Every finding on record at Morrison Woods Health Campus

Based on observation, interview, and record review, the facility failed to ensure self-reported incidents were accurately reported to the State Agency (Indiana Department of Health) to allow for evaluation of the need to advocate for the health and safety of facility residents for 3 of 3 self- reported incidents reviewed. (Resident 9, 41, and 34) Findings include: 1. Facility self-reported Incident Number 344, dated 6/1/25, indicated the following: Brief Description of Incident .Description added - - 6/1/25 (Resident 9) resides on rehab unit of health campus. Resident expressed concerns with approach to care provided by CRCA (C.N.A.) Preventive Measures Taken: .care plan to be reviewed and updated as indicated. Staff educated regarding abuse and neglect The, 6/1/25 Facility Incident Report did not indicate what Resident 9 alleged, where the event occurred, what care activity was occurring at the time, or that the resident had alleged abuse. The five-day follow-up also lacked this information. A, 6/1/25, [Facility Name] Statement of Witness Form, included in the facility's investigation (not included in the self-reported incident), indicated the following: Name of Interviewee: [Resident 9's name] . C.N.A. got aggravated because res [resident] kept putting call light for pain pill. C.N.A. told res [resident] nurse had other res [residents] to take care of. C.N.A. put res [resident's] socks on 'hard' & act mad. C.N.A. was rough, pulling arm to get hands under soap and water . The self-reported incident, nor the follow-up, did not contain information regarding an allegation of abuse. The facility's investigation included the following information regarding abuse: Ten (10) resident Abuse Interviews and a 6/1/25, Staff Attendance Record for a staff training titled, Abuse & Neglect. During an interview, on 6/26/25 at 11:09 a.m., Resident 9 indicated she once had an issue with how a staff member treated her. She had been asking for pain medication a lot and had yet to receive it. The CNA was upset because she was on her call light so much. The CNA put her socks on very roughly and pulled her arms really hard and it hurt. The CNA was trying to get the resident's hands under the sink for soap and water. Resident 9 reported it to other facility staff. Resident 9's clinical record was reviewed in 6/26/25 at 9:50 a.m. Current diagnoses included a history of a left femur and tibia fractures, cervical disc degeneration, and pain in the left knee. A 5/25/25, admission, Minimum Data Set (MDS) assessment indicated the resident was cognitively intact, required assistance for toileting and applying footwear, had impaired range of motion in both her upper and lower extremities, and used either a walker or wheelchair for mobility. 2. Facility self-reported Incident Number 345, dated 6/19/25, indicated the following: Brief Description of Incident Description added- - 6/20/25 Resident (Resident 41) exited the campus without making staff aware. Resident was noted to be outside on property. Type of Injury Type of injury added - - 6/20/25 Skin tears and abrasions noted . During an observation on 6/25/25 at 10:49 a.m., the RN Consultant identified the area where the resident was located after he exited the facility on 6/19/25. She walked to an area about 300 feet from the main exit door. She indicated the facility believed the resident had exited from this door. Because the cameras were not working on that day, the facility was unable to identify the exact door or time the resident exited the facility. The resident was found across the facility's rear road that lead to the [NAME]. The resident was found in an undeveloped field. He was lying on his back. He was approximately 50 to 55 feet from the road. There were five feet tall weeds and wildflowers in the field. The weeds could obscure the resident from view. The resident had minor abrasions and skin tears. The resident believed he needed to do work in his back yard. He was assessed and escorted back into the facility. Review of the facility's investigation (not included in the facility's self-reported incident) included: 6/19/25, Statement of Witness Forms which indicated the resident was last seen in his room at 3:55 p.m. At approximately 5:00 p.m., the resident could not be located when the evening meal was about to be served, a missing resident alert was sounded and staff members search both inside and outside of the facility, and the resident was located on the ground laying face-up in the east side field. Resident 41's record was reviewed on 6/24/25 at 2:21 p.m. Current diagnoses included anoxic brain damage, syncope and collapse, and Alzheimer's disease. At the time of the elopement, on 6/19/25, the resident resided on a secured dementia unit. A 6/10/25, admission, MDS assessment indicated the resident was moderately cognitively impaired, used a walker and wheelchair, required moderate staff assistance to go from sitting to standing, and required moderate staff assistance to ambulate 10 feet. 3. Facility self-reported Incident Number 345, dated 6/19/25, indicated the following: Brief Description of Incident Description added - - Resident (Resident 34) resides on health care side of health campus. Resident had an unwitnessed fall while attempting to transfer from toilet. Type of Injury Type of injury added - - 5/31/25 acute comminuted left femoral interochanteric fracture Immediate Action Taken Action taken added - -5/31/25 Staff responded immediately. Pain and skin assessment completed. Resident noted to have complaints of pain to left hip. Pain management immediately implemented and effective. MD gave orders to send to ER (emergency room) for further evaluation and treatment . The self-reported incident indicated the resident was sent to the emergency room immediately. The incident report did not indicate the resident fell at 5:41 a.m. and was assessed to have no pain or injury and 12:07 p.m. (over six hours later) experienced pain and was sent to the hospital. Resident 34's clinical record was reviewed on 6/26/25 at 9:42 a.m. Current diagnoses included left femur fracture, and diabetes mellitus with chronic kidney disease. A 5/13/25, quarterly, MDS assessment indicated the resident was cognitively intact, used a walker and wheelchair for mobility, was dependent for staff assistance for going from sitting to standing, and was dependent for staff assistance for toileting hygiene. A 5/31/25 at 5:41 a.m. progress note indicated the resident was using the bathroom for voiding, when she decided she could stand up to pull her pants, and in the process, she lost her balance and fell on the floor. Vital signs were within normal limits and no pain or injuries were noted. The writer reminded the resident to wait for help and the resident voiced understanding. A 5/31/25 at 12:07 p.m., progress note indicated, the resident was sent to the hospital emergency room at this time per physician request due to increased left hip pain, and increased blood pressure. The afternoon hydralazine (blood pressure medication) was given per order, and the resident's blood pressure decreased when follow up readings were taken. The physician was made aware of concern and pain and the resident's family was made aware. During an interview on 6/26/25 at 2:08 p.m., Administrator 1 and Administrator 2 indicated all self-Reported Incidents were reviewed at a corporate level prior to their submission to the Indiana Department of Health (IDOH). They had not been aware of the need to provide detailed, complete, accurate, and thorough information to allow IDOH to evaluate the need for further action to protect facility residents. A current, 4/1/24, facility policy titled, Long Term Care Abuse and Incident Reporting Policy, provided by Administrator 1 on 6/26/25 at 9:35 a.m., indicated the following: Abuse: .cause physical harm, pain . Alleged violation: alleged violation is a situation or occurrence that is observed or reported by .resident .but has not yet been investigated . 1. Initial reports should include: .c. Actual or identified date and time of the incident d. Name(s) of the resident involved e. Name and title of the staff involved f. Brief description of the event .

Based on observation, interview, and record review, the facility failed to provide treatment to promote healing of an open skin impairment for 1 of 3 residents reviewed for skin conditions. (Resident 24) Finding includes: During an interview on 6/23/25 at 2:53 p.m., Resident 24 was laying on a low air loss mattress with a urinary drainage bag hung on the right side of the bed. Resident 24 indicated he had a wound in the crevice of his left lower buttock for approximately the last ten weeks. He was concerned it hadn't healed up. Resident 24's clinical record was reviewed on 6/24/25 at 2:53 p.m. Diagnoses included obstructive uropathy, infection and inflammatory reaction due to indwelling urethral catheter, and a personal history of other infectious and parasitic diseases. A discontinued order, initiated on 5/27/25 and discontinued on 6/8/25, indicated to cleanse wound to the left lower gluteal (buttock) fold with a wound cleanser, pat dry, apply skin preparation around the wound, collagen power (wound treatment) to the wound bed, and cover with a bordered dressing every three days and as needed. Current orders included staff were required to use enhanced barrier precautions, wearing a gown and gloves at minimum during high contact care activities, cleanse moisture-acquired skin damage (MASD) to the groin with wound cleanser or normal saline, pat dry, apply skin protectant around the wound, and Nystatin (anti-fungal skin treatment) twice daily, and leave open to air (6/10/25). The clinical record lacked current treatment orders for the left lower buttock. A 5/2/25, quarterly, Minimum Data Set (MDS) assessment indicated the resident was cognitively intact. The resident used a wheelchair for mobility. He required an indwelling catheter, moderate assistance from staff for personal hygiene, and substantial assistance from staff for toileting hygiene and lower body dressing. Skin problems included MASD. Skin interventions included a pressure reducing device for the bed and chair and application of nonsurgical dressings with or without topical medications. A current care plan, dated 1/10/25, indicated the resident was at risk for skin breakdown related to decreased mobility. Interventions included the following: conduct weekly skin assessment (1/10/25), low air loss mattress (1/28/25), minimize skin exposure to moisture (1/10/25), treatments/preventative treatments as ordered (1/10/25). A wound summary report indicated the following: An area of MASD was identified and measured 3 centimeters (cm) length by 3 cm width to the groin/peri area on 6/8/25. The most recent observation and status, completed on 6/17/25 at 1:32 p.m., indicated the area was stable and measured 3 cm length by 3 cm width. The area was marked as healed on 6/24/25 at 5:22 p.m. During an interview on 6/25/25 at 2:12 p.m., Unit Manager 10 indicated the resident had an order for the left buttock fold to cleanse the area with wound wash, dry, apply skin preparation around the wound, and cover the area with a foam dressing every three days. She was not familiar with the resident's wound care. During a wound care observation on 6/25/25 from 2:14 p.m. to 2:31 p.m., Unit Manager 10 placed the wound care supplies on an overbed table at the foot of Resident 24's bed. Unit Manager 10 asked the resident to turn further onto his right side. An open, macerated skin wound was observed to the left lower buttock without a dressing or treatment in place. The resident explained to the nurse a treatment had not been in place for a couple of days and the area was tender to touch, especially when he was in his wheelchair. Unit Manager 10 confirmed a dressing was not in place on the open macerated area to the left lower buttock fold. Unit Manager 10 measured the open wound at 1.0 cm length by 1.3 cm width, applied skin preparation around the wound, then applied a bordered foam dressing to the left lower buttock fold. On 6/26/25 at 9:50 a.m., Wound Nurse 11 indicated she was familiar with Resident 24's wound care, as he had MASD to his left lower buttock fold and she rounded on residents with wounds. She was unable to find an order for a treatment to the left lower buttock fold, but expected nursing staff to follow the treatment order for MASD to the groin. She indicated they should have applied the treatment ordered for the groin from the groin area to around the left buttock MASD, even though the order was not specific to the location. A treatment had been added for the right buttock on 6/25/25, but she believed it had been added in error because it was not an appropriate treatment for MASD nor did it include the proper site. The MASD to the left lower buttock fold was not completely healed when she last looked at it on 6/24/25. During an interview on 6/26/25 at 1:26 p.m., the DON indicated Resident 24's treatment order lacked clarity because it indicated to apply the treatment to the groin MASD and did not include the left buttock. A current facility policy, revised 12/17/24, titled Guidelines for Medication Orders, provided by Administrator 1 on 6/25/25 at 3:16 p.m., indicated the following: Purpose Statement . The purpose of this policy is to: To establish uniform guidelines in the receiving and recording of medication orders . Procedure . 9. Treatment orders . a. When recording treatment orders specify: 1. What is to be done, location and frequency and duration of the treatment 3.1-37(a) 3.1-18(l)

Based on observation, interview, and record review, the facility failed to ensure shift to shift narcotic reconciliation was completed for 4 of 4 medication carts reviewed for medication storage. (300 hall cart, 2nd 200 hall cart, Legacy Way cart, and 100 hall cart) Finding includes: 1. During a medication storage observation of the 300 hall cart, accompanied by LPN 5, on 6/23/25 at 9:36 a.m., the Narcotic Count Sheet was reviewed and the following dates lacked staff signatures for shift to shift reconciliation of controlled substances: In June 2025- 6/4/25: 6:00 a.m.- 2:00 p.m. and 2:00 p.m. - 10:00 p.m., 6/9/25: 6:30 p.m.- 10:30 p.m., 6/13/25: 10:00 p.m. - 6:00 a.m., 6/17/25: 2:00 p.m. - 10:00 p.m., 6/18/25: 10:00 p.m. - 6:00 a.m. During an interview at the time of the observation, LPN 5 indicated the sign in/sign out sheet was completed at each shift change. The outgoing nurse marked all incoming and outgoing cards and/or medications. The oncoming nurse and outgoing nurse completed a card count and signed the log to indicate the count was completed and correct. Review of the 300 hall cart Narcotic Count Sheet records from 6/3/25 through 6/20/25, lacked medication counts for shift to shift reconciliation of controlled substances for 9 of 54 opportunities. 2. During a medication storage observation of the 2nd half 200 hall cart, accompanied by LPN 6, on 6/23/25 at 9:44 a.m., the Narcotic Count Sheet was reviewed and the following dates lacked staff signatures for shift to shift reconciliation of controlled substances: In June 2025- 6/19/25: 6:00 a.m.- 2:00 p.m., 6/20/25: 6:30 p.m. - 10:00 p.m. Review of the 2nd half 200 hall cart Narcotic Count Sheet records from 6/5/25 through 6/22/25, lacked medication counts for shift to shift reconciliation of controlled substances for 15 of 55 opportunities. 3. During a medication storage observation of the Legacy Way cart, accompanied by RN 7, on 6/23/25 at 10:00 a.m., the Narcotic Count Sheet was reviewed and the following dates lacked staff signatures for shift to shift reconciliation of controlled substances: In June 2025- 6/4/25: 2:00 p.m. - 10:00 p.m., 6/10/25: 2:00 p.m. - 10:00 p.m., 6/12/25: 6:30 p.m. - 10:30 p.m., 6/14/25: 10:00 p.m. - 6:00 a.m., 6/16/25: 6:30 p.m. - 10:30 p.m. Review of the Legacy Way hall cart Narcotic Count Sheet records from 6/2/25 through 6/19/25, lacked medication counts for shift to shift reconciliation of controlled substances for 6 of 55 opportunities. 4. During a medication storage observation of the 100 hall cart, accompanied by RN 8, on 6/23/25 at 10:22 a.m., the Narcotic Count Sheet was reviewed and the following dates lacked staff signatures for shift to shift reconciliation of controlled substances: In June 2025- 6/12/25: 2:00 p.m. - 10:00 p.m., 6/13/25: 10:00 p.m. - 6:00 a.m., 6/21/25: 6:00 a.m. - 2:00 p.m., 2:00 p.m. - 10:00 p.m., 10:00 p.m. - 6:00 a.m. Review of the 100 hall cart Narcotic Count Sheet records from 6/10/25 through 6/23/25, lacked medication counts for shift to shift reconciliation of controlled substances for 9 of 44 opportunities. During an interview, on 6/24/25 at 2:34 p.m., the DON indicated the expectation for nursing staff was to reconcile the narcotic medications per the facility policy. The Narcotic Count Sheet should be filled in completely and correctly. If a mistake was found during the count this was to be reported to the DON immediately. A facility policy, reviewed 12/17/24, titled, Guidelines for Narcotic Count, provided by the DON on 6/24/25 at 2:43 p.m., indicated the following: . 2. The narcotic book shall contain a sheet providing space for the off going and oncoming nursing staff to record their signature indicating the narcotics have been reviewed. 3. The narcotic count sheet will indicate how many items are in the narcotic drawer and counted to ensure they are all present and accounted for. The count will be updated by two nurses to validate the changes with initials and date, as other items are added or removed. 4. At the time one nurse or other staff qualified to pass medications relinquishes the keys to the medication cart to another staff member that narcotics hall be reconciled by comparing the medication in the cart to the count sheets. 5. Both staff members shall sign the narcotic count is accurately reconciled. 6. Should the available medications not match the count sheets the Director of Health Services shall be notified . 3.1- 25(b)(3)

Based on observation, interview, and record review, the facility failed to follow enhanced barrier precautions and infection control practices during wound care to prevent potential infection for 1 of 3 resident's reviewed for pressure ulcers. (Resident 24) Finding includes: During an interview on 6/23/25 at 2:53 p.m., Resident 24 was in bed with a urinary drainage bag hung on the right side of the resident's bed. His door contained an Enhanced Barrier Precaution (EBP) sign. The sign indicated providers and staff must perform hand hygiene and wear gloves and a gown for high-contact care activities. Resident 24's clinical record was reviewed on 6/24/25 at 2:53 p.m. Diagnoses included obstructive uropathy, infection and inflammatory reaction due to indwelling urethral catheter, and a personal history of other infectious and parasitic diseases. Current orders included staff were required to use enhanced barrier precautions, wearing a gown and gloves at minimum during high contact care activities, cleanse moisture acquired skin damage (MASD) to the groin with wound cleanser or normal saline, pat dry, apply skin prep around the wound and Nystatin (wound treatment) twice daily, and leave open to air (6/10/25). A 5/2/25, quarterly, Minimum Data Set (MDS) assessment indicated the resident was cognitively intact. The resident used a wheelchair for mobility. He required an indwelling catheter, moderate assistance from staff for personal hygiene, and substantial assistance from staff for toileting hygiene and lower body dressing. Skin problems included MASD. Skin interventions included a pressure reducing device for the bed and chair and application of nonsurgical dressings with or without topical medications. The clinical record lacked a care plan for enhanced barrier precautions. During a wound care observation on 6/25/25 from 2:14 p.m. to 2:31 p.m., the resident's door had an EBP sign upon entry to the room. Unit Manager 10 placed wound care supplies on an overbed table at the foot of the bed, performed hand hygiene, and donned gloves. A gown was not worn. With gloved hands, she moved the overbed table with supplies to the left side of the bed, pulled the blind cord with her right hand, pulled the light cord with her right hand as she leaned in against the resident's linens with her clothing, unsecured the resident's brief, and used both hands to raise the resident's bed with the bed control. Unit Manager 10 asked the resident to turn further onto his right side and an open macerated skin wound was noted to the left lower gluteal fold without any dressing or treatment in place. The resident explained to the nurse a treatment had not been in place for a couple of days. Without performing hand hygiene or changing gloves, Unit Manager 10 picked up the gauze in her right hand, sprayed it with wound wash, cleansed the wound with the gauze, then patted it dry with dry gauze in her right hand. While cleansing the wound, Unit Manager 10's left bare arm was against the resident's bed linens and her right pant leg was against the resident's urinary catheter tubing. She doffed her gloves, performed hand hygiene, donned gloves, measured the wound, applied skin preparation around the wound, then applied a bordered foam dressing to the left lower buttock fold. The gloves were doffed and hygiene was performed after the dressing was applied. During an interview on 6/25/25 at 2:55 p.m., Unit Manager 10 indicated Resident 24 required EBP during high-contact cares. She should have worn a gown and gloves during the wound observation and forgot because she was focused on the treatment. A gown and gloves were required during high contact care for residents who required EBP. She should not have touched potentially contaminated surfaces with her gloved hands and continued with wound care. On 6/26/25 at 9:50 a.m., Wound Nurse 11 indicated she was familiar with Resident 24's wound care as he had MASD to his left lower buttock fold. She indicated EBP required staff to wear a gown and gloves during wound care. After touching any surfaces with gloved hands, staff were required to doff the gloves, perform hand hygiene, and don a clean pair of gloves prior to touching the resident and continuing with the wound care to prevent infection. On 6/26/25 at 10:46 a.m., Administrator 2 indicated staff who provided wound care to residents in EBP were required to wear a gown and gloves. Hand hygiene and gloves changes were required after touching surrounding surfaces with gloved hands and prior to providing wound care A current facility policy, revised 4/1/24, titled Enhanced Barrier Precautions (EBP) Standard Operating Procedure, provided by Administrator 1 on 6/26/25 at 10:50 a.m., indicated the following: OVERVIEW . Guidance for enhanced barrier precautions (EBP) to decrease risk of becoming colonized and developing infections with multidrug-resistant organism (MDRO) status. EBP does not replace existing guidance regarding the use of Contact precautions for other pathogens . SOP DETAILS . 1. Enhanced Barrier Precautions (EBP) will be in place during high-contact care activities for residents with the following conditions: a. Residents at an increased risk of MDRO acquisition which include: i. All Residents with chronic wounds . ii. All Residents with indwelling medical devices 1. Includes but not limited to: catheters, central lines, feeding tubes, tracheostomy tubes . 2. Personal Protective Equipment (PPE) should be used even if blood and body fluid exposure is not anticipated. a. At minimum, staff shall wear gloves and gowns during high-contact care activities 3.1-18(b)(2) 3.1-18(l)

Based on observation, interview, and record review, the facility failed to notify the provider of an abnormal urine culture, resulting in a delay of care for 1 of 2 residents reviewed for urinary catheters. (Resident 33) Finding includes: Resident 33's clinical record was reviewed on 6/26/25 at 8:43 a.m. Diagnoses included obstructive and reflux uropathy, chronic kidney disease stage 3, hydronephrosis with renal and ureteral calculous obstruction, and bacteremia. Current orders included indwelling urinary catheter for neurogenic bladder (8/19/24), urinalysis complete one time (6/16/25), urine culture one time (6/16/25), ceftriaxone (antibiotic) 2 gram reconstitued solution inject 2 gram once daily (6/26/25). Review of a urinalysis, collected 6/16/25, indicated an abnormal result. The abnormal result was reported to the facility on 6/17/25. Review of the urine culture, collected 6/16/25, indicated an abnormal result of >100,000 colony forming units per milliliter (CFU/ml) of Hafnia alvei (bacteria) and 50,000 - 100,000 CFU/ml of Excherichia coli (bacteria). The abnormal result with sensitivity was reported on 6/20/25 at 8:45 a.m. The clinical record lacked indication the results were reported to the medical provider and lacked indication of treatment for the urinary tract infection from 6/20/25 until 6/26/25. During an interview on 6/27/25 at 12:59 p.m., RN 7 indicated Resident 33's last abnormal urinalysis was reported to the facility on 6/17/25 and the abnormal urine culture with sensitivity resulted on 6/20/25. She was unable to find indication that treatment started for the resident's urinary tract infection until 6/26/25. Timely treatment should have been initiated within eight hours of the reported abnormal results. On 6/27/25 at 1:28 p.m., the DON indicated she was unable to identify that treatment was provided prior to 6/26/25 for the resident's urinary tract infection identified on the 6/20/25 urine culture. On 6/27/25 at 2:13 p.m., the DON indicated the facility was unable to provide information regarding when the provider was notified of the resident's abnormal urine culture result with sensitivity on 6/20/25 for prompt intervention. A current facility policy, revised 12/17/24, titled Physician-Provider Notification Guidelines, provided by Administrator 1 on 6/27/25 at 2:15 p.m., indicated the following: Purpose Statement . The purpose of this policy is to: To ensure the resident's physician or practitioner (may include NP, PA or clinical nurse specialist) is aware of all diagnostic testing results or change in condition in a timely manner to evaluate condition for need of provision of appropriate interventions for care. Policy . Provider Notification Guidelines .Procedure . 1. Resident assessments for change in condition, suspected injury, event of unknown origin or ordered lab and /or other diagnostic test should be completed in a timely manner . 3. Prompt notification to practitioner of radiology results that fall outside of clinical normal reference range, or reference range for resident. 4. All other test results or order requests may be faxed to the physician/provider's office during office hours. 5. Faxed test results or order requests should indicated the staff member's name sending the results/request and the time sent. 6. During non-office hour times the nurse should notify the physician/provider by phone of abnormal lab results or the need for physician/provider intervention . 8. Diagnostic test results require a response from the physician noting they have reviewed the test results. Test results out of normal range should note whether or not treatment is desired. 9. The physician/provider may return his/her response to the facility by fax or phone. 10. If the facility has not had a response to abnormal test results or request for physician/provider intervention within 12 hours .the nurse on duty will call the physician to obtain further instructions. 11. Attempts to notify the physician/provider and other response should be documented in the resident electronic health record .13. If the attending physician, or their practitioner does not respond to notification attempts the Medical Director and Director of Health Services should be notified for further instructions Cross reference F690. 3.1-49(f)(2)

Based on observation and interview, the facility failed to date open insulin pens/vials, discard expired insulin pens/vials, and label medications with resident identifier information for 4 of 4 medication carts observed for medication storage. (300 hall cart, 2nd 200 hall cart, Legacy Way cart, and 100 hall cart) Finding includes: 1. During a medication storage observation of the 300 hall cart, accompanied by LPN 5, on [DATE] at 9:36 a.m., the following was observed: an unlabeled box of over the counter Coricidin BHP (cough and cold medication) and one unlabeled 30 ounce (oz) tube of Biofreeze (menthol pain gel). LPN 5 indicated she was not sure why these medication were not labeled. Medications without appropriate resident labels should be discarded immediately. 2. During a medication storage observation of the 2nd half 200 hall cart, accompanied by LPN 6, on [DATE] at 9:44 a.m., the following was observed: one unlabelled 100 milligram (mg)/milliliter (ml) vial of furosemide (a diuretic) injection solution, half full and one lispro (insulin) pen dated [DATE], with 135 units remaining. LPN 6 indicated she was not sure which resident utilized the furosemide injection solution. Medications should contain resident identifier labels. The insulin pen was expired and should be discharged . 3. During a medication storage observation of the Legacy Way cart, accompanied by RN 7, on [DATE] at 10:00 a.m., the following was observed: one unlabelled tube of 1% diclofenac sodium (for arthritis pain) topical gel and one undated glargine (insulin) pen, with 140 units remaining. RN 7 indicated insulin was good for 28 days and all insulin pens or vials should be labeled with the open date. All medications kept on the medication cart should contain resident identifier information. Any unlabelled or undated medication should be disposed of immediately. 4. During a medication storage observation of the 100 hall cart, accompanied by RN 8, on [DATE] at 10:22 a.m., the following was observed: one unlabelled fluticasone proprionate (to treat sinus inflammation) nasal spray, one undated Lispro (insulin) pen, with 180 units remaining, one undated Lantus (insulin) pen, with 220 units remaining, one Lantus (insulin) pen dated [DATE], with 100 units remaining, and one Humalog (insulin) pen, dated [DATE], with 220 units remaining. RN 8 indicated insulin expired 28 days after opening and expired insulin should be discarded. He was unsure why the other medications did not have resident labels. During an interview, on [DATE] at 2:34 p.m., the DON indicated the expectation for staff was to ensure all medications contained appropriate resident identifier labels. The staff was expected to date insulin vials or pens when opened. When the staff members provided insulin to residents, they would be expected to check the open date and ensure the medication was not expired. All expired medication were to be disposed of appropriately. A current facility policy, revised 1/17 and titled, Medication Storage in the Facility, provided by the RN Consultant, on [DATE] at 3:33 p.m., indicated the following: .A. The provider pharmacy dispenses medication in containers that meet regulatory requirements, including standards set forth by the United States Pharmacopeia (USP). Medications are kept in these containers . C. All medications dispensed by the pharmacy are stored in the container with the pharmacy label .C. Certain medications or package types, such as IV solutions, multiple dose injectable vials, ophthalmic, nitroglycerin tablets, blood sugar testing solutions and strips, once opened, require an expiration date shorter than the manufacturer's expiration date to insure medication purity and potency .E. The medication administration staff will check the expiration date of each medication before administering it. F. No expired medication will be administered to a resident. G. All expired medication will be removed from the active supply and destroyed in the facility, regardless of amount remaining. The medication will be destroyed in the usual manner . 3.1-25 (j) 3.1-25 (k)

Based on interview and record review, the facility failed to ensure a resident was free of significant medication errors regarding the crushing of non-crushable medications for 1 of 3 residents reviewed for medication administration. (Resident 106) Resident 106's record was reviewed on 6/24/25 at 12:46 p.m. Current diagnoses included, atrial fibrillation, chronic kidney disease, hyperlipidemia, hypertension, and history of rectal cancer with colostomy. Current orders included: pantoprazole (stomach acid reducer) tablet, delayed release/ enteric coated (coated to not dissolve in stomach acid) 40 milligram (mg) twice a day started 6/20/25, potassium chloride (mineral supplement) extended release tablet 20 millequivalents (mEq) give 10 mEq once a day started 6/20/25, and may crush meds or open capsules as needed unless contraindicated, refer to Do Not Crush list. Resident 106's electronic medication administration record (eMAR) was reviewed on 6/27/25 at 10:18 a.m. from 6/20/25-6/26/25. All medications were documented as administered. A nursing progress note dated 6/20/25 at 3:48 a.m. indicated the resident took his medication crushed in applesauce. A progress note dated 6/23/25 at 6:59 p.m. indicated the resident took his medication crushed in applesauce. A pharmacy medication regimen review dated 6/24/25 indicated Resident 106 was listed as a resident who received his medications crushed. Verbiage needed to be added to the administration instructions: Pantoprazole- sprinkle intact granules on one teaspoon of applesauce and swallow within 10 minutes of preparation. Do no crush or chew granules. It was noted in the chart that Resident 106 received his medication crushed, in applesauce. He was currently receiving potassium chloride XR 20 mEq daily. Per Lexicomp (drug reference), extended release potassium tablets should not be crushed. A medication administration observation for Resident 106's pantoprazole and potassium chloride was requested on 6/25/25 at 3:05 p.m. for the morning of 6/26/25 at 8:00 a.m. Administrator 1 indicated she would arrange for the observation in the morning. During an interview on 6/27/25 at 7:46 a.m., Administrator 1 indicated that the medications had already been given by night-shift staff. During an interview with LPN 9 on 6/27/25 at 9:30 a.m., she indicated that all of the resident's medications were crushed in applesauce except for a capsule that was floated in the applesauce. The LPN was unable to recall which medication this was. During an interview with LPN 5 on 6/27/25 at 9:35 a.m., she indicated that potassium chloride should not be crushed and she would normally allow the medication to dissolve in the applesauce or float the tablet. She was unsure if pantoprazole could be crushed. LPN 5 indicated if she was uncertain about crushing medication, she would call the physician for clarification of the order or for an alternative means of administration. During an interview with RN 7 on 6/27/25 at 10:11 a.m., she indicated the resident receives all of his medications crushed in applesauce. If she had a medication that was unable to be crushed, she would call the physician and pharmacy for clarification of the order and document the call in a progress note. A current facility document, received from the DON on 6/27/25 at 10:54 a.m. and titled, Medications Not To Be Crushed, indicated potassium chloride tablets were not to be crushed due to being a time release formulation and pantoprazole tablets were not to be crushed due to being enteric coated. A current facility policy, received from the Administrator on 6/27/25 at 12:58 p.m. and titled, IIA2: Medication Administration-General Guidelines, indicated the following: .Medications area administered as prescribed in accordance with good nursing principles and practices .a. Assure the tablet is appropriate and able to be split. No sustainced-release, enteric coated or unscored tablets should be split. Sustained-release tablets may be initially identified by the name which may contain a suffix such as -SR.-CR.-XR, or a part of the name such as MS Contin, OxyContin, KlorCon .Determining if a tablet can be safely and appropriately split should be based on an official reference list or by contacting the pharmacist prior to splitting any tablet .a. Long-acting or enteric-coated dosage forms should not be crushed;an alternative should be sought .d. Please consult with the product literature or Do Not Crush lists which the facility may have or with the pharmacist if there is a question about medications to be crushed A web article from healthy.kaiserpermanente.org titled, potassium chloride ER 20 mEq tablet, extended release,was reviewed on 6/27/25 at 11:15 a.m. and included the following, Do not crush, chew, or suck on the tablets. Doing so can release all of the drug at once, increasing the risk of side effects including: difficult/painful swallowing, vomit that looks like coffee grounds, stomach/abdominal pain, black/tarry stools A product label from Pfizer Medical for Protonix sodium (brand name for pantoprazole) revised 3/2022 was reviewed on 6/27/25 at 11:17 a.m. and included the following, .Do not split, chew, or crush PROTONIX tablets Do not split, crush, or chew PROTONIX For Delayed-Release Oral Suspension and PROTONIX Delayed-Release Tablets 3.1-48(c)(2)

Based on observation, interview, and record review, the facility failed to ensure catheter care was provided in a manner to prevent contamination and failed to monitor urinary output for 1 of 2 residents reviewed for catheters. (Resident 33) Finding includes: During an observation on 6/23/25 at 3:53 p.m., Resident 33 was sitting up in his wheelchair with a urinary catheter bag hung below his wheelchair. Tea colored urine was observed in the urinary catheter tubing during the observation. During a catheter care observation on 6/25/25 from 11:44 a.m. to 12:00 p.m., upon entry to the room, washcloths and a bottle of peri skin cleanser were placed on the resident's overbed table, without a barrier, next to the resident's personal items, including his lunch tray. CNA 12 entered the resident's restroom, washed his hands, and donned a gown and gloves. With his gloved hands, he picked up the washcloths from the overbed table and took them into the restroom, turned on the faucet, got one cloth wet, turned off the facet, and returned to the resident's overbed table. He placed the washcloths back onto the overbed table at the resident's bedside without a barrier. CNA 12 used both hands to unsecure the resident's brief. With his right hand, he sprayed skin cleanser onto the resident's catheter insertion site, then picked up the wash cloth from the overbed table and wiped from the insertion site outward. He used the dry cloth from the overbed table and moved from the insertion site outwards. The resident's brief was secured back in place. CNA 12 doffed the gloves, performed hand hygiene, and donned new gloves. CNA 12 emptied 750 milliliters (ml) of cloudy straw colored urine from the resident's urinary collection bag. During interview, CNA 12 indicated the aides had a place in the electronic medical record in which they charted the amount of urine output, and a description of the urine. During an interview on 6/25/25 at 4:13 p.m. CNA 13 indicated she was familiar with Resident 33's care. It was not appropriate to place washcloths for catheter care on surfaces without a barrier because it had the potential to cause an infection from cross contamination. Resident 33's clinical record was reviewed on 6/26/25 at 8:43 a.m. Diagnoses included obstructive and reflux uropathy, chronic kidney disease stage 3, hydronephrosis with renal and ureteral calculous obstruction, and bacteremia. Current orders included urinalysis complete one time (6/16/25), urine culture one time (6/16/25), monitor catheter output every shift three times a day (8/16/24), and change urinary catheter as needed based on clinical indications such as infection, obstruction, or when the closed system is compromised (8/16/24) Review of urine outputs from 6/1/25 to 6/27/25 lacked outputs three times daily as ordered on the following dates: 6/5/25, 6/10/25, 6/11/25, 6/18/25, 6/19/25, and 6/24/25. Twelve out of 27 days indicated urinary output documented as small, medium, or large. A 5/27/25, quarterly, Minimum Data Set (MDS) assessment indicated the resident had mild cognitive impairment and used a urinary catheter. The resident required substantial assistance from staff for toileting hygiene and was dependent on staff assistance for lower body dressing, bathing, toilet transfers and footwear. Resident 33's current care plans included the following: A 8/19/24 problem of a urinary catheter for obstructive and reflux uropathy and neurogenic bladder with retention. Interventions included observe for any signs of complication such as a urinary tract infection, urethral trauma, structure, bladder calculi, or silent hydronephrosis and notify the provider (8/19/24), and record the resident's urinary output (8/19/24). A progress note, dated 5/17/25, indicated the resident was started on antibiotic for a urinary tract infection. A progress note, dated 6/26/25, indicated a new order for antibiotic was received due to the resident's urine culture results. During an interview on 6/26/25 at 8:45 a.m., Administrator 2 indicated it was not appropriate to utilize wash cloths that were placed on surfaces without a barrier during catheter care due to potential contamination of the urinary catheter site. On 6/27/25 at 11:47 a.m., CNA 12 indicated he should have used a barrier on the overbed table for the resident's wash cloths to prevent cross contamination during the catheter care observation on 6/25/25. Touching of contaminated surfaces with his gloved hands prior to catheter care without glove changes and hand hygiene was a risk for potential infection. At times, he documented the urinary catheter output as small, medium, and large rather than milliliters. He probably should have documented the catheter urine output in milliliters for an accurate measurement. On 6/27/25 at 12:49 p.m. CNA 12 indicated he did not have a reference guide for documenting catheter urine output in small, medium, and large. It was just a visual of the urinary bag. Small was not much at all to 200 ml, medium was 500 ml to 750 ml, and large was greater than 750 ml. On 6/27/25 at 12:59 p.m., RN 7 indicated urine output should be obtained and recorded three times a day in the clinical record as ordered. Catheter urine output documented as small was one third of the collection bag, medium was half of the collection bag, and large was a full collection bag. On 6/27/25 at 1:28 p.m., the DON indicated catheter urine outputs should have been monitored as ordered and recorded in the clinical record in milliliters. On 6/27/25 at 2:36 p.m., Administrator 1 indicated catheter urine output had not been documented for some dates in June 2025 in Resident 33's clinical record as ordered. A policy for catheter output monitoring was not provided prior to facility exit on 6/27/25. A current facility policy, dated 12/16/24, titled Urinary Catheter Care, provided by Administrator 1 on 6/26/25 at 10:50 a.m., indicated the following: Overview . To prevent infection of the resident's urinary tract. SOP Details . 3. Check the urine for unusual appearance (i.e., color, blood, etc.) . 6. Notify the charge nurse in the event of hemorrhage (bleeding), or if the catheter is pulled out. 7. Maintain an accurate record of the resident's daily output, per campus guidelines . 13 Observe the resident for signs and symptoms of urinary tract infection and urinary retention. Report findings to the charge nurse and/or Director of Health Services . 20. To perform the procedure: a. Place the clean equipment on the bedside stand or over be table. Arrange the supplies so they can be easily reached. b. Wash and dry hands thoroughly . d. put on gloves. e. Wash the resident's genitalia and perineum thoroughly. f. Place soiled linen into designated container. g. Remove gloves and discard into the designated container. Wash and dry your hands thoroughly. h. Put on clean gloves . j. With non-dominant hand . retract the foreskin of the uncircumcised male resident. Maintain the position of this hand throughout the procedure . m. For the male: Use a wipe or washcloth with periwash to cleanse around the meatus. Cleanse the glans using circular strokes from the meatus outward. Change the position of the wipe or washcloth with each cleansing stroke. Return foreskin to normal position. n. Use a clean wipe or washcloth with periwash to cleanse and rinse the catheter from insertion site to approximately four inches outward . 22. Any change in character of urine such as color, clarity and odor or pain should be reported to the nurse 3.1-41(a)(2)

Based on observation, interview, and record review, the facility failed to implement preventative measures following an injury of unknown origin for 1 of 1 residents reviewed for injuries of unknown origin (Resident 24). Findings include: Resident 24's clinical record was reviewed on 8/20/24 at 3:33 p.m. Current diagnoses included dementia and Parkinson's Disease. The resident had an order for one antiplatelet medication, aspirin 81 mg taken one time daily. A 5/8/24, quarterly, Minimum Data Set (MDS) assessment indicated the resident was severely cognitively impaired, had mobility impairment in both the upper and lower extremities, and required staff assistance for bed mobility. A 7/29/24, 12:18 p.m., progress note indicated, while providing care, a CNA had observed a 9.5 centimeter (cm) long by 12 cm wide bruise on the inside of the resident's right knee. The bruise was purple/black in color. The bruise was tender to touch. The charge nurse was informed of the bruise. A 7/29/24, Wound Management Detail Report indicated the resident had a 9.5 cm by 12 cm black and purple bruise. This document was completed by LPN 8. A 7/30/24, Statement of Witness Form indicated LPN 8 had stated she was informed of Resident 24's knee bruise the day before when she had been the nurse on duty for the resident's hall. The form indicated the LPN had identified the bruises most likely likely cause as the resident's legs were contracted (shortening of muscles, tendons, skin, and nearby soft tissues that causes the joints to shorten and become very stiff, preventing normal movement), and his knees were very knobby. Staff placed pillows between his knees when they laid him down, however due to his disease progression, he got restless in bed and kicked/pulled the pillow off. He also used a mechanical lift for transfers and the way the sling positioned with his legs, the sling could have contributed to the bruising. The resident had a current care plan problem/need regarding the potential for bleeding and bruising related to medication. This problem originated 4/1/23. No new approaches were added to this care plan problem following the 7/29/24 bruise. The record lacked care plan interventions or preventative approaches to reduce the risk for knee bruising due to knee contractures, removing the pillow from between his knees, and/or the bruising risk associated with using a full body mechanical lift. During an interview on 8/23/24 at 11:32 a.m., QMA 7 indicated the resident had contractures. She was aware the resident had experienced a recent bruise to his knee. The staff placed pillows between the resident's knees. The resident frequently removed the pillow. She did not know of any updates or changes that had made since the resident had developed a bruise on his knee. Staff just continued to place the pillow between his knees and he sometimes removed or displaced it. She had never received any new or specific information about transferring the resident with a full body lift in a manner to reduce bruising. During an interview on 8/23/24 at 11:23 a.m., the Administrator and Assistant Director of Nursing both indicated related to Resident 24's injury, the root cause analysis had identified the most likely cause to be contractures to the knees, restless leg, removing the pillow between his knees, and the use of an anticoagulant medication as the medically likely cause of the bruising. During an interview on 8/23/24 at 11:48 a.m., the Administrator indicated the facility had not developed and implemented new approaches to prevent recurrence of bruising after completing the root cause analysis identified contractors, rubbing knees together, and knees touching while transferring in a mechanical full body lift were the most likely causes of the bruising on the resident's legs. 3.1-35(a)

Based on observation, interview, and record review, the facility failed to ensure physician's orders were followed regarding oxygen administration for 1 of 1 resident reviewed for respiratory care. (Resident 261) Findings include: During an observation, on 8/19/24 at 1:28 p.m., Resident 261 was lying in bed, eyes closed. He was wearing a nasal cannula. The oxygen concentrator was on at 3 liters per minute. During an observation, on 8/20/24 at 9:55 a.m., he was lying in bed. The head of the bed was elevated 90 degrees. He was wearing a nasal cannula. The oxygen concentrator was on at 3.5 liters per minute. During an observation, on 8/20/24 at 11:30 a.m., the resident was seated upright in bed. He was not wearing a nasal cannula. An oxygen mask was lying across his lap. During an interview, at the time of the observation, he indicated he had a heart attack earlier in the week and the doctor had him using oxygen for a few days. During an observation, on 8/21/24 at 10:19 a.m., Resident 261 was lying in bed. He was not wearing a nasal cannula. During an interview, at the time of the observation, he indicated he was a little short of breath. During an observation, on 8/21/24 at 3:35 p.m., the resident was seated upright in his bed visiting with family. He was not wearing a nasal cannula. During an interview, at the time of the observation, he indicated he did not feel well. During an observation, on 8/22/24 at 8:32 a.m., Resident 261 was lying in bed. He was not wearing a nasal cannula. The oxygen concentrator was off and against the wall by the head of bed. Resident 261's clinical record was reviewed on 8/21/24 at 4:05 p.m. Diagnosis included metabolic encephalopathy, unspecified atrial fibrillation, essential hypertension, and unspecified sepsis. The resident's admitted d was 8/16/24. A current physician's order, dated 8/19/24, indicated the following: send to emergency room if oxygen saturation is below 85 % on 4 liters per minute of oxygen or if mental status changes. A respiratory care plan, initiated 8/19/24, indicated to administer oxygen per physician's order and as needed and to elevate head of bed or place in upright position as needed. A vital sign record, on 8/19/24 at 11:31 p.m., indicated the resident's oxygen saturation was at 95%, and the resident was on 2 liters of oxygen per minute. A vital sign record, on 8/20/24 at 11:36 p.m., indicated the resident's oxygen saturation was at 95%, and the resident was on 2 liters of oxygen per minute. A vital sign record, on 8/21/24 at 11:18 p.m., indicated the resident's oxygen saturation was at 96%, and the resident was on 2 liters of oxygen per minute. A physician's progress note, dated 8/21/24 at 9:56 p.m., indicated the resident had an acute hypoxia episode during breakfast on Monday, 8/19/24 and was started on oxygen at 4 liters per minute. The plan was to wean the resident off the oxygen as tolerated but to send to the emergency room if oxygen saturation is below 85 % on 4 liters per minute of oxygen or if oxygen saturation is below 90% on room air. During an interview, on 8/22/24 at 8:45 a.m., RN 5 indicated Resident 261 did not wear oxygen and she was aware of the order to send him to the emergency room if his oxygen saturation was below 85% on 4 liters per minute of oxygen. During an interview, on 8/22/24 at 8:47 a.m., the ADON indicated she would need to call the physician and get clarification for the order as the resident was not wearing oxygen at this time. During an interview, on 8/22/24 at 3:00 p.m., Corporate Nurse Consultant indicated the order for Resident 261 to wear oxygen should have been a one time order related to his cardiac event earlier in the week and needed discontinued. She was not able to locate a titration order for the resident. A current facility policy, reviewed 12/31/23 and titled, Guidelines for Medication Orders, provided by the DON on 8/23/24 at 11:15 a.m., indicated the following: .2. A current list of orders will be maintained in the electronic medical record or each resident 6. Oxygen orders a. When recording oxygen orders specify: 1. The rate of flow, route, and rationale (i.e: 02, 2L/min per nasal cannula PRN for SOB.) . 3.1-47(a)(4)

Based on interview and record review, the facility failed to ensure consistent documentation and communication related to a resident's choice for advance directives for 1 of 8 residents reviewed for advance directives (Resident 35). Finding include: Resident 35's record was reviewed on [DATE] at 2:26 p.m. Diagnoses included rhabdomyolosis, severe sepsis with septic shock, acute respiratory failure with hypoxia, type 2 diabetes mellitus with diabetic chronic kidney disease, and unspecified dysphagia. A physician order, dated [DATE], included a code status of Full Code (perform Cardiopulmonary Resuscitation or CPR). A current face sheet indicated he was a full code. A current electronic Continuity of Care document in the electronic health record indicated he had signed a Do Not Resuscitate (DNR) form. The resident's current code status care plan, dated [DATE], indicated that the resident/ resident representative had chosen his advance directives to include a code status of full code and those advance directives would be honored. Reviews to the advance directives were to be completed quarterly and as needed. A Nurse Practitioner's progress note, dated [DATE], indicated the resident's code status was reviewed with the resident. It indicated he was a full code and his code status was reviewed and updated. During an interview, on [DATE] at 2:51 p.m., the DON indicated when evaluating a code status for a resident in need of CPR, she looked for verification in the Continuity of Care document. This was the location where she educated nursing staff to look for a resident's code status. The DON verified Resident 35's Continuity of Care document, signed by the resident, indicated he did not want CPR and was a DNR. However, his face sheet and his physician's order both indicated a Full Code status. These discrepancies would make it difficult to assess the resident's wishes in the event of need for CPR and should all list the same status. During an interview, on [DATE] at 2:58 p.m., LPN 6 indicated he verified a resident's code status from the face sheet. Resident 35's face sheet listed him as a full code which meant if needed, staff would perform CPR on Resident 35. LPN 6 would initiate CPR on any resident until the code status was proven to be a DNR. A current facility policy, dated [DATE] and provided by the DON on [DATE] at 2:53 p.m., titled Guidelines for Advance Directives, indicated the purpose of the care plan was .to ensure facility staff obtains and follows resident's advance directives regarding end of life care nursing staff will obtain an order from the attending physician for the desired code status Designation of code status and obtainment of physician order will be part of the medical record 3XXX,d+[DATE](f)(8)

Based on record review and interview, the facility failed to ensure narcotic reconciliation per facility policy for 2 of 3 medication carts reviewed for medication storage. (100 Hall and 300 Hall) Finding include: 1. During a medication storage observation of the 100 hall cart, accompanied by LPN 9 on 8/23/24 at 9:49 a.m., the Narcotic Count Sheet record was reviewed and the following dates lacked shift to shift reconciliation of controlled medications: In July 2024- 7/1/24- on day and night shifts, 7/6/24- on day shift, 7/7/24- on evening shift, 7/10/24- on day and evening shifts, 7/16/24- on night shift 7/17/24- on evening shift, 7/19/24- on evening shift, 7/20/24- on all three shifts, 7/25/24- on all three shifts, 7/26/24- on all three shifts, 7/27/24- on all three shifts, 7/28/24- on all three shifts, 7/29/24- on all three shifts, 7/30/24- on all three shifts, 7/31/24- on all three shifts. In August 2024- 8/2/24- on evening shift, 8/3/24- on evening shift, 8/4/24- on evening shift, 8/5/24- on evening shift, 8/7/24- on evening shift, 8/10/24- on all three shifts. 2. During a medication storage observation of the 300 hall cart, accompanied by LPN 10 on 8/23/24 at 11:04 a.m. the Narcotic Count Sheet record was reviewed and the following dates lacked shift to shift reconciliation of controlled medications: In July 2024- 7/4/24- on evening shift, 7/6/24- on day shift, 7/7/14- on night shift, 7/8/24- on evening shift, 7/12/24- on evening shift, 7/13/24- on night shift, 7/14/24- on day shift, 7/15/24- on day and evening shifts, 7/16/24- on day shift, 7/22/24- on evening shift, 7/23/24- on day and evening shifts, 7/29/24- on evening shift, 7/30/24- on evening shift, 7/31/24- on evening shift. In August 2024- 8/1/24- on all three shifts, 8/3/24- on night and evening shifts, 8/4/24- on evening shifts, 8/5/24- on evening shifts, 8/13/24- on evening shifts, 8/14/24- on night and evening shifts, 8/15/24- on day and evening shifts, 8/16/24- on night and day shifts, 8/17/24- on evening shift, 8/18/24- on evening shift, 8/19/24- on evening shift. During an interview, at the time of the observation, LPN 10 indicated the narcotic sign in/sign out sheet was to be completed after the narcotic medication count and with the exchange of keys. During an interview, on 8/23/24 at 2:08 p.m., the DON indicated the expectation was for the narcotic count sheet to be completed at every shift change and at any time the medication cart keys change hands. The DON indicated she was not able to locate any additional count sheets. A current facility policy, reviewed on 12/31/23, titled, Guidelines for Narcotic Count, provided by the DON on 8/23/24 at 11:15 a.m., indicated the following: . 2. The narcotic book shall contain a sheet providing space for the off going and oncoming nursing staff to record their signature indicating the narcotics have been reviewed 5. Both staff members shall sign that the narcotic count is accurately reconciled 3.1-25(b)(3)

Based on record review and interview, the facility failed to ensure staff reported allegations of abuse to the Administrator immediately per facility policy. This resulted in a delay in the reporting of allegation to the appropriate state agencies and initiation of an investigation for 1 of 2 residents reviewed for abuse. (Resident B) Findings include: The clinical record for Resident B was reviewed on 8/9/24 at 10:12 a.m. Diagnoses include urinary tract infection, hypertensive heart disease with heart failure, osteoporosis, and rheumatoid arthritis. The most current admission Minimum Data Set assessment (MDS), dated [DATE], indicated the resident was cognitively intact. The facility reportable, dated 7/8/24, indicated an allegation was received through a call from a family member regarding care concerns involving CNA 3. During an interview on 8/9/24 at 10:41 a.m., LPN 1 indicated, on 7/6/24, Resident B had complained to her about care received from CNA 3. LPN 1 assessed the resident for signs of physical injury. LPN 1 instructed CNA 3 to not enter Resident's B room for the remainder of the shift and instructed the other staff to provide care in pairs for Resident B. LPN 1 indicated she failed to report the allegation to the Administrator. During an interview on 8/9/24 at 2:00 p.m., the Administrator indicated they were made aware of the allegation on 7/8/24 (2 days after the alleged incident). The resident's family called the Administrator to verbalize the concern. The Administrator indicated staff had not reported the allegation per facility policy and regulation. The investigation was initiated once the Administrator had been made aware and CNA 3 was suspended pending investigation. During the survey, Resident B declined an interview with the surveyor. During the survey, CNA 3 was not available for interview. Review of CNA 3's time report indicated the CNA worked 32 hours after the allegation was made by Resident B. A current policy, dated 8/29/2019, titled Abuse and Neglect Procedural Guidelines and provided by the Administrator on 8/9/24 at 10:08 a.m., indicated the following: d. Identification ii. Any person with knowledge or suspicion of suspected violations shall report immediately, without fear of reprisal. iv. IMMEDIATELY notify the Executive Director. If the Executive Director is absent they may appoint a designee. e. Protection iv. Suspend suspected employee(s) pending outcome off investigation. This citation relates to Complaint IN00438284. 3.1-28(c)

Based on record review and interview the facility failed to ensure staff were providing resident care within their scope of practice for 3 of 4 residents reviewed for wound care. (Residents B, C,G, QMAs 1, 2, 3, 4 , and 5) Findings include: 1. The clinical record for Resident B was reviewed on 1/4/24 at 2:05 p.m. Diagnoses included Parkinson's disease, stage 3 chronic kidney disease with heart failure, type 2 diabetes, and stage 3 pressure ulcers. Review of the resident's orders indicated a wound care order , dated 12/11/23. The order was to clean the wound with wound cleaner or normal saline, then apply skin prep and cover with foam dressing. Dressing was to be changed every 3 days. Review of Resident B's Treatment Administration Record (TAR) for January 2024 indicated wound care for a pressure injury to the coccyx, dated 12/12/23, was completed by a Qualified Medication Aide (QMA) on 1/1/24, 1/2/24, 1/4.24, 1/5/24 and 1/6/24. Wound care for a pressure injury to the right buttocks was completed by a QMA on 1/1/24 and 1/4/24. QMAs who documented they had completed the wound treatment were QMAs 2, 3, 4, and 5. 2. The clinical record for Resident C was reviewed on 1/5/2024 at 12:19 p.m. Diagnoses included repeated falls, pressure ulcer, chronic obstructive pulmonary disease, and chronic kidney disease. Review of the resident's orders indicated a wound care order for the right ankle, dated 12/11/23. The order was to clean the wound with wound cleaner or normal saline then apply skin prep. Apply calcium alginate to the wound bed and cover with foam dressing. Review of Resident C's TAR for January 2024 indicated wound care for a pressure injury to the coccyx was completed by a QMA on 1/3/24 and 1/6/24. Wound care to the right ankle was completed by a QMA on 1/1/24, 1/2/24, /13/24, 1/4/24, 1/6/24 and 1/7/24. QMAs who documented they had provided wound treatment QMAs 2, 3, and 5. 3. The clinical record for Resident G was reviewed on 1/5/24 at 2:30 p.m. Diagnoses included pressure ulcers, anemia, coronary artery disease, hypertension, hypothyroidism, and malnutrition. Review of the resident's orders indicated a wound care order for the right foot webbing between the 4th and 5th toe. The order was dated 12/21/23. The order indicated the wound was to be cleaned with wound cleaner or normal saline, then apply gauze soaked with breadline between toes. Review of Resident G's TAR for January 2024 indicated wound care was completed by a QMA on 1/1/24, 1/3/24, 1/4/24 and 1/5/24. QMAs who documented they had provided wound treatment were QMA 1 and QMA 3. During an observation on 1/8/24 at 12:55 p.m., Resident G's pressure areas were open areas, with scabbing present. The surrounding skin was red, with drainage present. The Corporate Nurse Consultant confirmed the observation findings. During an interview on 1/5/24 at 12:11 p.m., QMA 1 indicated providing wound care was not within their scope of practice. QMA 1 denied providing care outside of their scope of practice. During an interview on 1/8/24 at 9:38 a.m., QMA 2 indicated providing wound care was not within their scope of practice. QMA 2 denied providing care outside of their scope of practice. During an interview on 1/8/24 at 2:41 p.m., QMA 3 indicated providing wound care was not within their scope of practice. QMA 3 denied providing care outside of their scope of practice. During an interview on 1/8/24 at 2:56 p.m., QMA 5 indicated providing wound care was not within their scope of practice. QMA 5 denied providing care outside of their scope of practice. During the survey, QMA 4 could not be reached for interview. During an interview and observation on 1/8/24 at 12:55 p.m., the Corporate Nursing Consultant indicated it was the expectation of the facility that all staff provide resident care within their scope of practice. QMA were authorized to apply topical medications on intact skin. If the skin was not intact, QMAs could not provide wound care. Review of a current policy, dated 11/18, titled Medication Administration-General Guidelines was provided by the Corporate Nursing Consultant on 1/8/24 at 4:14 p.m. The Corporate Nursing Consultant indicated this policy applied to the provision treatments as well as medication administration. The policy indicated the following: Policy Medications are administered as prescribed in accordance with food nursing principles and practices and only by persons legally authorized to do so. B. Administration 1) Medications are administered only by licensed nursing, medical, pharmacy or other personnel authorized by state laws and regulation as to administer medications. D. Documentation (including electronic) 1. The individual who administers the medication dose records the administration on the resident's MAR [Medication Administration Record] directly after the medication is given. At the end of each medication pass, the person administering the medications reviews the MAR to ensure necessary doses were administered and documented. In no case should the individual who administered the medications report off-duty without first recording the administration of any medication This citation relates to Complaint IN 00425466. 3.1-14(j)

Based on observation, record review an interview the facility failed to ensure infection control protocol was followed during a dressing change observation for 1 of 3 residents reviewed for wound care. (Resident B) Findings include: The clinical record for Resident B was reviewed on 1/4/24 at 2:05 p.m. Diagnoses included Parkinson's disease, stage 3 chronic kidney disease with heart failure, type 2 diabetes, and stage 3 pressure ulcers. Review of the resident's orders indicated a wound care order , dated 12/11/23. The order was to clean the wound with wound cleaner or normal saline, then apply skin prep and cover with foam dressing. Dressing was to be changed every 3 days. During an observation of wound care on 1/5/24 at 11:34 a.m., LPN 7 provided a dressing change and wound care for a stage 3 pressure area on Resident B's coccyx. LPN 7 washed her hands with soap and water then donned gloves and removed the old dressing. She then cleaned the wound and applied the medication and covered the wound with a new dressing. The wound treatment was provided per physician order, however the nurse did not change her gloves throughout the procedure and did not follow proper hand hygiene protocol. The Corporate Nurse Consultant and the Director of Nursing were present and assisting during the procedure. During an interview on 1/5/24 at 12:03 p.m., the Corporate Nurse Consultant indicated LPN 7 had been nervous during the observation and she realized she had not used proper hand hygiene and glove use during the procedure. LPN 7 had been re-educated. During an interview on 1/8/24 at 10:01 a.m., LPN 7 indicated she had been nervous during the dressing change observation of Resident G. She indicated she should have washed her hands after removing the old dressing. She should have washed her hands and donned clean gloves before medicating the wound and applying the new dressing. Review of a current policy, dated 5/23/2016, titled Dressing Changes, provided by the Administrator on 1/5/24 at 12:22 p.m. The policy indicated the following: Overview To ensure measures that will promote and maintain good skin integrity while maintaining standard measures that will minimize/control contamination. 3. Remove old adhesive with adhesive remover, if necessary, 4. Wash hands with soap and water. 5. Open dressing pack. 6. put on first pair of disposable gloves. 7. Remove soiled dressing and discard in plastic bag or trash can. 8. Dispose of gloves in plastic bag or trash can. 9. Wash hands with soap and water. 10. Put on second pair of disposable gloves This citation relates to Complaint IN00424262. 3.1-40(a)(2)

Based on observation, interview, and record review, the facility failed to ensure hospice communication between the facility and hospice provider was complete, accurate, and readily accessible to staff for collaboration of care for 1 of 6 residents reviewed for hospice. (Resident 15) Finding includes: During an observation on 9/19/23 at 11:35 a.m., the resident was in bed in his room. His eyes were closed and the resident had an unkempt appearance with 1/4 inch to 1/2 inch of hair stubble on his face. During a interview on 9/20/23 at 11:04 a.m., the resident indicated he was not happy with hospice services, as he could not count on them. He had services provided once a week by a hospice staff member. The hospice group was supposed to provide his bed baths. Facility staff did not bathe him on the days when hospice did not provide bathing. He preferred his bed bath twice a week. During the observation of the resident in his bed, his facial hair remained unkempt and between 1/4 inch to 1/2 inch hair growth on his face. Resident 15's clinical record was reviewed on 9/21/23 at 4:41 p.m. Diagnoses included heart failure, chronic kidney disease and other depressive episodes. A current order, dated 3/30/22, indicated hospices services were ordered. A quarterly Minimum Data Set assessment, dated 7/4/23, indicated the resident was cognitively intact. He was totally dependent on staff for bathing and frequently incontinent of bowel and bladder. The resident had a life expectancy of less than 6 months. A current care plan, dated 7/18/23, indicated the resident required hospice care related to hypertensive heart and chronic kidney disease with heart failure. Interventions included the following: coordinate care with the hospice provider - Number of days visited weekly by hospice nurse and aide: 3 (6/23/21), identify the care to be provided by the facility and hospice agency (6/23/21), provide basic comfort measures (6/23/21), and coordinate the plan of care with the hospice agency (6/23/21). During an observation on 9/21/23 at 4:34 p.m., the resident was up in his wheelchair in the hallway outside of the dining room. He was well groomed during the observation, without any facial hair. A review of shower sheets indicated college students provided a complete bed bath on Thursday 9/21/23. On 9/22/23 at 2:27 p.m., the resident's hospice binder was reviewed. The Facility Communication Log was included only three dates the resident had received services from the hospice provider: 8/25/23, 9/13/23 and 9/21/23. The binder lacked current visit notes. The following visit notes were the last visit notes available to staff for reference: Hospice Plan of Care, dated 7/5/23 (benefit period ended 8/11/23), Chaplain Visit Note, dated 8/28/23, Hospice Aide Visit Note, dated 8/25/23, Hospice Skilled Nurse Visit Note, dated 8/30/23, Hospice Social Worker Note, dated 8/8/23. The last IDG (Hospice Team Meeting) Summary Report, dated 7/24/23, indicated the resident had hospice aide services provided twice a week. It did not indicate how often the resident would have visits from the hospice skilled nurse and the hospice social worker. During an interview on 9/22/23 at 4:05 p.m., LPN 3 indicated the resident received his bathing by hospice on Wednesdays and Saturdays. She referenced the resident's hospice binder to determine if his shower services were provided, as hospice communicated the information on their visit notes in the binder. Current visits regarding showers were not in the hospice binder when reviewed during the interview. During an interview on 9/22/23 at 4:25 p.m., LPN 2 indicated she and the hospice providers were responsible to ensure hospice communication binders were kept current for staff reference during their shift. During an interview on 9/22/23 at 4:38 p.m., the Corporate Nurse Consultant indicated hospice communication should have been kept current in the resident's hospice binder for staff reference and continuity of care. During an interview on 9/25/23 at 1:49 p.m., the Hospice Care Consultant indicated she typically placed the visit notes in the resident's hospice binders for her hospice company weekly. The IDG Notes were done every two weeks. Hospice recertification should have been updated every 60 days and placed in the resident's hospice binder at the facility. The hospice staff had not signed in on the communication log for all of their visits to indicate the services were provided. The hospice communication between the facility and the hospice provider had not been kept current for the staff's reference because the hospice company was short on staff. The last visit notes in the binder, mentioned above, were delinquent as well as the Hospice Plan of Care and recertification date. She was made aware of the delinquent communications in the resident's hospice binder by the Hospice Case Manager on 9/13/23 but still failed to get the information updated. Resident 15 was scheduled to have hospice skilled nursing visits twice each week and hospice aide visits once weekly. The hospice aides were responsible for the resident's showers when they visited. Showers were not provided during the hospice skilled nursing visits. During an interview on 9/26/23 at 1:35 p.m., the Corporate Nurse Consultant indicated the facility lacked a facility policy regarding hospice services communication. A current facility document, dated January 2018, titled NURSING FACILITY HOSPICE SERVICES AGREEMENT, provided by the DON on 9/22/23 at 5:17 p.m., indicated the following: . 2.3 Plan of Care (a) Establishment of Plan of Care . All Hospice Services provided must be in accordance with the Plan of Care developed for each Resident . 2.6 Manner of Communication . All communication between the Hospice and Nursing Facility pertaining to the care and services provided to the Resident Patient shall be documented in the Resident Patient's clinical record . 3.8 Coordination of Services. The Nursing Facility Designee shall be responsible for (a) collaborating with Hospice representatives and coordinating Nursing Facility staff participation in the Hospice care planning process; (b) communicating with Hospice representatives . to ensure quality of care of the patient and family; (c) ensuring that the Nursing Facility communicates with the Hospice Medical Director, the patient's Attending Physician, and other practitioners participating in the provision of care to the patient as needed to coordinate the hospice care with the medical care provided by other physicians; and obtaining the following information from the Hospice: (i) the most recent Hospice plan of care specific to each patient . (iii) physician certification and recertification of the terminal illness specific to each patient

Based on record review and interview, the facility failed to offer and provide pneumococcal immunizations per Center for Disease Control (CDC) guidelines for 3 of 5 residents reviewed for immunizations. (Residents 6, 3, and 10) Findings include: 1. Resident 6's clinical record was reviewed on 9/21/23 at 2:01 p.m. The resident admitted on [DATE]. Diagnoses included acute on chronic diastolic congestive heart failure, stage four chronic kidney disease, asthma, and respiratory failure. She received the Pneumovax 23 (immunization for pneumonia) on 1/1/2007, when she was over [AGE] years of age. The clinical record lacked information regarding refusals or dates of offers of additional recommended pneumococcal doses. 2. Resident 3's clinical record was reviewed on 9/21/23 at 1:42 p.m. The resident admitted on [DATE]. Diagnoses included aphasia following cerebral infarction, heart failure, and vascular dementia. She declined a pneumococcal vaccination on 4/11/2017, when she was over [AGE] years of age. The clinical record lacked information regarding refusals or dates of offers of additional recommended pneumococcal doses. 3. Resident 10's clinical record was reviewed on 9/20/23 at 2:45 p.m. Diagnoses included Parkinson's disease, heart failure, dysphasia, and bi-polar disorder. He declined a pneumococcal vaccination on 2/25/2020, when he was over [AGE] years of age. The clinical record lacked information regarding refusals or dates of offers of additional recommended pneumococcal doses. During an interview with the Corporate Nurse Consultant on 9/25/23 at 11:24 a.m., she indicated vaccinations were tracked by the Infection Preventionist. The facility followed the CDC guidelines for pneumococcal vaccinations. Residents new to the facility received vaccination consent forms with the admission packet and those consents or declinations were uploaded into the residents electronic medical record (EMAR). She was not able to locate any further information related to residents being offered recommended pneumococcal vaccination. A review of the current facility policy, revised on 7/12/23, titled Guidelines for Influenza, Pneumococcal, and COVID-19 Immunizations, provided by the Corporate Nurse Consultant on 9/19/23 at 1:36 p.m., indicated the following: .Procedures . 12. Pneumococcal vaccinations per CDC recommendations. According to the CDC website page Pneumococcal Vaccination: Summary of Who and When to Vaccinate, at https://www.cdc.gov/vaccines/vpd/pneumo/hcp/who-when-to-vaccinate.html, retrieved on 9/29/23 at 10:15 a.m., indicated the following: .People over [AGE] years of age who have never received any pneumococcal vaccine, give 1 dose of pneumococcal conjugate vaccine 15 (PCV15) or pneumococcal conjugate vaccine 20 (PCV20) and for those that received one dose of Pneumovax 23 to receive 1 dose of PCV15 one year after the original dose 3.1-13(a)

Based on interview and record review, the facility failed to ensure a resident had a PASRR/Preadmission Screening completed upon admission for 1 of 1 residents reviewed for preadmission screening. (Resident 41) Findings include: Resident 41's clinical record was reviewed on 9/8/22 at 10:07 a.m. Current diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was admitted to the facility on [DATE]. The record lacked a PASRR/Preadmission screening. The resident had a 8/1/22 hospital discharge record which indicated: the resident had physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 9/12/22 at 11:23 a.m., the Social Services Director indicated Resident 41 had not had a Preadmission screening/PASRR completed in error. The first screening was not completed due to an error with the social security number. She had intended to resubmit the information, but had forgotten to do so in error. She indicated she had resubmitted the screening on this date 9/12/22. A current, undated, facility policy, titled, PASRR Quick Sheet, provided by the Corporate Nurse Consultant on 9/12/22 at 3:07 p.m., included, but was not limited to, the following: New Admissions: If any of the following triggers a positive response, the Level 1 (MAP 409) will be checked YES .Individual has a severe mental illness/behavioral health (BH) diagnosis.[CONDITION(S)] Disorder, Anxiety Disorder . 3.1-16(d)

Based on observation, interview and record review, the facility failed to ensure a resident who had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . (Resident 17) Findings include: During an interview on 9/08/22 at 12:58 p.m., Resident 17's spouse indicated the resident had a hand splint that had somehow gone to the laundry and not returned. She indicated the brace had been missing about three weeks. She also indicated she had told a laundry worker and a therapy person about the missing splint, and it still had not been located. Resident 17's clinical record was reviewed on 9/07/22 at 9:38 a.m. Current diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident had a current, 6/03/2022, physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident had a current, 3/04/2022, care plan for the resident care profile which listed the services needed by the resident. Approaches to this need included, but was not limited to, Ted Hose/Splints: right hand splint, trough arm on R [right] side W/C [wheelchair]. The clinical record for August 2022 and September 1 to 8, 2022 lacked documentation of the resident refusing to wear his hand splint. In addition, the clinical record lacked a care plan regarding the resident refusing to wear a splint prior to 9/8/22. The behavior monitoring record for, Target Behavior-refusing hand brace for 9/8/22 (date of initiation) to Sunday 9/11/22 lacked documentation of the resident refusing to wear his hand brace for 12 of 12 monitored shifts. During observations on the following dates and times the resident was observed without a hand splint in place: a. During an observation on 9/06/22 at 10:03 a.m., the resident was in his room, seated in a wheelchair. His feet were on the foot rest. He was well groomed in daytime clothing. He was not wearing a hand splint. b. During an observation on 9/06/22 at 10:35 a.m., the resident was in his wheelchair in the lounge during an activity. He was not wearing a hand splint. c. During an observation on 9/06/22 at 1:38 p.m., the resident was awake in bed. He indicated he was trying to take a nap. He was not wearing a hand splint. d. During an observation on 9/07/22 at 9:44 a.m., the resident was seated in a wheelchair in his room. He was dressed for the day. He was not wearing a hand splint. e. During an observation on 9/08/22 at 10:24 a.m., the resident was in the lounge in his wheelchair attending an activity. He was not wearing a hand splint. f. During an observation on 9/08/22 at 12:06 p.m., the resident was seated at a table in the dining room. He was not wearing a hand splint. g. During an observation on 9/08/22 at 12:57 p.m., the resident was in a wheelchair in his room without a hand splint. During an interview on 9/8/22 at 3:27 p.m., the Director of Nursing (DON) indicated Resident 17's hand splint had been found either yesterday or today (9/7/22 or 9/8/22). She indicated she believed the resident had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 3:43 p.m., the Corporate Nurse Consultant indicated the facility did not have a policy specific to the application of splints. 3.1-37

Based on observation, interview and record review, the facility failed to promptly revise the comprehensive care plan to reflect changes as they occurred for 1 of 2 residents reviewed for [CONDITION(S)]. (Resident 1) Findings include: During an interview on 9/6/22 at 2:08 p.m., Resident 1 indicated she had [CONDITION(S)] at the [CONDITION(S)] center in the mornings on Tuesday, Thursday, and Saturday each week. During an observation on 9/8/22 at 11:18 a.m., the resident self propelled down the 200 unit hallway in her wheelchair from her room. She indicated she had not been to [CONDITION(S)] on this date. Resident 1's clinical record was reviewed on 9/8/22 at 3:24 p.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Current physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Complete [CONDITION(S)] Center Communication Observation under 'Other Clinical Observation' and send with resident. A care plan for renal failure, dated 9/16/20, indicated the resident required [CONDITION(S)]. Interventions included, but were not limited to, coordinate care with [CONDITION(S)] center. The care plan lacked interventions for resident refusal of [CONDITION(S)] treatments. A Nurse's Note, dated 7/23/22, indicated the resident refused [CONDITION(S)] on this date. A Nurse's Note, dated 8/6/22, indicated the resident refused [CONDITION(S)] on this date. A Nurse's Note, dated 8/18/22, indicated the resident refused [CONDITION(S)] on this date. A Nurse's Note, dated 9/8/22, indicated the resident refused [CONDITION(S)] on this date. The clinical record lacked documentation of [CONDITION(S)] center notification on the following dates the resident refused [CONDITION(S)]: 7/23/22, 8/6/22 and 8/18/22. During an interview on 9/12/22 at 3:44 p.m., the Corporate Nurse Consultant indicated the [CONDITION(S)] center should have been notified if the resident refused to go to [CONDITION(S)]. During an interview on 9/13/22 at 10:58 a.m., Licensed Practical Nurse (LPN) 5 indicated Resident 1 has been known to refuse [CONDITION(S)] and refused [CONDITION(S)] one day last week. The transportation service, [CONDITION(S)] center, and physician required notification when a resident refused [CONDITION(S)]. The communication should have been documented in the Nurse's Notes. During an observation at the time of interview on 9/13/22 at 11:13 a.m., the Corporate Nurse Consultant reviewed the residents care plan obtained from the clinical record on 9/8/22 and indicated it lacked any care plan interventions regarding [CONDITION(S)] refusals and notifications. Further information was not provided. A current policy, titled, Comprehensive Care Plan Guideline, provided by the Corporate Nurse Consultant on 9/13/22 at 11:25 a.m., included, but was not limited to, the following: PURPOSE .To ensure appropriateness of services and communication that will meet the resident's needs, severity/stability of conditions, impairment, disability, or disease in accordance with state and federal guidelines. PROCEDURES .3. The comprehensive care plan should be . revised to reflect changes in the resident's condition as they occur 6. Comprehensive care plans need to remain accurate and current 3.1-35(b)

Based on observation, interview and record review, the facility failed to ensure a cognitively impaired resident, who was at risk for elopement, received the supervision to prevent elopement from the facility for 1 of 3 residents reviewed for accidents. This failure resulted in the resident being out of the facility without supervision for approximately 30 minutes and picked up by a citizen approximately 1/4 mile from the facility. The citizen then alerted the police. (Resident B) The immediate jeopardy began on 3/1/2018 when the cognitively impaired resident eloped from the facility and was picked up 1/4 mile away by a concerned citizen. The Administrator was notified of the immediate jeopardy on 3/6/2018 at 10:57 a.m. Findings include: The clinical record for Resident B was reviewed on 3/5/2018 at 11:00 a.m. [DIAGNOSES REDACTED]. Review of an admission Minimum Data Set (MDS) assessment, dated 2/18/2018, Resident B was found to be moderately cognitively impaired with poor decision making and cueing required. The MDS also indicated the resident required extensive physical assistance of one for ambulation and the use of a walker. Review of an Admission Assessment, dated 2/2/2018, indicated Resident B was at risk for elopement. Review of an Admission Assessment, dated 2/11/2018, indicated Resident B was at risk for elopement. Review of an event for new or worsening behaviors, dated 2/17/2018, indicated the following: Resident still continues to wander. Has wander-guard alert bracelet in place. Resident can be redirected most of the time. Family very supportive and will come and sit with resident when needed. Family educated on the need of secured unit. Review of a nursing note, dated 2/22/2018 at 12:32 p.m., indicated the resident was wandering hallways and at times hard to redirect. The note also indicated the wader-guard was placed on the resident's left ankle because she had removed it from her wrist earlier. A Progress Note, dated 2/22/2018, indicated the resident was exit seeking and stated she needed to go home. A Progress Note, dated 2/27/2018, indicated there was a Care Plan Meeting with the family present. The facility indicated, to the family, the resident needed to be in an locked memory care unit. The family was going to discuss and make a decision. Review of a nursing note, dated 2/23/2018 at 6:21 a.m., indicated the resident continued to wander the hallways and was confused to person, place and time. Review of the Progress notes for 3/1/2018 indicated the following: At 2:35 a.m., the resident came to the nurses station with her coat stating she was going home. The resident was confused, but able to be redirected. At 2:45 a.m., the resident was checked on. At 4:20 a.m., the resident was checked on. At 5:15 a.m., the resident checked on. At 5:47 a.m., the facility was notified of the resident's elopement. Review of a nursing note, dated 3/1/2018 at 6:15 a.m., indicated at approximately 5:50 a.m. the facility was called and informed the resident had eloped from the facility indicated the temperature at the time was 51 degrees and drizzling. The resident was wearing a sweatshirt, cardigan and socks and shoes. Review of a Social Services Progress Note dated 3/1/2018 at 9:49 a.m., indicated the resident was reassessed and had a BIMS (Brief Interview for Mental Status) of 4 indicating severe cognitive impairment. Review of the the police report from the local police department indicated they received a call on 3/1/2018 at 5:29 a.m., from a citizen indicating the resident had been seen walking down North(NAME)Road (approximately one quarter of a mile from facility) at approximately 5:25 a.m. The citizen picked the resident up and noted she was very confused and stating she was going to Hartford City. The police were able to confirm the resident was living at(NAME)Woods Health Campus at 5:39 a.m. The facility was called and a staff member transported the resident back to the facility at 5:49 a.m The report lacked any documentation the resident had a walker when found. During an interview on 3/5/2018 at 10:09 p.m., CNA (Certified Nursing Aide) 1 indicated on 3/1/2018 she was getting coffee from the dining room. She observed a contracted transporter outside the front doors and the alarm (was sounding) going off. She indicated she did not see Resident B and assumed the transporter had triggered the alarm by holding the door open too long. The CNA indicated she turned the alarm off and returned to her unit without saying anything to the transporter or reporting the incident to her nurse. The CNA indicated when the door alarms is triggered, staff are instructed to do a sweep of the facility to ensure all the residents are present. During an interview on 3/6/2018 at 9:42 a.m., LPN 2 indicated she worked the night of 3/1/2018 and was aware of the incident and knew the resident. LPN 2 indicated she did not hear the door alarm. She did not know a resident was missing until she was returned to the facility. LPN 2 indicated if she had heard the alarm she would have looked around the building to see if anyone was missing. LPN 2 also indicated the resident was a standby assist with a walker and the resident was confused. The night shift walk her around if she woke up in the middle of the night, they will stop by and talk so LPN 2 could help distract her. During an interview on 3/5/2018 at 6:01 p.m., the Director of Nursing (DON) indicated CNA 1 should have told the nurse about the alarm and they should have done a head count. The DON indicated the facility has ongoing education related to elopements and has elopement drills. The last elopement drill was dated 2/26/2018. During an interview on 3/5/2018 at 6:15 p.m., the facility video of the elopement was reviewed with the Administrator. On the video the resident could be seen banging on the door then exiting the facility by the front door. The contracted transporter was the only other person near the door at the time of the resident's exit. CNA 1 was noted to arrive at the door while the contracted transporter was standing on the other side of the door. The CNA could be seen turning off the alarm and leaving the front door. No time stamp was available on the video. During an interview on 3/6/2018 at 10:12 a.m., the Speech Therapist (ST) indicated she had attempted to do a standard cognitive assessment on the resident. The ST indicated based on the observations and family interviews she found the resident to be severe to profoundly cognitively impaired. Review of a current policy dated 3/20/2017 titled Guideline for Elopement/Missing Resident indicated the following: Purpose: To establish guidelines to report and investigate all reports of elopement/missing persons. It is the responsibility of all personnel to report any resident attempting to leave the premises or suspected of being missing to the charge nurse as soon as practical. Procedure: . 3. Door Alarm Sounding/Missing Resident a. Staff should respond promptly to a sounding door alarm b. The charge nurse, facility supervisor or Executive Director should call staff to a central area and designate the following: i. A staff person to perform a facility head count to determine who may be missing . ThePast Noncompliance Immediate Jeopardy began on 3/1/2018. The Immediate Jeopardy was removed and the deficient practice corrected on 3/2/2018 when the facility completed elopement re-assessments on all residents and re-educated all staff in recognition, prevention and reporting of resident elopement. The correction date was prior to the start of the survey and was therefore Past Noncompliance. This Federal tag relates to Complaint IN 737. 3.1-45(a)(2)

Based on observation, interview and record review, the facility failed to complete thorough root cause analysis after falls, implement interventions associated with the root cause of a fall, update care plans to reflect current fall interventions and ensure interventions were communicated to direct care staff for 3 of 4 residents, who met the criteria for falls (Residents #53, #34 and #1). This deficient practice resulted in a hip fracture from repeated falls for Resident # 53. Findings include: 1. Resident #53's clinical record was reviewed on 4/27/16 at 10:37 a.m. Resident #53's, 4/27/16, [DIAGNOSES REDACTED]. Resident #53 was admitted to the facility on [DATE]. Resident #53 had a, 3/16/16, admission, Minimum Date Set (MDS) assessment which indicated the resident had severe cognitive impairment and rarely or never made decisions, required assistance for transferring from surface to surface, required assistance to safely stand once seated, required assistance for all activities of daily living and had a history of [REDACTED]. Resident #53 had a 3/22/16, care plan problem/need which indicated she was at risk for falls due to a fall history prior to admission. Resident #53 had a 3/25/16, 6:26 p.m., Event Report which indicated: Res (resident) fell @ 6:20 pm in room. Res attempting to self dress for bed. She had fallen in her room. She was transferring herself. The fall was unwitnessed. The resident complained of pain due to a skin tear on her left arm. The resident had cognitive or memory impairment which effected safety or judgement. The 3/25/16, Event Report form additionally indicated the New Interventions added to reduce falls was to help the resident get ready for bed after dinner. The 3/28/16 IDT (Inter Disciplinary Team) Review note, also contained on this form, indicated the a new fall intervention would be to educate resident to use call light to assist with dressing. Resident #53's fall prevention care plan interventions were updated 3/28/16 to remind me to use call light to ask for assistance with dressing. The approach to assist the resident with changing her clothes after dinner was not added to the care plan. Resident #53 had a 4/1/16, 3:08 p.m.,Event Report which indicated: Resident lying on back with head resting on couch. She had fallen in her room. She was transferring herself. She had her walker. The fall was unwitnessed. She had complaints of pain in her right thigh. The resident had horrible, intense pain. The resident had cognitive or memory impairment which effected safety or judgement. The 4/1/16, Event Report form additionally indicated the New Interventions added to reduce falls werebed in lowest position and moved items to easy reach, describe-call light. The form did not indicate the resident was in bed or attempting to get in or out of bed at the time of her fall. The 4/1/16, Event Report form also indicated hip/femur/fibula/tibia x-rays were ordered as a result of this fall. The form did not indicate if the resident had been injured. The form did not contain an IDT note. Resident #53 had a 4/6/16, 2:15 p.m., Resident Progress Note, which indicated the resident was readmitted to the hospital status [REDACTED].R hip incision (with) 15 staples intact. Resident #53 had a 4/13/16, 10:17 p.m.,Event Report which indicated: Resident found on floor in bathroom .CNA had took (sic) resident to the toilet and was told to pull call light when finished. Call was pulled by resident .found resident on the floor. She had fallen in her bathroom. She had attempted to transfer herself. She was in a new room following her recent hospitalization . The fall was not witnessed. The resident had cognitive or memory impairment which effected safety or judgement, the resident had difficulty understanding and following directions and the resident required assistance for transferring. The 4/13/16,Event Report form additionally indicated the New Interventions was awaiting orders from MD (medial doctor). The 4/18/16, IDT (Inter Disciplinary Team) Review note, also contained on this form, indicated the facility will monitor. No interventions regarding toileting or bowel/bladder continence was added to the care plan. The facility did not assess the resident's ability to be left safely in the bathroom without a staff member present. The care plan intervention, added on 4/18/16, after the fall in the bathroom, was I will wear proper, well maintained footwear with transfers and ambulation. The clinical record and Event Report lacked any indication that foot wear or lack there of was a contributing factor to the 4/18/16 fall or any other fall. During a 4/28/16, 12:39 p.m., interview with RN Consultant #20 and the Assistant Director of Nursing, they indicated an approach to remind a cognitively impaired and/ or memory impaired resident to ask for help or use the call light would most likely not be effective due to the resident's limitations. They indicated Resident #53's cognitive status should have been considered when adding fall prevention interventions. They also indicated if lowering the bed was an approach after a fall, the assessment should reflect that the resident was possibly trying to get in or out of bed at the time of the fall. They additionally indicated if foot wear was an added approach after a fall, the assessment should indicate footwear issues may have influenced the fall. The ADON and RN consultant indicated they could not determine why lowering the bed and proper footwear were added as fall prevention approaches following Resident #53's falls. Lastly they indicated that toileting needs and/or toileting assistance was not assessed after Resident #53's fall in the bathroom. During a 4/27/16, 10:51 a.m., observation, Resident #53 was being wheeled down the hallway by therapy staff. Resident #53 was seated calmly in her wheel chair and complied with all requests. During a 4/28/2016, 10:46 a.m., observation, Resident #53 was seated in her wheelchair in the lounge. She was calm and did not attempt to stand. 2. The record of Resident #34 was reviewed on 4/27/16 at 1:54 p.m. Resident #34 had current [DIAGNOSES REDACTED]. Resident #34 had a current, 3/14/16, physician's orders [REDACTED]. Resident #34 had a, 4/10/16, quarterly, Minimum Data Set (MDS) assessment which indicated functional ability of extensive assist with bed mobility, transfers, ambulation, locomotion on and off the unit, dressing, toileting, and personal hygiene. Resident #34 had a current, 4/16/16 care plan problem/need regarding I have a history of falling related to decreased balance. This care plan problem/need originated on 10/14/15. The goal for this problem/need was I will remain free from injury. Approaches to this problem/need included, but were not limited to, please add clip alarm to my chair and pressure alarm to bed to remind me to wait for assistance Resident #34 had a 4/16/16, Fall Circumstance, which indicated resident had a fall leaning forward trying to pick something up off the floor. Resident will have chair alarm replaced with clip alarm to alert staff if resident is leaning forward too far. During a 4/28/16, at 2:03 p.m., observation, Resident #34 was sitting on the side of her bed with her feet on the floor. CNA #15 pulled the wheel chair and placed it beside Resident #34's bed. CNA #15 applied a gait belt to the resident, assisted her to stand and pivot into the wheel chair. CNA #15 asked Resident #34 if she would like to remain in her wheel chair or be transferred into a cloth chair located in the room. Resident #34 indicated she would like to sit in the cloth chair. CNA #15 assisted Resident #34 into the cloth chair where a pad alarm was located on the seat of the cloth chair. She removed the gait belt and asked the resident if she needed anything else. Resident #34 indicated no. CNA #15 left the room. No clip alarm was attached to Resident #34 before CNA #15 left the room. During a 4/28/16, 2:14 p.m., interview, CNA #15 indicated she was unaware of a clip alarm intervention. CNA #15 indicated the interventions were located on the CNA's assignment sheet. During a 4/28/16, 2:24 p.m., interview, Medical Record Personnel #19 indicated she was responsible for updating interventions on the flowsheets for the CNA's. During a 4/29/16, 1:13 p.m., interview, CNA #16 and CNA #17 indicated they viewed the profile of the resident on the computer terminal to know what type of alarm interventions were needed. CNA #16 and CNA #17 looked at Resident #34's profile at the computer terminal. Resident #34's profile indicated a clip alarm to the chair. During a 4/29/16, 1:13 p.m., observation, CNA #17 went to Resident #34's room. No clip alarm was observed attached to the resident. Resident #34 indicated no one had utilized a clip alarm and she had not been informed of a clip alarm intervention. During a 4/29/16, 1:25 p.m., interview, LPN #18 indicated the clip alarm should have been utilized continuously for Resident #34. During a 4/29/16, 1:35 p.m., observation, CNA # 17 applied a clip alarm to Resident #34. A current 4/25/16, facility flowsheet titled, Assignment Sheet, provided by CNA #15 on 4/28/16 at 2:14 p.m., indicated Resident #34's devices were bed and chair alarms. No clip alarm was indicated. 3. A review of the medical record for Resident #1 was completed on 4/25/2016 at 10:46 a.m. Her [DIAGNOSES REDACTED]. A, 3/18/16 quarterly Minimum Data Set assessment indicated Resident #1 was moderately cognitively impaired and was an extensive assist for mobility, transfer and locomotion. During a transfer of Resident #1 with CNA #1 and CNA #5 on 4/28/2016, 2:21 p.m., the following was observed: CNA #1 placed a gait belt around Resident #1 as she assisted her to sit on the edge of the bed. CNA #1 stood in front of Resident #1 and placed her right arm under the resident's right arm and CNA #5 placed her left arm under Resident #1's left arm. Together they transferred Resident #1 to her wheel chair. CNA #5 indicated she always used two people to transfer Resident #1. CNA #1 indicated that some days she can transfer Resident #1 by herself but it depended on how tired Resident #1 was and what kind of day she was having. Both CNA #1 and CNA #5 indicated they did not use any type of mechanical lift for Resident #1 for transfers. The Event Report for Resident #1, dated 3/17/2016, was provided by LPN #7 on 4/28/2016 at 8:06 a.m. It indicated Resident #1 fell out of the Sara Lift while transferring. The intervention listed was to use the sling lift with all transfers. The CNA assignment sheet was provided by LPN #4 on 4/28/2016 at 3:01 p.m. It indicated Resident #1 was to be assisted by one staff member for transferring. The care plan for Resident #1 for the problem category listed ADL's I have had a decline in my ability to perform ADL's due to weakness. I require extensive assist with my ADL's. Interventions included, but were not limited to, Please use stand up lift to assist me when I need. This care plan was last updated on 2/22/2016. A current, 6/15, facility policy titled Falls Management Program Guidelines, provided by Medical Records Personnel #19 on 4/28/16 at 4:30 p.m., indicated: Should the resident experience a fall the attending nurse shall complete the 'Fall Circumstance and Reassessment Form.' The form includes an investigation of the circumstances surrounding the fall to determine the cause of the episode, a reassessment to identify possible contributing factors, interventions to reduce risk of repeat episodes and a review by IDT to evaluate thoroughness of the investigation and appropriate interventions . 6. The resident Icare plan/profile should be updated to reflect new or change in interventions. 3.1-45(a)(1)

Based on record review and interview, the facility failed to ensure residents were free from significant medication errors resulting in a resident going to the emergency room for evaluation due to a change of mental status in 1 of 3 residents reviewed for medication administration. (Resident C) Findings include: The clinical record of Resident C was reviewed on 4/14/16 at 9:00 a.m. [DIAGNOSES REDACTED]. Review of the hospital discharge instructions, dated 4/1/16, indicated Resident C had been discharged on the following medications: [REDACTED] Review of the hospital discharge medication reconciliation record, dated 4/1/16, indicated the facility sent the following medication orders electronically to the pharmacy: [MEDICATION NAME] ([MEDICATION NAME][MEDICATION NAME] medication) 2.5 mg/3 ml inhalation solution every 4 hours as needed for wheezing, [MEDICATION NAME] (antianxiety medication) 0.5 mg 3 times a day as needed for anxiety, [MEDICATION NAME] ([MEDICAL CONDITION] medication) 10 mg once daily, calcium [MEDICATION NAME] (antacid medication) 600 mg once daily, [MEDICATION NAME] (Vitamin D3) 2,000 Intl (international) Units once daily, [MEDICATION NAME] ([MEDICATION NAME] medication) 10 mg before meals, [MEDICATION NAME]-[MEDICATION NAME] (antidiarrheal medication) 2.5 mg - 0.025 mg 4 times a day as needed for loose stools, [MEDICATION NAME] sodium (stool softer) 100 mg once daily, [MEDICATION NAME] (anticoagulant medication) 40 mg subcutaneous every 24 hours, [MEDICATION NAME] (anticonvulsant medication) 300 mg 3 times daily, [MEDICATION NAME]-[MEDICATION NAME] ([MEDICATION NAME] medication) 5 mg - 325 mg twice daily as needed for pain, [MEDICATION NAME] (antidepressant medication) 150 mg at bed time, [MEDICATION NAME] ([MEDICAL CONDITION] hormone) 0.125 mg once daily, [MEDICATION NAME] (proton pump inhibitor medication) 20 mg once daily, [MEDICATION NAME] (antidepressant medication) 40 mg once daily, polyethylene [MEDICATION NAME] (laxative) 17 gm once daily and sodium [MEDICATION NAME] (acid medication) 1,950 mg once daily. The medication reconciliation record had another hospital inpatient's name on the top and bottom of the pages. The medications listed were not linked to a diagnoses. Review of Resident C's MAR (Medication Administration Record) for April, 2016 indicated Resident C received these incorrect medications from 4/1/16 through 4/4/16 as follows: [MEDICATION NAME] 10 mg, three doses calcium [MEDICATION NAME] 600 mg, three doses [MEDICATION NAME] 2,000 units, three doses [MEDICATION NAME] 10 mg, nine doses [MEDICATION NAME] 100 mg, three doses [MEDICATION NAME] 40 mg, three doses [MEDICATION NAME] 300 mg, nine doses [MEDICATION NAME] 150 mg, two doses [MEDICATION NAME] 0.125 mg, three doses [MEDICATION NAME] 20 mg, three doses [MEDICATION NAME] 40 mg, three doses polyethylene [MEDICATION NAME] 17 gm, three doses Review of Resident C's MAR (Medication Administration Record) for April, 2016 indicated the facility failed to provide Resident C the correct medications from 4/1/16 through 4/4/16 as follows: apixaban 2.5 mg, seven doses atorvastatin 40 mg, four doses [MEDICATION NAME] 125 mcg, three doses [MEDICATION NAME]-[MEDICATION NAME] 12.5 mg-20 mg, three doses [MEDICATION NAME] 2.5 mg, three doses [MEDICATION NAME] 5 mg, three doses sildenafil 50 mg, eight doses Review of the nursing note, dated 4/4/16 at 9:53 a.m. indicated Resident C presented with clear speech and able to make needs and wants known. Review of the nursing note, dated 4/4/16 at 11:51 a.m., indicated Resident C was having episodes of confusion and impulsiveness. Review of the nursing note, dated 4/4/16 at 1:11 p.m., indicated Resident C continued to have confusion and impulsiveness. Review of the nursing note, dated 4/4/16 at 1:30 p.m., indicated Resident C remained confused and the family requested Resident C be sent to the emergency room for evaluation. Review of the nursing note, dated 4/4/16 at 8:38 p.m., indicated Resident C returned to the facility from the emergency room . He was confused and in an altered mental status. EMT's had to transfer res (resident) to the bed with a 2 assist. Res did not come back with new orders. Nurse took vitals, WNL (within normal limits). Nurse called (name of hospital) ER to get new orders. Nurse talked to nurse that took care of res during ER stay, they said they didn't have any new orders. This nurse talked to 3 other (name of hospital) employees, they wouldn't send over original orders or new orders. This nurse talked to a secretary and was told she would transfer nurse to the 9th floor where he (Resident C ) stayed originally. This nurse was transferred to a pt (patient) room. This nurse tried to call back to (name of hospital) to talk to someone on the 9th floor. The charge nurse said she couldn't pull up his information because he had been discharged but she would try to get a hold of an employee in medical records. They were not available. The charge nurse called her supervisor. She then told this nurse, 'We don't feel comfortable giving original orders since your facility has been giving him wrong meds for several days.' This nurse then called on call nurse (name of nurse), (name of nurse) advised to call DON (name of DON). (Name of DON) said to print off the medication list that the res was taking during the hospital stay and call (name of physician) and go over each medication with him to see if he still wants the medication continued. This nurse then called (name of physician), (name of physician) said to hold all medication until he could be seen in the AM. Res was restless and confused through the night. He made several attempts to get up. Nurse was afraid res was too unsteady, and it would be harmful to apply pressure to left foot due to pressure ulcer. Bed alarm was placed for safety. Will continue to monitor. During an interview on 4/14/16 at 8:45 a.m., Resident C indicated the facility had given him the wrong medication and he had to be sent to the emergency room for evaluation. Resident C indicated he did not remember much about the incident. It really knocked me pretty good. During an interview on 4/14/16 at 1:00 p.m., LPN #7 indicated she had been the nurse on duty at the time of Resident C's admission on 4/1/16. LPN #7 indicated the hospital had sent the discharge paperwork with Resident C. He (Resident C) came with the paperwork from the hospital. I didn't realize they were someone else's orders. I had the 3rd shift nurse check the written orders against the computer to make sure I put them in right. LPN #7 indicated it had been easier to wait for the third shift nurse instead of getting a second shift nurse from another hall to verify the orders. During an interview on 4/14/16 at 1:05 p.m., RN #8 indicated she had worked the third shift on 4/1/16 and had been asked by LPN #7 to verify the admission MEDICATION ORDERS FOR [REDACTED]. I read the orders and verified them in the computer to make sure they were entered right. RN #8 indicated she did not notice the medication orders were for another hospital patient. During an interview on 4/14/16 at 10:43 a.m., LPN/Unit Manager #6 indicated on 4/4/16 orders for an unknown resident were found. I searched admitted s and realized (Resident C) had been admitted on the same date. I compared the orders on the written orders to what was in the computer - they were the same. I told (Director of Nursing's name) and (physician's name). By this time he (Resident C) was already in the ER per family request. (DON's name) notified the hospital of the error, she also notified the family. LPN/Unit Manager #6 also indicated the verification of the medication orders should have been done on the same shift. We have a nurse on each hall and she should have gotten one of them to verify the orders. During an interview on 4/14/16 at 2:03 p.m., the Clinical Consultant indicated the medication error had been reported to the State and nursing staff re-education had been initiated immediately. All orders should be verified, including making sure it is the correct person. Requested policy for admission order transcription and verification. No policy was found. This federal tag relates to Complaint IN 313. 3.1-25(b)(9) 3.1-48(c)(2)

Based on record review and interview, the facility failed to ensure residents were provided patient care in accordance with professional standards for 1 of 3 residents who was reviewed for admission medication order transcription. (Resident C) Findings include: The clinical record of Resident C was reviewed on 4/14/16 at 9:00 a.m. [DIAGNOSES REDACTED]. Review of the hospital discharge instructions, dated 4/1/16, indicated Resident C had been discharged on the following medications: [REDACTED]. Review of the hospital discharge medication reconciliation record, dated 4/1/16, indicated the facility sent the following medication orders electronically to the pharmacy: [MEDICATION NAME] ([MEDICATION NAME][MEDICATION NAME] medication) 2.5 mg/3 ml inhalation solution every 4 hours as needed for wheezing, [MEDICATION NAME] (antianxiety medication) 0.5 mg 3 times a day as needed for anxiety, [MEDICATION NAME] ([MEDICAL CONDITION] medication) 10 mg once daily, calcium [MEDICATION NAME] (antacid medication) 600 mg once daily, [MEDICATION NAME] (Vitamin D3) 2,000 Intl (international) Units once daily, [MEDICATION NAME] ([MEDICATION NAME] medication) 10 mg before meals, [MEDICATION NAME]-[MEDICATION NAME] (antidiarrheal medication) 2.5 mg - 0.025 mg 4 times a day as needed for loose stools, [MEDICATION NAME] sodium (stool softer) 100 mg once daily, [MEDICATION NAME] (anticoagulant medication) 40 mg subcutaneous every 24 hours, [MEDICATION NAME] (anticonvulsant medication) 300 mg 3 times daily, [MEDICATION NAME]-[MEDICATION NAME] ([MEDICATION NAME] medication) 5 mg - 325 mg twice daily as needed for pain, [MEDICATION NAME] (antidepressant medication) 150 mg at bed time, [MEDICATION NAME] ([MEDICAL CONDITION] hormone) 0.125 mg once daily, [MEDICATION NAME] (proton pump inhibitor medication) 20 mg once daily, [MEDICATION NAME] (antidepressant medication) 40 mg once daily, polyethylene [MEDICATION NAME] (laxative) 17 gm once daily and sodium [MEDICATION NAME] (acid medication) 1,950 mg once daily. The medication reconciliation record had another hospital patient's name on the top and bottom of the pages. The medications listed were not linked to a diagnoses. Review of Resident C's MAR (Medication Administration Record) for April, 2016 indicated Resident C received the incorrect medications and failed to receive the correct mediations from 4/1/16 through 4/4/16. Review of the nursing note, dated 4/4/16 at 11:51 a.m., indicated Resident C was having episodes of confusion and impulsiveness. Review of the nursing note, dated 4/4/16 at 1:11 p.m., indicated Resident C continued to have confusion and impulsiveness. Review of the nursing note, dated 4/4/16 at 1:30 p.m., indicated Resident C remained confused and the family requested Resident C be sent to the emergency room for evaluation. During an interview on 4/14/16 at 1:00 p.m., LPN #7 indicated she had been the nurse on duty at the time of Resident C's admission on 4/1/16. LPN #7 indicated the hospital had sent the discharge paperwork with Resident C. He (Resident C) came with the paperwork from the hospital. I didn't realize they were someone else's orders. I had the 3rd shift nurse check the written orders against the computer to make sure I put them in right. During an interview on 4/14/16 at 1:05 p.m., RN #8 indicated she had worked the third shift on 4/1/16 and had been asked by LPN #7 to verify the admission MEDICATION ORDERS FOR [REDACTED]. I read the orders and verified them in the computer to make sure they were entered right. RN #8 indicated she did not notice the medication orders were for another hospital patient. During an interview on 4/14/16 at 10:43 a.m., LPN/Unit Manager #6 indicated on 4/4/16 orders for an unknown resident were found. I searched admitted s and realized (Resident C) had been admitted on the same date. I compared the orders on the written orders to what was in the computer - they were the same. I told (Director of Nursing's name) and (physician's name). By this time he was already in the ER per family request. (DON's name) notified the hospital of the error, she also notified the family. LPN/Unit Manager #6 also indicated the verification of the medication orders should have been done on the same shift. We have a nurse on each hall and she should have gotten one of them to verify the orders. LPN/Unit Manager #6 indicated the facility uses an admission check list that was to be completed with each admission to ensure all documentation had been completed. The admission check list was not kept as part of the clinical record and Resident C's admission checklist was no longer available. LPN/Unit Manager #6 also indicated nursing staff were educated on this process during orientation. During an interview on 4/14/16 at 2:03 p.m., the Clinical Consultant indicated the medication error had been reported to the State and nursing staff re-education had been initiated immediately. All orders should be verified, including making sure it is the correct person. Requested policy for admission order transcription and verification. No policy was found. This federal tag relates to Complaint IN 313. 3.1-35(g)(1)

Based on record review and interview, the facility failed to ensure a resident identified at risk for falls had a safety alarm on as ordered by the physician for 1 of 6 residents in a sample of 14 reviewed for application of interventions to prevent falls resulting in a fall requiring transfer to the emergency room and treatment for [REDACTED]. (Resident #B) Findings include: 1.) The clinical record for Resident #B was reviewed on 2/14/11 at 1:00 p.m. [DIAGNOSES REDACTED]. A Quarterly Minimum Data Set assessment (MDS), dated [DATE], indicated Resident #B had problems understanding others and of being understood by others. The MDS indicated the resident had poor decision making ability and required cueing and supervision. The MDS indicated the resident required the assistance of the staff for all transfers and toileting. A health care plan problem, last reviewed on 1/25/11, indicated Resident #B was at risk for falls due to a history of falls, Alzheimer's dementia, and antipsychotic and antidepressant medication use. One of the approaches for this problem was for the staff to utilize bed and chair alarms as ordered. A current physician's orders [REDACTED]." A nursing note, dated 1/26/11 at 3:35 p.m., included, but was not limited to, the following: "Called to living area on 200 hall by TSA (Trilogy service assistant-corporation name for a CNA). Resident found on side on the floor. Lacerations to nose and lip. Contusion to mid forehead... MD (medical doctor) gave order to send to ER (emergency room ) for eval (evaluation) and tx (treatment).... C/O (complains of) pain all over, but generalized in head." The nursing note lacked any information relating to the residents personal alarm having sounded at the time of the fall. A nursing note, dated 1/26/11 at 9:10 p.m., included, but was not limited to, the following: "Resident returned to facility. Has a C3 (cervical vertebrae 3) fx (fracture). To have collar on at all x's (times).... Resident give an (sic) Hydrocodone 10/325 (a narcotic pain medication) at 2030 (8:30 p.m.) for pain.... An ED (emergency department) physician progress notes [REDACTED]. " The patient presents following a fall. The onset was just prior to arrival. The occurrence was a single episode. fell face forward out of wheelchair. The location where the incident occurred was at a nursing home.... ...Skin symptoms: Very large hematoma forehead with abrasion.... ...Diagnosis Closed fracture of the cervical vertebra... ...Discharge plan Condition: Stable... Patient was given the following educational materials: Cervical Collar. Follow up with: (name of physician) within 1-2 days: (name of orthopedic physician) within 1-2 days. Pt has a C3 fracture. To have collar on at all times. Nursing home to make appointment for patient to follow up with (name of orthopedic physician)." A "Fall Circumstance Assessment and Intervention" form, dated 1/27/11, indicated the resident had been found on the floor in the 200 hall living area on 1/26/11 at 3:35 p.m. The form indicated the resident sustained [REDACTED]. The form contained a section for "Equipment inspection" which read "Safety equipment in place and functioning at time of incident?" There was a place to circle either yes or no. No answer was circled. During an interview with the Director of Nursing on 2/15/11 at 12:30 p.m., additional information was requested related to Resident #B's fall on 1/26/11. An "Episodic Event Form", provided by the Administrator on 2/15/11 at 1:50 p.m., dated as completed on 2/1/11, included, but was not limited to, the following: "Event What occurred? Res (resident) was found lying on floor in front of w/c (wheelchair) on 1/26/11 at 3:35 p.m. in the living area next to the 200 hall nurses station. She had large hematoma above right eye, laceration to nose, and abrasion to lip. Complained of head and nose pain. Fall was NOT witnessed. Res did not have personal alarm on her w/c as per her CP (care plan). Sent to ER via 911. [DIAGNOSES REDACTED]. During an interview on 2/15/11 at 1:50 p.m., the Administrator indicated the resident's personal alarm had not been on and functioning at the time of the resident's fall on 1/26/11 at 3:35 p.m. 2.) Review of a current revised facility policy dated 3/08, provided by DoN on 2/16/11 at 1:00 p.m., titled "FALLS MANAGEMENT PROGRAM GUIDELINES", included, but was not limited to, the following: "PURPOSE: Trilogy health Services (THS) strives to maintain a hazard free environment, mitigate fall risk factors and implement preventative measures.... PROCEDURE: 1. The fall risk assessment is included as part of the Admission and Monthly Nursing Assessment and Review and Circumstance forms:... ...b. Care plan interventions should be implemented that address the residents's risk factors...." This federal tag relates to complaint #IN 707. 3.1-45(a)(2)