oxygen, and most probably the patient aspirated and had aspiration pneumonia versus hospital-acquired pneumonia. The resident was on intravenous antibiotic, developed acute, on top of her chronic [MEDICAL CONDITION], and the family requested the resident to be on hospice and provide her with comfort measures only, secondary to her other comorbidities, including the stroke, which left her with chronic, right side [MEDICAL CONDITION]. The resident was started on comfort measures and was comfortable with pain medications, other palliative and comfort measures, and she expired on the 6th. Interview with the DON on [DATE] at 5:35 a.m. indicated she was not aware of the incident with Resident #B. 2). Resident #D's clinical record was reviewed on [DATE] at 12:35 p.m. and indicated the resident was admitted to the facility on [DATE] and re-admitted on [DATE] and had [DIAGNOSES REDACTED]. Resident #D's care plan dated [DATE] and revision on [DATE] indicated a care plan for "Fall Risk Resident is at risk for falls due to resident has hx (history) of falls, poor positioning and poor trunk control d/t (due to) dx (diagnoses) [MEDICAL CONDITION] with right sided weakness and [MEDICAL CONDITION]. Resident takes an anti-hypertensive med daily d/t dx [MEDICAL CONDITION](hypertension). Resident also takes an antidepressant med daily for dx of depression. Above puts resident at risk for falls." Interventions included, reinforce need to call for assistance, encourage resident to use handrails or assistive devices properly, ensure environment is free of clutter, analyze previous resident falls to determine whether pattern/trend can be addressed, reassess fall risk factors at least quarterly, notify MD of changes in condition, notify therapy of changes in condition, monitor for changes in gait/positioning, call light in reach, explain use of it upon admission and reinforce as needed, encourage and assist with wearing non-skid foot-wear, low bed with mat, and lip mattress [DATE]. Interview with the Director of Nursing (DON) on [DATE] at 5:35 a.m. indicated the facility had terminated LPN #3 for sleeping on the job and for not checking on a resident (Resident #D) immediately after a fall. Review of the electronic Occurrence Initial Assessment notes dated [DATE] which was put into the computer by LPN #3 indicated, "Called to room by CNA, resident found on floor next to bed. Resident lying on her right side. Resident turned over, resident has large hematoma on right side of forehead. No other open/bruised/swollen areas noted. Resident non-verbal, per yes/no questions does not know how she (sic) fell to floor. Room-mate reports hearing loud bump then turning on call light. Resident assisted to bed. Neuro checks started, wnl (within normal limits). Denies pain. bed (sic) was in low postion (sic) with mat on floor. Also has bumpers on bed, bed has overlay on air mattress, bumper on side of bed, not on top of bed. Overlay repositioned and bumpers in place on top of mattress." Notes indicated the physician was notified. The Post Occurrence assessment dated [DATE] at 9:11 a.m. indicated, Date and time of occurrence as [DATE] at 12:45 a.m.; summary of occurrence: "Resident on floor on right side"; type of injury: "Hematoma to forehead"; root cause: "Low air loss mattress provided by hospice, very sensitive to movement"; IDT (Interdisciplinary Team) recommendations: "Low air loss mattress removed, lip mattress placed." LPN #3 indicated on the "Investigation of reasons/causes of the incident: bed mattress has bumpers, pad of mattress overlay which was under over to side, allowing bumper to move to side of mattress." The "Action taken to prevent reoccurrence: Will notify unit manager about need to change bed overlay." Underneath the above documentation was written, "Low air loss mattress with bumper pads removed and resident given lip mattress. The facility's new intervention was to remove the low air loss mattress, and a lip mattress was placed." The Administrator and DON signed the sheet. Resident #D was observed on [DATE] at 10 a.m. and was observed asleep in low bed with mat on the floor beside the bed. Bruises were observed on the resident's right forehead area and right cheek. Interview with LPN #11 on [DATE] at 10:45 a.m. indicated the right forehead area was partially scabbed at the top of the hematoma. Interview with the Administrator and DON on [DATE] at 11:05 a.m. indicated Resident #D fell on [DATE] at 12:45 a.m.. The DON explained the Administrator and Assistant Director of Nursing (ADON) was made aware of the incident about LPN #3 not responding immediately the first time when told about the resident's fall during an in-service on [DATE]. CNA #2 told LPN #4 that the nurse did not respond when told about the resident having fallen. The Administrator indicated LPN #4 was told by CNA #2 that she went once to get the nurse and then had to go a second time to get the nurse to come down and check on the resident. During termination of LPN #3, the nurse just said he assessed the resident, but did not say anything about the second time of the aide coming to get him. The Administrator indicated LPN #3 was pretty quiet that day of termination. Review of the facility's policy on Abuse Prohibition, Reporting, and Investigation dated [DATE] indicated, "... Abuse - Physical, sexual, verbal and/or mental (known or alleged) abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. This includes deprivation of an individual, including caretaker, of goods or services that are necessary to attain or maintain physical, mental, or psychosocial well being. ... Neglect - means the failure to provide goods and services necessary to avoid physical harm, mental anguish or mental illness...." The policy indicated,"1. It is the policy of _______(name of health system) that all residents have the right to be free from verbal, sexual, physical and mental abuse, corporal punishment, and involuntary seclusion. 2. ________(name of health system) has policies and procedures in place that prohibit mistreatment, neglect and abuse of residents and misappropriation of resident property. These policies and procedures include but not limited to employment procedures: individuals who have been found guilty of abusing, neglecting or mistreating residents by a court of law or have had a finding entered into the State nurse aide registry concerning abuse, neglect, mistreatment of [REDACTED]. 3. ________(name of health system) has policies and procedures in place that ensures that all alleged violations involving mistreatment, neglect or abuse, including injuries of immediately to the Administrator of the facility and to other officials in accordance with State law through established procedures (including to the State survey and certification agency). 4. ______(name of health system) has policies and procedures in place that all alleged violations are thoroughly investigated, and must prevent further potential abuse while the investigation is in progress." The facility's policy and procedures also indicated, "It is the responsibility of every employee of _____(name of health system) to not only report abuse situations, but also suspicion of abuse and unusual observations and circumstances, to their immediate supervisor. ... All reports of alleged abuse/abuse and all unusual occurrences, must be reported to the Administrator immediately, and to the resident's representative (sponsor, responsible party), as soon as feasible possible, but no later than within 24 hours of the reporting or discovery of the incident. ... Violations of the aforementioned will be reported to the Long Term Care Division of the Indiana State Department of Health and other officials in accordance with state law through established procedures as outlined in the "Unusual Occurrence Reporting Policy and Procedure. ... The Administrator, or designee, shall initiate and direct the investigation immediately, and within 5 days a report of this investigation must be forwarded to the Long Term Care Division of the Indiana State Department of Health." Review of the Disciplinary Detail for LPN #3 dated [DATE] indicated, "Employee was witnessed sleeping while on duty for an uninterrupted period of 45 minutes. According to investigation, this has been a repeated violation of company policy. In addition, it was reported on this date a resident fell and a request had been made for this nurse to come quickly and assess (Nurse was not in middle of care with another resident.) Nurse had to be requested a second time to come assess resident. At which time this nurse did not assess above 2 violation demonstrate a lack of professional standard necessary for the protection of our resident's welfare." The Separation Form indicated, "I _____(name of LPN #3) certify that there are no incidences, that I am aware of, regarding "resident abuse" that are unresolved as of this date. I certify, further, that I have been trained in the recognition of resident abuse, both physical and mental, and ascertain no such violations of Resident's Rights are unresolved." This was initialed by LPN #3. This federal deficiency is related to Complaint IN 653. 3XXX,[DATE](a)(3)

Based on observation, interview, and record review, the facility failed to implement their written policies and procedures that prohibit mistreatment, neglect, and abuse of residents for 2 of 2 alleged incidents of neglect/abuse investigated. (Resident #B and Resident #D) Findings include: 1). Resident #B's closed clinical record was reviewed on [DATE] at 6:10 a.m. and indicated the resident was admitted to the facility on [DATE] and re-admitted on [DATE]. The resident's [DIAGNOSES REDACTED]. difficile. Resident #B's care plan dated [DATE] with recent revision on [DATE] for Potential for exacerbation of : [MEDICAL CONDITION], CAD, HTN, [MEDICAL CONDITION] Fib and [MEDICAL CONDITION] indicated a goal of, "Will have s/s (signs/symptoms) of exacerbation recognized early." Interventions included, but were not limited to, "Notify MD as needed"; "Observe for changes in cardio/respiratory system and notify MD as needed"; and "Observe for s/s i.e. increased secretions, cough, SOB (shortness of breath) and notify MD for treatment." Electronic Nurse's Notes dated [DATE] at 2:30 a.m. by LPN #3 indicated the resident was alert and oriented to self, situation, place, and time, currently experiencing no pain, blood pressure ,[DATE], pulse 74, respirations 18, temperature 97.3 oxygen sats at 96%, shortness of breath when anxious, receives respiratory treatments, mucous membranes pink and moist, skin color pink, skin turgor good, and no cough present. The resident's lung sounds were absent or diminished. Electronic Nurse's Notes dated [DATE] at 9:05 a.m. indicated the medical doctor (MD) was notified and order received for transfer to hospital. The responsible party was notified of transfer, receiving facility was notified and given verbal report and the resident was transferred via ambulance. Vital signs at time of transfer were blood pressure ,[DATE], pulse 88, respirations 28, oxygen sats 92% and indicated in the notes was, "Res (Resident) having difficulty getting breath, warm to touch, sweaty." Interview with the Director of Nursing (DON) on [DATE] at 5:35 a.m. indicated the facility had terminated LPN #3 for sleeping on the job and for not checking on a resident (Resident #D) immediately after a fall. The DON was not aware of any other incidents with LPN #3. Interview with CNA #1 on [DATE] at 5:15 a.m. indicated LPN #3 works nights, sleeps during the shift, and plays on his phone. Employee #1 indicated LPN #3 told Resident #A he does not refill oxygen tanks until 4 a.m. Resident #A was observed at this time with 2 portable oxygen tanks on the back of her electric wheel chair. Interview with CNA #2 on [DATE] at 5:20 a.m. indicated she knew Resident #B and she was one of her favorite residents. CNA #2 indicated she got to work at 10 p.m. the night Resident #B went bad. CNA #2 indicated she was passing ice water and noticed Resident #B did not look good at all and was not her normal self. CNA #2 indicated she told LPN #3 about Resident #B and LPN #3 said it was just her anxiety. CNA #2 indicated Resident #B was pushing on her call light and later wanted to go to the hospital. CNA #2 indicated she told LPN #3 that the resident wanted to go to the hospital and he said it was just her anxiety and never went to check on Resident #B. CNA #2 indicated another aide - CNA #10 came into work and she had her look at Resident #B and CNA #10 said she looked like she was dying. CNA #2 indicated the resident was still pushing her call light and was still asking to go to the hospital and at 3:30 a.m. CNA #2 approached LPN #3 again and told him he needed to check on Resident #B and he finally got up and gave her a breathing treatment. Interview with RN #5 on [DATE] at 5:40 a.m. indicated she knew LPN #3 and indicated he was a nice person, caught him sleeping one time and nodding off, had concerns about medications and thought he might have passed meds only to alert and oriented residents, because he would get done so fast, and indicated when she followed him one time he did not do his dressing change as the old dressing was still on when she came on shift. RN #5 indicated she was not working the night Resident #B got bad, but heard about it from 3 different aides. RN #5 indicated one aide told her Resident #B was really different, not her normal self and employee #3 just ignored the situation. The other 2 aides had the same story that LPN #3 just ignored the resident and her condition. Interview with CNA #6 on [DATE] at 5:50 a.m. indicated she knew LPN #3, indicated he was very nice, corgal, took naps, and read a lot. CNA #6 indicated if she asked him for help, he would help her, but he would not answer call lights. Interview with CNA #10 on [DATE] at 9:27 a.m. indicated she came into work at 2 a.m. the night Resident #B went bad, and indicated Resident #B was unresponsive, very weak, very short of breath, clinching her chest, and wanted to go to the hospital. CNA #10 indicated Resident #B's stomach was trying to breathe, her respirations were 32 and her oxygen saturation was in the 90's, but she couldn't breath. CNA #10 indicated she informed LPN #3, three (3) times that Resident #B wanted to go to the hospital, but he ignored her. CNA #10 indicated LPN #3 finally got up from his nap at 3:30 a.m. and gave Resident #B a breathing treatment, but it didn't help at all and actually made her worse as it sometimes makes the resident more nervous and Resident #B's respirations went up to 36. CNA #10 indicated he still would not send Resident #B to the hospital, but day shift came in and finally sent her out that morning. Hospital records dated [DATE] indicated in emergency department notes the resident was awake, could follow commands, makes purposeful movements, does not verbalize answers, but makes sounds as what she wants. Right extremities contracted, positive for multiple discolored areas noted on bilateral upper extremities and right lower extremity. The resident's eyes open spontaneously, positive for labored breathing at rest noted. Positive for course crackles, rhonchi noted throughout. Skin hot to touch. Upon examination, the notes indicated the resident appeared cachactic and had a sickly appearance. Tachypnea was noted and notes indicated the resident was in respiratory distress. The resident had rhonchi and rales coarse throughout. Chest x-ray results from the hospital dated [DATE] indicated chronic upper lung interstitial infiltrates. Lab results indicated a blood Troponin T at 0.102 high (which is an indication of a [MEDICAL CONDITION]), red blood cell 3.56 low, hemoglobin 11.0 low, and hematocrit 33.0 low (indicators of [MEDICAL CONDITION] or blood loss). The clinical impression was dyspnea, aspiration pneumonitis, and cardiac ischemia. Hospital Discharge Summary Notes dated [DATE] indicated date of death as [DATE]. The notes indicated the resident was admitted with cough and congestion with increased need for oxygen, and most probably the patient aspirated and had aspiration pneumonia versus hospital-acquired pneumonia. The resident was on intravenous antibiotic, developed acute, on top of her chronic [MEDICAL CONDITION], and the family requested the resident to be on hospice and provide her with comfort measures only, secondary to her other comorbidities, including the stroke, which left her with chronic, right side [MEDICAL CONDITION]. The resident was started on comfort measures and was comfortable with pain medications, other palliative and comfort measures, and she expired on the 6th. Interview with the DON on [DATE] at 5:35 a.m. indicated she was not aware of the incident with Resident #B and LPN #3. 2). Resident #D's clinical record was reviewed on [DATE] at 12:35 p.m. and indicated the resident was admitted to the facility on [DATE] and re-admitted on [DATE] and had [DIAGNOSES REDACTED]. Resident #D's care plan dated [DATE] and revision on [DATE] indicated a care plan for "Fall Risk Resident is at risk for falls due to resident has hx (history) of falls, poor positioning and poor trunk control d/t (due to) dx (diagnoses) [MEDICAL CONDITION] with right sided weakness and [MEDICAL CONDITION]. Resident takes an anti-hypertensive med daily d/t dx [MEDICAL CONDITION](hypertension). Resident also takes an antidepressant med daily for dx of depression. Above puts resident at risk for falls." Interventions included, reinforce need to call for assistance, encourage resident to use handrails or assistive devices properly, ensure environment is free of clutter, analyze previous resident falls to determine whether pattern/trend can be addressed, reassess fall risk factors at least quarterly, notify MD of changes in condition, notify therapy of changes in condition, monitor for changes in gait/positioning, call light in reach, explain use of it upon admission and reinforce as needed, encourage and assist with wearing non-skid foot-wear, low bed with mat, and lip mattress [DATE]. Interview with the Director of Nursing (DON) on [DATE] at 5:35 a.m. indicated the facility had terminated LPN #3 for sleeping on the job and for not checking on a resident (Resident #D) immediately after a fall. Review of the electronic Occurrence Initial Assessment notes dated [DATE] which was put into the computer by LPN #3 indicated, "Called to room by CNA, resident found on floor next to bed. Resident lying on her right side. Resident turned over, resident has large hematoma on right side of forehead. No other open/bruised/swollen areas noted. Resident non-verbal, per yes/no questions does not know how she (sic) fell to floor. Room-mate reports hearing loud bump then turning on call light. Resident assisted to bed. Neuro checks started, wnl (within normal limits). Denies pain. bed (sic) was in low postion (sic) with mat on floor. Also has bumpers on bed, bed has overlay on air mattress, bumper on side of bed, not on top of bed. Overlay repositioned and bumpers in place on top of mattress." Notes indicated the physician was notified. The Post Occurrence assessment dated [DATE] at 9:11 a.m. indicated, Date and time of occurrence as [DATE] at 12:45 a.m.; summary of occurrence: "Resident on floor on right side"; type of injury: "Hematoma to forehead"; root cause: "Low air loss mattress provided by hospice, very sensitive to movement"; IDT (Interdisciplinary Team) recommendations: "Low air loss mattress removed, lip mattress placed." LPN #3 indicated on the "Investigation of reasons/causes of the incident: bed mattress has bumpers, pad of mattress overlay which was under over to side, allowing bumper to move to side of mattress." The "Action taken to prevent reoccurrence: Will notify unit manager about need to change bed overlay." Underneath the above documentation was written, "Low air loss mattress with bumper pads removed and resident given lip mattress. The facility's new intervention was to remove the low air loss mattress, and a lip mattress was placed." The Administrator and DON signed the sheet. Resident #D was observed on [DATE] at 10 a.m. and was observed asleep in low bed with mat on the floor beside the bed. Bruises were observed on the resident's right forehead area and right cheek. Interview with LPN #11 on [DATE] at 10:45 a.m. indicated the right forehead area was partially scabbed at the top of the hematoma. Interview with the Administrator and DON on [DATE] at 11:05 a.m. indicated Resident #D fell on [DATE] at 12:45 a.m.. The DON explained the Administrator and Assistant Director of Nursing (ADON) was made aware of the incident about LPN #3 not responding immediately the first time when told about the resident's fall during an in-service on [DATE]. CNA #2 told LPN #4 that the nurse did not respond when told about the resident having fallen. The Administrator indicated LPN #4 was told by CNA #2 that she went once to get the nurse and then had to go a second time to get the nurse to come down and check on the resident. During termination of LPN #3, the nurse just said he assessed the resident, but did not say anything about the second time of the aide coming to get him. The Administrator indicated LPN #3 was pretty quiet that day of termination. Review of the facility's policy on Abuse Prohibition, Reporting, and Investigation dated [DATE] indicated, "... Abuse - Physical, sexual, verbal and/or mental (known or alleged) abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. This includes deprivation of an individual, including caretaker, of goods or services that are necessary to attain or maintain physical, mental, or psychosocial well being. ... Neglect - means the failure to provide goods and services necessary to avoid physical harm, mental anguish or mental illness...." The policy indicated,"1. It is the policy of _______(name of health system) that all residents have the right to be free from verbal, sexual, physical and mental abuse, corporal punishment, and involuntary seclusion. 2. ________(name of health system) has policies and procedures in place that prohibit mistreatment, neglect and abuse of residents and misappropriation of resident property. These policies and procedures include but not limited to employment procedures: individuals who have been found guilty of abusing, neglecting or mistreating residents by a court of law or have had a finding entered into the State nurse aide registry concerning abuse, neglect, mistreatment of [REDACTED]. 3. ________(name of health system) has policies and procedures in place that ensures that all alleged violations involving mistreatment, neglect or abuse, including injuries of immediately to the Administrator of the facility and to other officials in accordance with State law through established procedures (including to the State survey and certification agency). 4. ______(name of health system) has policies and procedures in place that all alleged violations are thoroughly investigated, and must prevent further potential abuse while the investigation is in progress." The facility's policy and procedures also indicated, "It is the responsibility of every employee of _____(name of health system) to not only report abuse situations, but also suspicion of abuse and unusual observations and circumstances, to their immediate supervisor. ... All reports of alleged abuse/abuse and all unusual occurrences, must be reported to the Administrator immediately, and to the resident's representative (sponsor, responsible party), as soon as feasible possible, but no later than within 24 hours of the reporting or discovery of the incident. ... Violations of the aforementioned will be reported to the Long Term Care Division of the Indiana State Department of Health and other officials in accordance with state law through established procedures as outlined in the "Unusual Occurrence Reporting Policy and Procedure. ... The Administrator, or designee, shall initiate and direct the investigation immediately, and within 5 days a report of this investigation must be forwarded to the Long Term Care Division of the Indiana State Department of Health." Review of the Disciplinary Detail for LPN #3 dated [DATE] indicated, "Employee was witnessed sleeping while on duty for an uninterrupted period of 45 minutes. According to investigation, this has been a repeated violation of company policy. In addition, it was reported on this date a resident fell and a request had been made for this nurse to come quickly and assess (Nurse was not in middle of care with another resident.) Nurse had to be requested a second time to come assess resident. At which time this nurse did not assess above 2 violation demonstrate a lack of professional standard necessary for the protection of our resident's welfare." The Separation Form indicated, "I _____(name of LPN #3) certify that there are no incidences, that I am aware of, regarding "resident abuse" that are unresolved as of this date. I certify, further, that I have been trained in the recognition of resident abuse, both physical and mental, and ascertain no such violations of Resident's Rights are unresolved." This was initialed by LPN #3. This federal deficiency is related to Complaint IN 653. 3XXX,[DATE](a)

Based on observation, interview and record review, the facility failed to ensure all alleged violations of neglect/abuse were immediately reported to the Administrator and other officials in accordance with State law through established procedures (including to the State survey and certification agency) for 2 of 2 incidents of abuse/neglect investigated. (LPN #3). Findings include: 1). Resident #B's closed clinical record was reviewed on [DATE] at 6:10 a.m. and indicated the resident was admitted to the facility on [DATE] and re-admitted on [DATE]. The resident's [DIAGNOSES REDACTED]. difficile. Resident #B's care plan dated [DATE] with recent revision on [DATE] for Potential for exacerbation of : [MEDICAL CONDITION], CAD, HTN, [MEDICAL CONDITION] Fib and [MEDICAL CONDITION] indicated a goal of, "Will have s/s (signs/symptoms) of exacerbation recognized early." Interventions included, but were not limited to, "Notify MD as needed"; "Observe for changes in cardio/respiratory system and notify MD as needed"; and "Observe for s/s i.e. increased secretions, cough, SOB (shortness of breath) and notify MD for treatment." Electronic Nurse's Notes dated [DATE] at 2:30 a.m. by LPN #3 indicated the resident was alert and oriented to self, situation, place, and time, currently experiencing no pain, blood pressure ,[DATE], pulse 74, respirations 18, temperature 97.3 oxygen sats at 96%, shortness of breath when anxious, receives respiratory treatments, mucous membranes pink and moist, skin color pink, skin turgor good, and no cough present. The resident's lung sounds were absent or diminished. Electronic Nurse's Notes dated [DATE] at 9:05 a.m. indicated the medical doctor (MD) was notified and order received for transfer to hospital. The responsible party was notified of transfer, receiving facility was notified and given verbal report and the resident was transferred via ambulance. Vital signs at time of transfer were blood pressure ,[DATE], pulse 88, respirations 28, oxygen sats 92% and indicated in the notes was, "Res (Resident) having difficulty getting breath, warm to touch, sweaty." Interview with the Director of Nursing (DON) on [DATE] at 5:35 a.m. indicated the facility had terminated LPN #3 for sleeping on the job and for not checking on a resident (Resident #D) immediately after a fall. The DON was not aware of any other incidents with LPN #3. Interview with CNA #1 on [DATE] at 5:15 a.m. indicated LPN #3 works nights, sleeps during the shift, and plays on his phone. Employee #1 indicated LPN #3 told Resident #A he does not refill oxygen tanks until 4 a.m. Resident #A was observed at this time with 2 portable oxygen tanks on the back of her electric wheel chair. Interview with CNA #2 on [DATE] at 5:20 a.m. indicated she knew Resident #B and she was one of her favorite residents. CNA #2 indicated she got to work at 10 p.m. the night Resident #B went bad. CNA #2 indicated she was passing ice water and noticed Resident #B did not look good at all and was not her normal self. CNA #2 indicated she told LPN #3 about Resident #B and LPN #3 said it was just her anxiety. CNA #2 indicated Resident #B was pushing on her call light and later wanted to go to the hospital. CNA #2 indicated she told LPN #3 that the resident wanted to go to the hospital and he said it was just her anxiety and never went to check on Resident #B. CNA #2 indicated another aide - CNA #10 came into work and she had her look at Resident #B and CNA #10 said she looked like she was dying. CNA #2 indicated the resident was still pushing her call light and was still asking to go to the hospital and at 3:30 a.m. CNA #2 approached LPN #3 again and told him he needed to check on Resident #B and he finally got up and gave her a breathing treatment. Interview with RN #5 on [DATE] at 5:40 a.m. indicated she knew LPN #3 and indicated he was a nice person, caught him sleeping one time and nodding off, had concerns about medications and thought he might have passed meds only to alert and oriented residents, because he would get done so fast, and indicated when she followed him one time he did not do his dressing change as the old dressing was still on when she came on shift. RN #5 indicated she was not working the night Resident #B got bad, but heard about it from 3 different aides. RN #5 indicated one aide told her Resident #B was really different, not her normal self and employee #3 just ignored the situation. The other 2 aides had the same story that LPN #3 just ignored the resident and her condition. Interview with CNA #6 on [DATE] at 5:50 a.m. indicated she knew LPN #3, indicated he was very nice, corgal, took naps, and read a lot. CNA #6 indicated if she asked him for help, he would help her, but he would not answer call lights. Interview with CNA #10 on [DATE] at 9:27 a.m. indicated she came into work at 2 a.m. the night Resident #B went bad, and indicated Resident #B was unresponsive, very weak, very short of breath, clinching her chest, and wanted to go to the hospital. CNA #10 indicated Resident #B's stomach was trying to breathe, her respirations were 32 and her oxygen saturation was in the 90's, but she couldn't breath. CNA #10 indicated she informed LPN #3, three (3) times that Resident #B wanted to go to the hospital, but he ignored her. CNA #10 indicated LPN #3 finally got up from his nap at 3:30 a.m. and gave Resident #B a breathing treatment, but it didn't help at all and actually made her worse as it sometimes makes the resident more nervous and Resident #B's respirations went up to 36. CNA #10 indicated he still would not send Resident #B to the hospital, but day shift came in and finally sent her out that morning. Hospital records dated [DATE] indicated in emergency department notes the resident was awake, could follow commands, makes purposeful movements, does not verbalize answers, but makes sounds as what she wants. Right extremities contracted, positive for multiple discolored areas noted on bilateral upper extremities and right lower extremity. The resident's eyes open spontaneously, positive for labored breathing at rest noted. Positive for course crackles, rhonchi noted throughout. Skin hot to touch. Upon examination, the notes indicated the resident appeared cachactic and had a sickly appearance. Tachypnea was noted and notes indicated the resident was in respiratory distress. The resident had rhonchi and rales coarse throughout. Chest x-ray results from the hospital dated [DATE] indicated chronic upper lung interstitial infiltrates. Lab results indicated a blood Troponin T at 0.102 high (which is an indication of a [MEDICAL CONDITION]), red blood cell 3.56 low, hemoglobin 11.0 low, and hematocrit 33.0 low (indicators of [MEDICAL CONDITION] or blood loss). The clinical impression was dyspnea, aspiration pneumonitis, and cardiac ischemia. Hospital Discharge Summary Notes dated [DATE] indicated date of death as [DATE]. The notes indicated the resident was admitted with cough and congestion with increased need for oxygen, and most probably the patient aspirated and had aspiration pneumonia versus hospital-acquired pneumonia. The resident was on intravenous antibiotic, developed acute, on top of her chronic [MEDICAL CONDITION], and the family requested the resident to be on hospice and provide her with comfort measures only, secondary to her other comorbidities, including the stroke, which left her with chronic, right side [MEDICAL CONDITION]. The resident was started on comfort measures and was comfortable with pain medications, other palliative and comfort measures, and she expired on the 6th. Interview with the DON on [DATE] at 5:35 a.m. indicated she was not aware of the incident with Resident #B and LPN #3. 2). Resident #D's clinical record was reviewed on [DATE] at 12:35 p.m. and indicated the resident was admitted to the facility on [DATE] and re-admitted on [DATE] and had [DIAGNOSES REDACTED]. Resident #D's care plan dated [DATE] and revision on [DATE] indicated a care plan for "Fall Risk Resident is at risk for falls due to resident has hx (history) of falls, poor positioning and poor trunk control d/t (due to) dx (diagnoses) [MEDICAL CONDITION] with right sided weakness and [MEDICAL CONDITION]. Resident takes an anti-hypertensive med daily d/t dx [MEDICAL CONDITION](hypertension). Resident also takes an antidepressant med daily for dx of depression. Above puts resident at risk for falls." Interventions included, reinforce need to call for assistance, encourage resident to use handrails or assistive devices properly, ensure environment is free of clutter, analyze previous resident falls to determine whether pattern/trend can be addressed, reassess fall risk factors at least quarterly, notify MD of changes in condition, notify therapy of changes in condition, monitor for changes in gait/positioning, call light in reach, explain use of it upon admission and reinforce as needed, encourage and assist with wearing non-skid foot-wear, low bed with mat, and lip mattress [DATE]. Interview with the Director of Nursing (DON) on [DATE] at 5:35 a.m. indicated the facility had terminated LPN #3 for sleeping on the job and for not checking on a resident (Resident #D) immediately after a fall. Review of the electronic Occurrence Initial Assessment notes dated [DATE] which was put into the computer by LPN #3 indicated, "Called to room by CNA, resident found on floor next to bed. Resident lying on her right side. Resident turned over, resident has large hematoma on right side of forehead. No other open/bruised/swollen areas noted. Resident non-verbal, per yes/no questions does not know how she (sic) fell to floor. Room-mate reports hearing loud bump then turning on call light. Resident assisted to bed. Neuro checks started, wnl (within normal limits). Denies pain. bed (sic) was in low postion (sic) with mat on floor. Also has bumpers on bed, bed has overlay on air mattress, bumper on side of bed, not on top of bed. Overlay repositioned and bumpers in place on top of mattress." Notes indicated the physician was notified. The Post Occurrence assessment dated [DATE] at 9:11 a.m. indicated, Date and time of occurrence as [DATE] at 12:45 a.m.; summary of occurrence: "Resident on floor on right side"; type of injury: "Hematoma to forehead"; root cause: "Low air loss mattress provided by hospice, very sensitive to movement"; IDT (Interdisciplinary Team) recommendations: "Low air loss mattress removed, lip mattress placed." LPN #3 indicated on the "Investigation of reasons/causes of the incident: bed mattress has bumpers, pad of mattress overlay which was under over to side, allowing bumper to move to side of mattress." The "Action taken to prevent reoccurrence: Will notify unit manager about need to change bed overlay." Underneath the above documentation was written, "Low air loss mattress with bumper pads removed and resident given lip mattress. The facility's new intervention was to remove the low air loss mattress, and a lip mattress was placed." The Administrator and DON signed the sheet. Resident #D was observed on [DATE] at 10 a.m. and was observed asleep in low bed with mat on the floor beside the bed. Bruises were observed on the resident's right forehead area and right cheek. Interview with LPN #11 on [DATE] at 10:45 a.m. indicated the right forehead area was partially scabbed at the top of the hematoma. Interview with the Administrator and DON on [DATE] at 11:05 a.m. indicated Resident #D fell on [DATE] at 12:45 a.m.. The DON explained the Administrator and Assistant Director of Nursing (ADON) was made aware of the incident about LPN #3 not responding immediately the first time when told about the resident's fall during an in-service on [DATE]. CNA #2 told LPN #4 that the nurse did not respond when told about the resident having fallen. The Administrator indicated LPN #4 was told by CNA #2 that she went once to get the nurse and then had to go a second time to get the nurse to come down and check on the resident. During termination of LPN #3, the nurse just said he assessed the resident, but did not say anything about the second time of the aide coming to get him. The Administrator indicated LPN #3 was pretty quiet that day of termination. Review of the facility's policy on Abuse Prohibition, Reporting, and Investigation dated [DATE] indicated, "... Abuse - Physical, sexual, verbal and/or mental (known or alleged) abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. This includes deprivation of an individual, including caretaker, of goods or services that are necessary to attain or maintain physical, mental, or psychosocial well being. ... Neglect - means the failure to provide goods and services necessary to avoid physical harm, mental anguish or mental illness...." The policy indicated,"1. It is the policy of _______(name of health system) that all residents have the right to be free from verbal, sexual, physical and mental abuse, corporal punishment, and involuntary seclusion. 2. ________(name of health system) has policies and procedures in place that prohibit mistreatment, neglect and abuse of residents and misappropriation of resident property. These policies and procedures include but not limited to employment procedures: individuals who have been found guilty of abusing, neglecting or mistreating residents by a court of law or have had a finding entered into the State nurse aide registry concerning abuse, neglect, mistreatment of [REDACTED]. 3. ________(name of health system) has policies and procedures in place that ensures that all alleged violations involving mistreatment, neglect or abuse, including injuries of immediately to the Administrator of the facility and to other officials in accordance with State law through established procedures (including to the State survey and certification agency). 4. ______(name of health system) has policies and procedures in place that all alleged violations are thoroughly investigated, and must prevent further potential abuse while the investigation is in progress." The facility's policy and procedures also indicated, "It is the responsibility of every employee of _____(name of health system) to not only report abuse situations, but also suspicion of abuse and unusual observations and circumstances, to their immediate supervisor. ... All reports of alleged abuse/abuse and all unusual occurrences, must be reported to the Administrator immediately, and to the resident's representative (sponsor, responsible party), as soon as feasible possible, but no later than within 24 hours of the reporting or discovery of the incident. ... Violations of the aforementioned will be reported to the Long Term Care Division of the Indiana State Department of Health and other officials in accordance with state law through established procedures as outlined in the "Unusual Occurrence Reporting Policy and Procedure. ... The Administrator, or designee, shall initiate and direct the investigation immediately, and within 5 days a report of this investigation must be forwarded to the Long Term Care Division of the Indiana State Department of Health." Review of the Disciplinary Detail for LPN #3 dated [DATE] indicated, "Employee was witnessed sleeping while on duty for an uninterrupted period of 45 minutes. According to investigation, this has been a repeated violation of company policy. In addition, it was reported on this date a resident fell and a request had been made for this nurse to come quickly and assess (Nurse was not in middle of care with another resident.) Nurse had to be requested a second time to come assess resident. At which time this nurse did not assess above 2 violation demonstrate a lack of professional standard necessary for the protection of our resident's welfare." The Separation Form indicated, "I _____(name of LPN #3) certify that there are no incidences, that I am aware of, regarding "resident abuse" that are unresolved as of this date. I certify, further, that I have been trained in the recognition of resident abuse, both physical and mental, and ascertain no such violations of Resident's Rights are unresolved." This was initialed by LPN #3. This federal deficiency is related to Complaint IN 653. 3XXX,[DATE](g)(1) 3XXX,[DATE](b)(2) 3XXX,[DATE](c) 3XXX,[DATE](d) 3XXX,[DATE](e)