Every finding on record at North Park Nursing Center

Based on observation, interview, and record review, the facility failed to prevent falls for 2 of 3 residents reviewed for accidents. Following a significant decline, a dependent resident was encouraged to participate in dressing which resulted in a fall, and a resident's care plan intervention was not in place to prevent an additional fall. (Resident C, Resident D)Findings include: 1. A record review on 12/22/25 at 1:40 P.M. indicated Resident C's diagnoses included, but were not limited to, vascular dementia with agitation, anxiety disorder, muscle weakness, and unsteadiness on feet.Resident C's Significant Change Minimum Data Set (MDS) assessment, dated 8/20/25, indicated the resident required set-up assistance with the Activity of Daily Living (ADL) of upper and lower body dressing. Resident C's most recent Significant Change MDS, dated [DATE], indicated the resident had significant cognitive impairment, was dependent (helper does ALL of the effort. Resident does none of the effort to complete the activity or the assistance of 2 or more helpers is required for the resident to complete the activity) with the ADL of upper and lower body dressing, and had 2 or more falls and 1 fall with injury since the previous assessment. A fall risk assessment dated [DATE] indicated Resident C was at a high risk for falls. Resident C's care plan specific to ADL assistance was last reviewed or revised on 12/3/25. A focus of Resident required assistance with ADLs, including bed mobility, transfers, eating, and toileting, related to decreased mobility and weakness, and impaired cognition due to dementia (started 7/10/23). An intervention included assist with dressing, grooming, and hygiene as needed. Encourage the resident to do as much for self as possible (started 7/10/23). Resident C's nurse's progress notes included, but were not limited to:11/23/25 at 8:05 P.M. - Resident stood from the wheelchair and fell backward onto the floor.11/24/25 at 7:00 P.M. - CNA on duty alerted the LPN to witnessed fall of resident in his room. CNA was performing bedtime care with the resident and allowing for as much independence as possible with the resident as the resident was standing upright, near the bed, and lost his balance. 11/25/25 at 9:23 A.M. (Intra-disciplinary team) IDT note - Determined root cause of fall: resident immediately became unsteady when assisted by one staff member with PM care. Intervention put in place to address the root cause of fall: Dress the resident while lying in bed or sitting at the bedside.During an observation on 12/23/25 at 11:40 A.M., Resident C was observed in the dining room sitting in a high-back wheelchair. During an interview on 12/23/25 at 11:45 A.M., LPN 2 indicated Resident C had several falls recently following a general decline in health and functional abilities. Resident C would, at times, stand without assistance, which resulted in falls. During an interview on 12/23/25 at 12:30 P.M., the MDS nurse indicated Resident C's plan of care should have been updated following the significant change to reflect the assessments that indicated the resident was dependent for ADL care, which included upper and lower body dressing. 2. A record review on 12/23 at 10:40 A.M., Resident D's diagnoses included but were not limited to vascular dementia with mood disturbance, abnormalities in gait and mobility, and repeated falls. dA fall risk assessment dated [DATE] indicated Resident D was at a high risk for falls.Resident D's most recent Significant Change MDS assessment dated [DATE], indicated the resident had moderate cognitive impairment, used a wheelchair for mobility, was dependent for mobility and transfers, and had two or more falls with one with injury since the previous assessment. Resident D's care plan included, but was not limited to, the resident at risk for falls due to a history of one ormore falls within the previous 6 months, age greater than or equal to 80, incontinence, oxygen use, takes one or more high fall risk drugs, requires assistance or supervision for mobility, transfer, has altered awareness of immediate physical environment, lack of understanding of one's physical and cognitive limitations and she is impulsive. The resident often refuses to lie down after dinner (started 5/21/23 and last reviewed/revised 12/22/25). Interventions included but were not limited to, if the resident declines to go to bed after dinner, provide a sensory activity or a busy box within staff's eyesight (started 11/26/25). Resident D's nurse progress notes included, but were not limited to:11/25/25 at 8:45 P.M. - Staff heard the resident yelling out from the activity area. Upon arrival, the resident was observed to be lying on the right side in front of the wheelchair. The resident could not explain how fall occurred. 11/26/25 at 8:33 P.M. - IDT note - Determined root cause of fall: Resident initially refused to be placed into bed after dinner, then attempted to transfer self. Intervention put in place to address root cause of fall: If the resident declines to go to bed after dinner, provide a sensory activity or a busy box within staff eyesight.11/28/25 at 7:24 P.M. - CNA reported to the nurse that resident was found seated on the floor in another resident's room.Resident C Fall Event for the fall that occurred on 11/28/25 at 7:24 P.M., indicated the fall was unwitnessed. On 12/23/25 at 12:45 P.M., the Facility Administrator supplied a facility policy titled Fall Management Policy, dated 6/2025. The policy included, It is the policy of [company name] to ensure residents residing within the community have adequate assistance to prevent injury related to falls . Communities will implement resident-centered fall prevention plans for each resident at risk for falls or who have a history of falls within the previous 6 months . 6. All falls will be discussed by the interdisciplinary team at the next clinical meeting after the fall to determine the root cause and other interventions to prevent future falls . c. The care plan will be reviewed and updated as necessary .This citation relates to intake 2697971. 3.1-45(a)(1)

Based on observation, interview, and record review, the facility failed to ensure staff performed proper hand hygiene and sanitation during care for 3 of 4 resident care observations. Staff failed to perform hand hygiene between glove changes and failed to perform hand hygiene immediately following care and prior to touching resident belongings and room door handles. (Resident B, Resident C, Resident F) Findings include: 1. On 8/6/25 at 2:02 P.M., LPN 2 was observed providing wound care to Resident B's lower extremities. Resident B was observed sitting in bed. LPN 2 gave a clear plastic trash bag to Resident B to hold. LPN was observed during the treatment of the wounds to dispose of the old, soiled dressings and supplies into the bag that Resident B was holding on his lap. On 8/6/25 at 2:34 P.M., the Infection Preventionist Nurse indicated that she would have put a trash can at the end of the bed to drop the soiled dressing in. On 8/7/25 at 2:48 p.m., the Infection Preventionist Nurse provided the current skills competency nursing policy and procedure for dressing change clean technique (Incision or Wound) with a revision date of 10/2024. The policy included but was not limited to: .6. Place trash receptacle next to the bed or a disposable plastic bag at the foot of the bed (or on a chair) to dispose of waste and soiled dressing and supplies . 2. On 8/7/25 at 10:56 a.m., CNA 2 entered Resident C's room, walked to the closet to obtain a clean brief, walked to the door, opened it, and obtained hand sanitizer from the dispenser on the wall outside the room and sanitized her hands before donning gloves. CNA 2 was observed providing incontinence care to Resident C, who had feces on the front and back of her peri area and buttocks. CNA 2 moved the clean brief closer to Resident C, doffed her gloves, walked to the door, opened it, and obtained hand sanitizer from the dispenser outside the room. CNA 2 indicated she usually carries hand sanitizer in her pocket, it exploded yesterday, and that was why she had to use the hand sanitizer outside the room. 3. During an observation on 8/7/25 at 10:09 A.M., CNA 9 and CNA 10 provided incontinence care for Resident F. CNA 9 used a wet washcloth to clean Resident F's perineal area after pulling down a brief that was wet with urine. CNA 9 then removed her gloves and donned a new glove without performing hand hygiene. CNA 9 could not find a second glove and, without performing hand hygiene, reached into CNA 10's pocket to retrieve a glove. CNA 9 then removed the wet brief and cleaned around the resident's anus and buttocks area. CNA 9 then placed the soiled brief in a trash bag and the linens in a separate trash bag. CNA 9 removed her gloves and, without performing hand hygiene, opened the resident's door by turning the inside door handle and exited the resident's room. CNA 9 returned to the resident's room and donned gloves before she applied a new brief to the resident and placed fresh linens on the resident's bed. CNA 9 and CNA 10 applied a new gown to the resident and placed a wedge cushion between his legs. CNA 9 then removed her gloves and, without performing hand hygiene, closed the resident's bedside table drawer, picked up and placed the resident's call light on his bed, and opened the resident's shared room door by turning the inside door handle. During an interview on 8/7/25 at 11:50 A.M., the Infection Control Preventionist (ICP) indicated that staff should change gloves between clean and dirty tasks and should perform hand hygiene following the removal of gloves. The ICP also indicated that they (staff) are not encouraged to carry hand sanitizer to prevent them from putting their contaminated hands into their pockets to retrieve the sanitizer. On 8/7/25 at 11:58 A.M., the ICP provided a facility policy titled, Hand Hygiene Policy, dated 12/2021. The policy included, .5 Moments of hand hygiene - a term that describes the hand hygiene opportunities that prevent infection transmission linked to healthcare activities . After body fluid exposure risk. After touching a resident. After touching the resident surroundings . Procedure: Healthcare personnel should use an alcohol-based hand rub or wash with soap and water for the following clinical indications: .Before moving from work on a soiled body site to a clean body site on the same resident. After touching a resident or the resident's immediate environment . Immediately after glove or PPE (Personal Protective Equipment) removal . 3.1-18(b) 3.1-18(l)

Based on observation, interview, and record review, the facility failed to implement a resident's plan of care for 1 of 3 residents reviewed for accidents. A resident's care plan intervention to reduce a risk for falls was not in place for a resident with a recent fall. (Resident D)Finding includes:During an observation and interview on 8/6/25 at 8:45 A.M., Resident D was sitting up in her bed with a breakfast tray in front of her. The resident indicated she was not sure how long she had been in the facility and that she was not sure how much assistance she needed to get out of bed. During an interview on 8/6/25 at 9:30 A.M., LPN 2 indicated that Resident D had a recent fall and had occasional falls due to attempting to transfer herself in her room. Record review on 8/6/25 at 11:00 A.M., Resident D's diagnoses included but were not limited to hemiplegia and hemiparesis following cerebral infarction, depression, need for assistance with personal care, muscle weakness, abnormalities of gait and mobility, and unsteadiness on feet. Resident D's most recent quarterly Minimum Data Set (MDS) assessment, dated 5/29/25, indicated the resident had severely impaired cognition. Resident D's at-risk care plan was implemented on 12/20/2023 and last revised 8/4/2025 included, but was not limited to, Resident is at risk for falls. An intervention, dated 8/4/25, indicated the Resident was to eat in the dining room during all meals. Resident D's nurses' progress notes included, but were not limited to: 7/29/25 at 9:21 A.M - Resident is alert to self and familiar faces. Staff encourages the resident to eat in the dining room. Resident is one (1) assist with transfers. 8/1/25 at 1:56 P.M. - Resident was found in her room on her left knee in front of her recliner.During an interview on 8/7/25 at 12:15 P.M., LPN 5 indicated resident fall interventions should be in place, and if a resident refused an intervention, a refusal should be documented in the resident's record. During an interview on 8/7/25 at 12:30 P.M., RN 4 indicated that if a resident refused a care plan intervention, such as going to the dining room for meals, the CNA on the hall should notify the nurse on duty, and the nurse should document a refusal in the resident's progress notes. On 8/7/25 at 3:00 P.M., the Facility Administrator supplied facility policies titled, Fall Management Policy, dated 8/2022, and a policy titled IDT (Intradisciplinary Team) Comprehensive Care Plan Policy, dated 8/2023. The Fall Management Policy included, .Post Fall . 6. All falls will be discussed by the interdisciplinary team . to determine the root cause and other possible interventions to prevent further falls . The care plan will be reviewed and updated, as necessary. The IDT Comprehensive Care Plan Policy included, It is the policy of this facility that each resident will have an interdisciplinary comprehensive person-centered care plan developed and implemented . The care plan must include measurable goals and resident-specific interventions based on resident needs and preferences .This citation relates to complaint 1253631. 3.1-35(g)(2)

Based on observation, interview, and record review, the facility failed to prevent accidents for 1 of 3 residents reviewed for falls. The plan of care was not followed while transferring a resident to obtain a weight chair when a fall occurred. ( Resident C) Finding includes: On 6/12/25 at 11:20 a.m., Resident C's clinical record was reviewed. Diagnoses included, but were not limited to, nontraumatic intercranial hemmorrhage, unspecified, diabetes mellitus with hyperglycemia, polyneuropathy in diseases classified elsewhere, morbid obesity. A quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated cognition intact, sit to stand substantial/maximal assist (sit to stand: the ability to come to a standing position from sitting in a chair, wheelchair, or on the side of the bed.) Chair/bed -to-chair transfer- substantial/maximal assist (the ability to transfer to and from a bed to a chair (or wheelchair). Toilet transfer- substantial/maximal assist-(the ability to get on and off a toilet or commode.) Care plans were reviewed and included but were not limited to: [Resident] is at risk for falls due to history of one or more falls within the previous 6 months, incontinence, on 2 or or more high fall risk drugs, tethering equipment, requires assistance or supervision for mobility, transfer, or ambulation, unsteady gait, no cognitive concerns, start date 1/29/25. Approaches included but were not limited to: Place weight chair against the wall to prevent resident from pushing wheelchair back, start date 6/10/25. Resident to transfer to bathroom using wheelchair with assist of 2 staff and gait belt, start date 3/31/25. Staff to transfer to/from wheelchair using FWW (front wheeled walker), and gait belt with assist of 2, start date 3/3/125. [Resident ] requires assistance with ADL's (activities of daily living) including bed mobility, transfers, eating and toileting related to nontraumatic intercranial hemorrhage, start date 1/29/25. Approaches included but were not limited to: Staff to transfer to/from wheelchair using FWW and gait belt with assist of 2, start date 3/24/25. A staff assignment sheet was reviewed and included, but was not limited to: Resident to transfer to bathroom using wheelchair with assist of 2 staff and gait belt. Place weight chair against wall to prevent resident from pushing wheelchair back. Staff to transfer to/from wheelchair using FWW and gait belt with assist of 2. Progress notes were reviewed and included but were not limited to: Documented on 6/9/25 at 5:32 p.m., CNA (Certified Nursing Assistant) weighing resident to obtain monthly weight. When res stood from wt (weight) chair, res pushed locked chair back et sat onto ground onto buttocks. No injury noted. Res c/o (complained of) pain in knees but full ROM (range of motion) upon assessment. Res able to get self back into bed without assistance, put weight on knees w/o (without) issue. PRN (as needed) Oxycodone (pain medication) given, no further c/o voiced. NP (nurse practitioner) notified, attempted to call POA (power of attorney) no answer. INTERVENTION: When being weighed, secure weight chair against wall to prevent sliding back. No new orders at this time. On 6/13/25 at 10:21 a.m., CNA 2 indicated Resident C was a two staff assist with a gait belt and walker for all transfers. On 6/13/25 at 10:23 a.m., the Administrator indicated she did not know if resident C was transferred by one or two staff assist at the time of his fall, she would check. The Administrator returned to the room and indicated she had called the CNA who had transferred Resident C and only one staff was used to transfer the resident to the weight chair from bed, the CNA had told her she did not know he was a two assist to transfer to the weight chair. On 6/13/25 at 12:14 p.m., the Administrator provided the current fall management policy with a revised date of 3/24. The policy included but was not limited to: Policy: It is the policy of [name of corporation] to ensure residents residing within the community have adequate assistance to prevent injury related falls .Communities will implement resident-centered fall prevention plans for each resident at risk for fall within the past 6 months .5. Residents who are categorized at a moderate to high risk for falls should have fall interventions implemented based on resident specific factors. 6. The resident specific care requirements will be communicated to the assigned caregiver utilizing the resident profile through the point of care/RAI (Resident Assessment Instrument) documentation in matrix or the CNA assignment sheet . This citation relates to Complaint IN00461103. 3.1-45(a)(2)

Based on interview and record review, the facility failed to ensure a newly admitted resident had immediate orders for wounds for 1 of 3 residents reviewed for wounds. (Resident B) Finding includes: On 3/20/25 at 8:44 a.m., Resident B's clinical record was reviewed. Diagnoses included, but were not limited to, hemiplegia and hemaparesis following cerebral infarction affecting right dominant side, dysphagia following cerebral infarction,chronic obstructive pulmonary disease, unspecified protein-calorie malnutrition, hyperlipidemia. An Admission Minimum Data Set (MDS) assessment dated [DATE], indicated Resident B's cognition was intact, range of motion, impairment one side upper and lower extremities. Pressure injury, 2 unstageable deep tissue injury present on admission. Resident B admitted to the facility on [DATE], discharged on [DATE]. Care plans included, but were not limited to: [Resident B] is at risk for skin breakdown or further skin breakdown due to refuses showers at times. Responds to verbal commands but can't always communicate discomfort or need to be turned. Or has some sensory impairment that limits ability to feel pain/discomfort in 1 or 2 extremities. Skin is kept moist almost constantly by perspiration, urine, etc. Ability to walk severely limited or nonexistent. Can't bear own weight and/or must be assisted into chair or wheelchair. Makes, frequent though slight, changes in body or extremity position independently. Eats over half of most meals. Eats a total of 4 servings of protein (meat and dairy products) each day. Occasionally will refuse a meal, but will usually take a supplement when offered. Requires moderate to maximum assist in moving. During a move, skin probably slides to some extent, against sheets, chair, restraints or other device. Maintains relatively good position in chair or bed most of the time but occasionally slides down, start date 7/25/24, edited 11/4/24. Approaches included, but were not limited to: Assess and document skin condition weekly and as needed. Notify MD of abnormal findings, start 7/25/24 Preventative treatment as ordered, start 7/25/24. Resident has bruise to right heel, start 7/26/24, d/c'd 7/30/24. Approaches included, but were not limited to: Document abnormal findings and notify MD, start 7/25/24, d/c'd 7/30/24 Observe for increase in size of bruise or development of new bruising, start date 7/26/24, d/c'd 7/30/24. Treatment as ordered, start 7/26/24, d/c'd 7/30/24. Resident has impaired skin integrity to: DTI (deep tissue injury) to right outer heel and bottom of left foot (bottom of left foot healed 8/23/24) start date 7/30/24. Approaches included, but were not limited to: Float heels while in bed, start 8/8/24. Pressure relieving boot when up in chair and during transfers, start 8/8/24. A progress note dated 7/25/24 at 6:45 p.m., indicated: Resident arrived to facility from hospital transportation vehicle via wheelchair. Resident placed into room [room number] placed in bed by facility staff x2 with gait belt. Resident alert and oriented to self only. V/S (vital signs) stable, afebrile. Incontinent of B&B (bowel and bladder). Resident presented with right sided weakness. Upon skin assessment this nurse observed a small bruise 1 cm x 1 cm to right lateral heel, abrasion on the right side of middle back 4cm (centimeters) x 3cm, and a non fluid filled previous blister that was calloused and dry. No family or visitors in at present. A admission observation report dated 7/25/24 included but was not limited to: Skin: .alterations in skin =yes Abrasion -right thoracic back, 4 cm length, 3 cm width Bruise- right heel, 1 cm length, 1 cm width Wound- left bottom of foot, length 11 cm, width 6 cm A wound assessment note dated 8/2/24 included but was not limited to: right heel- Length 1.50 cm, width 1.0 cm, depth 0.10, pressure, DTI left bottom of foot- length 11.20 cm, width 9.50 cm, depth 0.10 cm. pressure, DTI Physicians orders for July 2024 were reviewed and included but were not limited to: Apply skin prep to DTI on outer heel and to bottom of left foot, order date 7/30/24. On 3/21/25 at 10:58 a.m., RN 2 indicated when a skin assessment is done on a new resident admission, she documents what she sees, if sees a skin issue, notify's the physician and the the Assistant Director Of Nursing, there is a place on the admission assessment to put measurements. On 3/21/25 at 11:56 a.m., the DON indicated she and the IP nurse (Infection Prevention Nurse) both did Resident B's admission, they were both new at that time and learning, they assumed the area on the palm of left foot was an reabsorbed blister, it almost looked like he had stepped on something, there was a thick layer of skin. They thought the area on the right heel was a bruise, she now knows the policy, and typically will open a skin event on admission on any skin issue. Ob 3/21/25 at 2:40 p.m., the Regional Nurse Consultant provided the current policy on alterations in skin integrity/wound management policy with a revision date of 9/22. The policy included but was not limited to: It is the policy of [name] to ensure that each resident receives care, consistent with professional standards of practice, and receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection .All residents will be interviewed at admission, semiannually, and with significant change of condition about any impairment in skin integrity .1. Alterations in skin integrity will be reported to the MD/NP, the resident and/or resident representative. 2. A treatment order will be obtained from the MD/NP including order for third party if applicable 4. All newly identified areas after admission will be documented in the New Skin Event. 5. The Director of Nursing/Clinical Director/designee will be notified of alterations in skin integrity. a. The DON/CD/designee will complete further evaluation of the skin impairment identified and complete the appropriate skin evaluation on the next business day. The assessment may include measurements,staging, condition of tissue, and drainage. The assessment will be documented in the clinical record. 6. The DON/CD/designee will assess the area and complete an IDT (interdisciplinary team) initial wound review using the progress note template .Wound management : 1. Wound management for ulcers: any Stage 2 or greater pressure injuries; arterial, diabetic, venous ulcers; or suspected deep tissue injury will be referred to a third-party provider for care or the resident will be considered for referral to comprehensive care facility .2. Wound management for non-ulcers: bruises, skin tears, rashes, etc, will be assessed by the DON/CD/designee. If no signs of complications or worsening the skin event can be closed after 72 hours, and no further documentation is required . On 3/21/125 at 12:46 p.m., the DON provided the current policy on skin management with the latest date of 5/22. The policy included but was not limited to: It is the policy of [name] to ensure that each resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless individual's clinical condition demonstrates that they were unavoidable; and a resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing . This citation relates to Complaint IN00455053. 3.1-30(a)

Based on interview and record review, the facility failed to ensure a resident without diabetes was free from a significant medication error for 1 of 1 resident reviewed for significant medication errors. (Resident L) This deficient practice resulted in Resident L receiving an overdose of rapid-acting and long-acting insulins and a significant change in condition that required emergent, intensive care at an acute care hospital for treatment of low blood sugar. Finding includes: On 8/22/24 at 2:40 P.M., Resident L's clinical record was reviewed. Diagnoses included, but were not limited to, Alzheimer's disease. The resident did not have a diagnosis of diabetes. A Quarterly Minimum Data Set (MDS) Assessment, dated 4/1/24, indicated Resident L was not assessed for cognitive ability because the resident was rarely or never understood, was dependent on staff for eating, did not have insulin orders, and did not receive any insulin injections during the 7-day look back period. The physician orders, dated 5/1/24 to 8/22/24, did not include documentation to indicate Resident L had a diagnosis or history of diabetes or should receive insulin. A Medication/Treatment Error Report, dated 5/15/24, indicated Resident L was mistaken for another resident and was given an incorrect dosage of insulin. The physician was notified at 10:00 P.M. and gave orders to administer 1 milligram (mg) Glucagon (medication used to raise blood sugar) intramuscularly (IM), recheck the blood sugar, and send the resident to the emergency room (ER) for treatment and monitoring if needed. The report did not include the specific type and amount of insulin administered to the resident. Nursing progress notes, dated 5/15/24 at 11:04 P.M. to 5/16/24 at 1:30 P.M., indicated Resident L had a blood sugar of 49 mg/dL (milligrams per deciliter) at 11:00 P.M. The nurse attempted to give the resident orange juice, but the resident was not swallowing. The blood sugar was rechecked at 11:30 P.M. and was 47 mg/dL. Glucagon was administered in the resident's right thigh. The blood sugar at 12:00 A.M. was 110 mg/dL. At 12:30 A.M., the blood sugar was 69 mg/dL. At 1:04 A.M., Emergency Medical Services (EMS) was called. Emergency Medical Technicians (EMTs) started an intravenous (IV) line and transported the resident to the ER by ambulance. A hospital triage report, dated 5/16/24 at 1:02 A.M., indicated facility staff reported Resident L was given 45 units of Lantus (a long-acting insulin) and 12 units of Novolog (a rapid-acting insulin) that were not prescribed to her. The EMTs gave the resident 250 milliliters (mL) of D10 (dextrose 10% solution given to symptomatic or suspected patients with low blood sugar). Blood sugar rose to 220 mg/dL in route to the hospital but was 110 mg/dL upon arrival to the ER. Resident L was admitted to the Intensive Care Unit (ICU) where she required a D10 IV drip and frequent blood sugar checks. An untimed handwritten statement from Qualified Medication Aide (QMA) 8, dated 5/16/24, indicated that on the night of 5/15/24, she prepared insulins for her hallway as we always have done and asked a nurse to administer them to the residents. The nurse administering the insulins came to QMA 8 and indicated she had accidentally given Resident L insulin that was meant for Resident N. Hospital discharge papers, dated 5/17/24, indicated Resident L was discharged back to the facility on [DATE] with a diagnosis of incidental insulin overdose and hypoglycemia. An untimed handwritten statement from Registered Nurse (RN) 32, dated 5/17/24, indicated on 5/15/24, she accidentally administered two doses of insulin in insulin pens to Resident L that were prepared by QMA 8 for Resident N. RN 32 indicated she thought the facility's protocol was for the QMAs to check a resident's blood sugar, draw up the insulin, and then a nurse would administer the insulin. RN 32 indicated the usual practice was for a QMA to prepare the insulin dose, label the insulin pen with a permanent marker, and set the insulin pen on the top of a medication cart. RN 32 indicated she was an internal float nurse, and she was not familiar with the residents on QMA 8's assignment for 5/15/24. On 8/23/24 at 9:47 A.M., the Administrator, Director of Nursing (DON), Clinical Support 5, and Clinical Support 7 indicated Resident L received the wrong medication resulting in an overdose because QMA 8 drew up insulin and RN 32 went to a hall she was not assigned to or was familiar with to give insulin that she hadn't prepared. Corporate policy did not allow for QMAs to administer insulin, and medications should only be given by the nurse who prepared them. On 8/23/24 at 10:04 A.M., the Administrator provided a QMA Parameters and Scope of Practice policy, revised 7/26/19, that indicated The following tasks shall NOT be included in the QMA scope of practice: Administer medication by the injection route, including the following: . Subcutaneous route . On 8/29/24 at 10:51 A.M., the Administrator provided a Medication Administration policy, revised 7/2034, that indicated Medications are prepared for one resident at a time . Perform the 5 [five] rights of medication: Right Resident, Right Medication, Right Dose, Right Route, Right Time. On 8/29/24 at 10:51 A.M., the Administrator provided an Insulin Pen Administration policy, dated 6/2018, that indicated Verify resident, physician orders and drug allergies . Ensure that insulin pen is labeled with resident name and used for only that resident. The article, LANTUS Labeling - Package Insert, dated 6/29/23, was retrieved on 9/4/24 from the Federal Drug Administration (FDA) website at www.fda.gov/drugsatfda. The guidance included: LANTUS is a long-acting human insulin analog indicated to improve glycemic control in adult and pediatric patients with diabetes mellitus . Adverse reactions commonly associated with LANTUS include hypoglycemia, allergic reactions, injection site reactions, lipodystrophy, pruritus, rash, edema, and weight gain . Hypoglycemia is the most common adverse reaction associated with insulins, including LANTUS. Severe hypoglycemia can cause seizures, may be life-threatening or cause death . Severe symptomatic hypoglycemia was defined as an event with symptoms consistent with hypoglycemia requiring the assistance of another person and associated with either a blood glucose below 50 mg/dL .or prompt recovery after oral carbohydrate, intravenous glucose, or glucagon administration . Excess insulin administration may cause hypoglycemia and hypokalemia. The article, NOVOLOG Labeling - Package Insert, dated 2/28/23, was retrieved on 9/4/24 from the Federal Drug Administration (FDA) website at www.fda.gov/drugsatfda. The guidance included: NOVOLOG is rapid acting human insulin analog indicated to improve glycemic control in adults and pediatric patients with diabetes mellitus . Adverse reactions observed with NOVOLOG include: hypoglycemia, allergic reactions, local injection site reactions, lipodystrophy, rash, and pruritus . Hypoglycemia is the most common adverse reaction of all insulins, including NOVOLOG. Severe hypoglycemia can cause seizures, may lead to unconsciousness, may be life threatening or cause death . Severe hypoglycemia was defined as hypoglycemia associated with central nervous system symptoms and requiring the intervention of another person or hospitalization . Excess insulin administration may cause hypoglycemia and hypokalemia. The article, GLUCAGON Labeling - Package Insert, dated 7/14/22, was retrieved on 9/4/24 from the Federal Drug Administration (FDA) website at www.fda.gov/drugsatfda. The guidance included: Glucagon for Injection is an antihypoglycemic agent and a gastrointestinal motility inhibitor indicated: for the treatment of severe hypoglycemia in pediatric and adult patients with diabetes . Most common adverse reactions ( >5% or greater incidence): Injection site swelling, injection site erythema, vomiting, nausea, decreased blood pressure, asthenia, headache, dizziness, pallor, diarrhea, and somnolence . If overdosage occurs, the patient may experience nausea, vomiting, inhibition of GI tract motility, increase in blood pressure and pulse rate. This citation relates to complaint IN00435599. 3.1-48(c)(2)

Based on interview and record review, the facility failed to ensure documentation was complete for 5 of 6 residents reviewed for medications. Medications on the Medication Administration Record (MAR) were not documented as completed. (Resident M, Resident N, Resident Q, Resident 86, and Resident 45) Findings include: 1. On 8/26/24 at 2:35 P.M., Resident M's clinical record was reviewed. Diagnoses included, but were not limited to, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, diabetes mellitus, generalized anxiety disorder, chronic embolism and thrombosis of unspecified deep veins of unspecified lower extremity, and chronic pain syndrome. The most current Quarterly Minimum Data Set (MDS) Assessment, dated 7/5/24, indicated Resident M was cognitively intact, required supervision for eating, and received an antianxiety medication, anticoagulant, opioid, and insulin during the 7-day look back period. Physician orders included, but were not limited to: insulin lispro (a rapid-acting insulin) - insulin pen; 100 unit/mL (units per milliliter) - give 10 units subcutaneous three times a day, dated 8/27/22 lorazepam (an antianxiety mediation) tablet - Give 1 mg (milligram) by mouth every 8 hours, dated 11/7/21 hydrocodone-acetaminophen (an opioid) tablet - Give 7.5-325 mg by mouth every 6 hours, dated 2/25/24 insulin glargine (a long-acting insulin) insulin pen; 100 unit/mL - give 35 units subcutaneous every 12 hours, dated 7/3/24 Baclofen (muscle relaxer) - give 10 mg by mouth three times a day, dated 7/4/24 Baclofen - give 5 mg with 10 mg by mouth to equal 15 mg three times a day, dated 7/4/24 Eliquis (an anticoagulant) - give 5 mg twice a day, dated 8/7/23 The May 2024 MAR indicated: Insulin lispro was left blank on 5/8 at 12:00 P.M., 5/15 at 5:00 P.M., 5/17 at 8:00 A.M., 5/19 at 12:00 P.M., and 5/21 at 5:00 P.M. Hydrocodone-acetaminophen was left blank on 5/4 at 12:00 P.M. Lorazepam was left blank on 5/17 at 8:00 A.M. The June 2024 MAR indicated: Insulin lispro was left blank on 6/27 at 8:00 A.M. Lorazepam was left blank on 6/27 at 8:00 A.M. The July 2024 MAR indicated: Insulin lispro was left blank on 7/26 at 8:00 A.M. and 7/29 at 5:00 P.M. Insulin glargine was left blank on 7/26 at 8:00 A.M. The August 2024 MAR indicated: Insulin lispro was left blank on 8/4 at 5:00 A.M., 8/19 at 8:00 A.M., and 8/19 at 5:00 P.M. Insulin glargine was left blank on 8/19 at 8:00 A.M. Baclofen was left blank on 8/19 at 8:00 A.M. Eliquis was left blank on 8/19 at 8:00 A.M. Lorazepam was left blank on 8/19 at 8:00 A.M. 2. On 8/22/24 at 11:33 A.M., Resident N's clinical record was reviewed. Diagnoses included, but were not limited to, diabetes mellitus and hypertension. The most current Quarterly Minimum Data Set (MDS) Assessment, dated 6/25/24, indicated Resident N was cognitively intact, required setup assistance for eating, and received insulin during the 7-day look back period. Physician orders included, but were not limited to: insulin glargine (a long-acting insulin) - insulin pen; 100 unit/mL (units per milliliter) - give 4 units subcutaneous every 12 hours, dated 12/28/23 insulin aspart (a rapid-acting insulin) - insulin pen; 100 unit/mL - give 12 units subcutaneous at bedtime, dated 6/2/23 insulin aspart (a rapid-acting insulin) - insulin pen; 100 unit/mL - give 15 units subcutaneous at bedtime, dated 6/3/24 amlodipine (a medication to treat high blood pressure) tablet - give 5 mg (milligrams) once a day, dated 8/17/23 The May 2024 MAR indicated: Insulin glargine was left blank on 5/6 at 8:00 A.M., 5/7 at 8:00 P.M., and 5/22 at 8:00 A.M. Insulin aspart (12-unit dose) was left blank on 5/7 Amlodipine was left blank on 5/17 The June 2024 MAR indicated: Insulin glargine was left blank on 6/27 at 8:00 A.M. and 6/29 at 8:00 P.M. Insulin aspart (15-unit dose) was left blank on 6/27 at 8:00 A.M. Insulin aspart (12-unit dose) was left blank on 6/4 and 6/29 The July 2024 MAR indicated: Insulin glargine was left blank on 7/26 at 8:00 A.M. Insulin aspart (15-unit dose) was left blank on 7/26 at 8:00 A.M. and 7/27 at 12:00 P.M. The August 2023 MAR indicated: Insulin glargine was left blank on 8/19 at 8:00 A.M. Insulin aspart (15-unit dose) was left blank on 8/4 at 5:00 P.M., 8/19 at 8:00 A.M. and 5:00 P.M., and 8/20 at 5:00 P.M. 3. On 8/23/24 at 10:09 A.M., Resident Q's clinical record was reviewed. Diagnoses included, but were not limited to, diabetes mellitus, generalized anxiety disorder, hypertension, irritable bowel syndrome, glaucoma, atrial fibrillation, hypertension, gastro-esophageal reflux disease, and depression. The most current Significant Change Minimum Data Set (MDS) Assessment, dated 6/13/24, indicated Resident Q was cognitively intact, required setup assistance for eating, and received an antianxiety medication, antidepressant, anticoagulant, diuretic, and a hypoglycemic medication during the 7-day look back period. Physician orders included, but were not limited to: Diabetic orders: Accu-Chek (test to determine blood glucose level) - Notify MD (medical doctor) if Accu-Chek is below 70 or greater than 400 - every Monday, dated 11/14/2022 gabapentin (an anticonvulsant) capsule - give 300 mg (milligrams) three times a day, dated 8/5/23 Xanax (an antianxiety medication) tablet - give 0.25 mg three times a day, dated 5/31/23 insulin degludec (an ultralong-acting insulin) - insulin pen; 100 unit/mL - give 10 units subcutaneous at bedtime, dated 7/18/24 acetazolamide (a diuretic) tablet - give 250 mg twice a day, dated 12/17/23 colestipol (medication to treat high cholesterol levels) tablet - give 1 gram twice daily, dated 10/13/23 Combigan (medication to treat glaucoma) drops 0.2-0.5 % - give 1 drop in left eye twice daily, dated 12/17/23 Eliquis (an anticoagulant) tablet - give 5 mg by mouth twice a day, dated 5/20/24 metformin (a hypoglycemic medication) tablet - give 250 mg by mouth twice daily, dated 7/18/24 metoprolol tartrate (medication to treat high blood pressure) tablet - give 25 mg by mouth twice a day, dated 12/17/23 omeprazole (a proton-pump inhibitor) capsule, delayed release - give 20 mg by mouth once a day, dated 8/12/22 Zoloft (an antidepressant) tablet - give 100 mg by mouth once a day, dated 5/22/24 The May 2024 MAR indicated: Accu-Chek was left blank on 5/6. Gabapentin was left blank on 5/6 at 7:00 A.M., 5/10 at 7:00 A.M., 5/16 at 7:00 A.M., 5/17 at 7:00 A.M., 5/18 at 7:00 A.M., 5/19 at 7:00 A.M., 5/24 at 7:00 A.M., 5/25 at 7:00 A.M., and 5/29 at 7:00 A.M. Xanax was left blank on 5/6 at 7:00 A.M., 5/10 at 7:00 A.M., 5/16 at 7:00 A.M., 5/17 at 7:00 A.M., 5/18 at 7:00 A.M., 5/19 at 7:00 A.M., 5/24 at 7:00 A.M., 5/25 at 7:00 A.M., and 5/29 at 7:00 A.M. The June 2024 MAR indicated: Accu-Chek was left blank on 6/3, 6/17, and 6/24. Gabapentin was left blank on 6/3 at 7:00 A.M. Xanax was left blank on 6/3 at 7:00 A.M. The July 2024 MAR indicated: Accu-Chek was left blank on 7/22 and 7/29. Gabapentin was left blank on 7/25 at 7:00 A.M., 7/28 at 7:00 A.M., and 7/29 at 7:00 A.M. Xanax was left blank on 7/22 at 7:00 A.M., 7/25 at 7:00 A.M., 7/28 at 7:00 A.M., and 7/29 at 7:00 A.M. The August 2024 MAR indicated: Accu-Chek was left blank on 8/5 and 8/19. Gabapentin was left blank on 8/5 at 7:00 A.M., 8/7 at 7:00 A.M., 8/18 at 7:00 A.M., 8/19 at 7:00 A.M., and 8/20 at 7:00 A.M. Xanax was left blank on 8/5 at 7:00 A.M., 8/7 at 7:00 A.M., 8/18 at 7:00 A.M., 8/19 at 7:00 A.M., and 8/20 at 7:00 A.M. Insulin degludec was left blank on 8/1. Acetazolamide was left blank on 8/19 at 7:00 A.M. - 11:00 A.M. Eliquis was left blank on 8/19 at 7:00 A.M. - 11:00 A.M. Metformin was left blank on 8/19 at 7:00 A.M. - 11:00 A.M. Colestipol was left blank on 8/19 at 7:00 A.M. - 11:00 A.M. Combigan drops was left blank on 8/19 at 7:00 A.M. - 11:00 A.M. Omeprazole was left blank on 8/19 at 7:00 A.M. - 11:00 A.M. Metoprolol tartrate was left blank on 8/19 at 7:00 A.M. - 11:00 A.M. Zoloft was left blank on 8/19 at 7:00 A.M. - 11:00 A.M. 4. On 8/26/24 at 12:36 P.M., Resident 86's clinical record was reviewed. Diagnoses included, but were not limited to, back pain, dementia with agitation, body posture rigidity, and major depressive disorder. The most current Admission Minimum Data Set (MDS) Assessment, dated 6/10/24, indicated Resident 86 was rarely or never understood, required supervision for eating, and received an antipsychotic medication, an antianxiety medication, and a hypoglycemic medication during the 7-day look back period. Physician orders included, but were not limited to: acetaminophen (a pain reliever) capsule - give 650 mg (milligrams) by mouth three times a day, dated 7/23/24 memantine (a medication to treat dementia symptoms) tablet - give 10 mg by mouth every 12 hours, dated 6/4/24 carbidopa-levodopa tablet (a medication to treat symptoms of Parkinson's disease) - give one 25-100 mg tablet by mouth three times a day, dated 7/25/24 and discontinued on 8/22/24 Xanax (an antianxiety medication) tablet - give 0.25 mg by mouth twice daily, dated 6/4/24 risperidone (an antipsychotic) tablet - give 0.25 mg by mouth twice daily, dated 8/13/24 The July 2024 MAR indicated: Acetaminophen was left blank on 7/26 at 2:00 P.M. Memantine was left blank on 7/5 at 8:00 P.M., 7/6 at 8:00 P.M, and 7/11 at 8:00 P.M. Carbidopa-levodopa was left blank on 7/26 at 2:00 P.M. Xanax was left blank on 7/14 at 2:00 P.M., 7/20 at 2:00 P.M., 7/21 at 2:00 P.M., and 7/26 at 2:00 P.M. The August 2024 MAR indicated: Acetaminophen was left blank on 8/3 at 8:00 P.M., 8/4 at 2:00 P.M., 8/17 at 2:00 P.M., 8/19 at 8:00 P.M., 8/22 at 8:00 P.M., and 8/25 at 8:00 P.M. Memantine was left blank on 8/3 at 8:00 P.M., 8/19 at 8:00 P.M., 8/22 at 8:00 P.M., and 8/25 at 8:00 P.M. Risperidone was left blank on 8/19 at 7:00 P.M. - 10:00 P.M., 8/22 at 7:00 P.M. - 10:00 P.M., and 8/23 at 7:00 P.M. - 10:00 P.M. Carbidopa-levodopa was left blank on 8/4 at 2:00 P.M., 8/13 at 6:00 P.M., 8/14 at 6:00 P.M., and 8/17 at 2:00 P.M. Xanax was left blank on 8/4 at 2:00 P.M. and 8/17 at 2:00 P.M. 35733 5. On 8/27/24 at 1:30 P.M., Resident 45's clinical record was reviewed. Diagnoses included, but were not limited to, chronic atrial fibrillation, unspecified, age-related osteoporosis without current pathological fracture, malignant neoplasm of colon, unspecified, malignant neoplasm of prostate, and gastro-esophageal reflux disease without esophagitis. A Quarterly MDS (Minimum Data Set) Assessment, dated 7/11/24, indicated Resident 45's cognition was severely impaired and received an anticoagulant and opioid medication. Care plans included but were not limited to: [name of resident] is at risk for pain related to diagnosis of prostate and colon cancer, osteoporosis and GERD (gastroesophageal reflux disease) Approach: Administer meds as ordered, start date 7/9/22. Resident is at risk for ineffective tissue perfusion related to heart failure, ASHD, A-Fib, hypokalemia and hyperlipidemia. Approach: Administer meds as ordered, start date 7/9/22. Resident has a urinary tract infection (UTI). Approach: Administer antibiotic as ordered, start date 8/22/24. Discomfort related to gastric reflux disease. Approach: Administer medications as ordered, start date 12/10/22. August 2024 physician orders and EMAR (Electronic Medication Administration Record) were reviewed and included, but were not limited to: bicalutamide (nonsteroidal antiandrogen) tablet, 50 mg (milligram) amount to administer: 50 mg (milligrams), once a day, start date 4/16/24. On 8/3 the medication was not documented given for the morning dose. amiodarone (antiarrhythmic) tablet 200 mg amount to administer: 200 mg once a day, start date 4/16/24. On 8/3 the medication was not documented as given for the morning dose. calcium 600+D(3) (nutritional supplement) tablet, 600 mg- 10 mcg ( microgram) (400 unit) twice a day, start date 4/16/24. On 8/3 the medication was not documented as given for the morning dose. Eliquis (anticoagulant) (apixaban) tablet, 2.5 mg, twice a day, start date 6/21/24. On 8/3 the medication was not documented as given for the morning dose. midodrine (vasoconstrictor) 5 mg twice a day, start date 4/16/24 On 8/3 the medication was not documented as given for the morning dose. Namenda (N-methyl D-aspartate inhibitor) (memantine) tablet 10 mg twice a day, start date, 4/16/24. On 8/3 the medication was not documented as given for the morning dose. omeprazole capsule delayed release 20 mg once a day, start date 4/16/24. On 8/3 the medication was not documented as given. hydrocodone-acetaminophen (pain medication) 5-325 mg, oral, start date 4/22/24. The morning dose on 8/3 and the evening dose on 8/9 was not documented as given. cephalexin 500 mg oral, twice a day, start date 8/21//24. The evening dose on 8/26 was not documented as given. On 8/27/24 at 11:07 A.M., the Director of Nursing (DON) indicated she was unsure why there were blank spaces in the MAR. She indicated the medication could not have been given due to the resident refusing or being on a leave of absence, but since the nurse did not document it, she couldn't be sure. She indicated the medication was probably given and that staff were not being diligent to mark it done once completed. On 8/29/24 at 10:57 A.M., the Administrator indicated staff were expected to completely and accurately document in the clinical record and follow physician orders. On 8/29/24 at 10:51 A.M., the Administrator provided a current Medication Administration policy, revised 7/2023, that indicated Medication administration will be recorded on the MAR/EMAR [electronic medication administration record] or TAR [treatment administration record] after given . Refusal of medication document as appropriate. 3.1-50(a)(1)

Based on observation, interview, and record review, the facility failed to ensure dishwasher temperatures were within range and food was prepared under sanitary conditions for 1 of 1 kitchens observed. The temperature on the final rinse of the dishwasher did not reach required levels, hairnets did not cover hair, and staff touched food with their bare hands. (Kitchen, [NAME] 10, Dietary Aide 25) Findings include: 1. On 8/21/24 at 8:45 A.M., a dishwasher cycle was observed. The final rinse reached 173 degrees Fahrenheit (F). On 8/21/24 at 10:36 A.M., the Dietary Manager indicated the regulation stated the dishwasher final rinse needed to reach 180 F, but the manufacturer said 175 F was acceptable. A service technician had been called that morning. At that time, a high temp dishmachine temperature log was provided. Final rinse temperatures recorded for the month of August ranged from 168 F to 178 F. On 8/29/24 at 10:51 A.M., the Administrator provided a Work Order for the dishwasher, dated 8/21/24, that indicated Customer stated that dish machine was not getting to 180 degrees. Upon inspection seen [sic] dish machine was at 177-178 degrees. Checked the booster set point temp and it was at 180 degrees. Changed set point to 185 degrees. 2. On 8/23/24 at 11:50 A.M., [NAME] 10 and Dietary Aide 25 were observed plating food for lunch. Hairnets for [NAME] 10 and Dietary Aide 25 did not cover all their hair. 3. On 8/23/24 at 11:50 A.M., [NAME] 10 was observed plating food for lunch. [NAME] 10 used her bare hands to grab sandwich buns out of a bag, separate the sandwich bun, and place it on a plate. At that time, the Dietary Manager indicated gloves were supposed to be used because food cannot be touched with bare hands. On 8/29/24 at 8:50 A.M., the Dietary Manager indicated hairnets should be covering all hair. On 8/29/24 at 10:51 A.M., the Administrator provided a Recording Dish Machine Temperature/Sanitizer policy, revised 7/23, that indicated Dishwashing staff will be trained to report any problems with the dish machine temperatures and/or sanitizer concentration to the Culinary Manager as soon as they occur. The Culinary Manager will promptly assess any dish machine problems and take corrective action to assure appropriate cleaning and sanitizing of dishes. On 8/29/24 at 10:51 A.M., the Administrator provided a Use of Gloves policy, revised 10/22, that indicated Employees will not use bare hand contact with foods. Clean gloves will be used when handling any food directly. On 8/29/24 at 10:51 A.M., the Administrator provided a Culinary Personal Hygiene policy, revised 5/24, that indicated All employees working in the culinary department must wear a clean hair restraint which effectively covers all hair. 3.1-21(i)(2) 3.1-21(i)(3)

Based on observation, interview, and record review, the facility failed to ensure that food was served at palatable temperatures for 1 of 1 trays tested for temperature. (A-Hall) Finding includes: On 8/21/24 at 10:06 A.M., Resident Q indicated the food was always cold. On 8/21/24 at 10:44 A.M., Resident 36 indicated the food was usually cold. On 8/21/24 at 2:20 P.M., Resident 33 indicated the food was cold all the time. On 8/23/24 at 1:06 P.M., a test tray was obtained. Food temperatures for that meal were: chicken 114 F (Fahrenheit) fries 109 F coleslaw 55.5 F mandarin oranges 60 F On 8/29/24 at 8:50 A.M., the Dietary Manager indicated food temperatures should be palatable. On 8/29/24 at 10:51 A.M., the Administrator provided a Food Temperatures policy, revised 6/23, that indicated All hot and cold food items will be served to the resident at a temperature that is considered palatable at the time the resident receives the food. The Retail Food Establishment Sanitation Requirements 410 IAC 7-24 Sec. 166, effective November 13, 2004, indicated (a) .refrigerated, potentially hazardous food shall be at a temperature of forty-one (41) degrees Fahrenheit or below when received . (c) received hot shall be at a temperature of one hundred thirty-five (135) degrees Fahrenheit or above. 3.1-21(a)(2)

Based on observation, interview, and record review, the facility failed to ensure that medications were properly stored and labeled in 2 of 6 medication carts and 2 of 2 treatment carts observed. (E-Hall, F-Hall, Short Hall Cottage Treatment Cart, A-Hall Treatment Cart) Findings include: 1. On 8/21/24 at 8:50 A.M., the following loose pill was observed in the E-Hall Medication Cart for rooms 141-147: 1/2 small round white pill 2. On 8/21/24 at 8:55 A.M., the following loose pills and unlabeled medications were observed in the E-Hall Medication Cart for rooms 131-140: 2 1/2 small round white pills 1 bottle of Honey Robitussin (cough medicine) with [Resident 33] on bottle but no label or open date 3. On 8/21/24 at 9:05 A.M., the following unlabeled materials were observed in the Short Hall of the Cottage: 1 Honey Dressing (medicated) package no label or open date 4. On 8/21/24 at 9:25 A.M., the following unlabeled materials were observed in the A-Hall Treatment Cart: 1 tube of opened antifungal cream for [Resident 27] no label 1 bottle of wound cleaner open with [Resident 8] no label On 8/23/24 at 12:04 P.M., the following unlabeled materials were observed in the A Hall Treatment Cart: 1 opened antifungal cream ointment for [Resident 52] with no label 1 bottle of wound cleanser [Resident 8] no label During an interview on 8/21/24 at 9:00 A.M., RN (Registered Nurse) 37 indicated there should be no loose pills and that the medications should be labeled. On 8/29/24 at 10:54 A.M., the Administrator provided a current Medication Storage policy, dated August 2023. The policy indicated Proper medication storage is a standard or practice . Medications are properly labeled with name, lot number . Medication is available for all active medication orders . 3.1-25(b)(4) 3.1-25(j)

Based on interview and record review, the facility failed to ensure through assessments were completed for 1 of 1 residents receiving a diuretic for congestive heart failure. Daily weights were not obtained as ordered. (Resident 36) Finding includes: On 8/27/24 at 10:27 A.M., Resident 36's clinical record was reviewed. Diagnoses included, but were not limited to, chronic systolic (congestive) heart failure, localized edema, primary pulmonary hypertension. A quarterly MDS (Minimum Data Set) assessment, dated 7/5/24, indicated Resident 36's cognition was intact and received a diuretic medication. June and July 2024 physician orders and the EMAR (Electronic Medication Administration Record) were reviewed and included but was not limited to: Daily weight for CHF (congestive heart failure), once a day. Notify MD (Medical Doctor) of weight gain of 3 lbs. (pounds) a day or 5 lbs. in a week, start date 11/25/23, discontinued 7/13/24. June dates not documented: 6/3, 6/12, 6/13, 6/22, 6/27. 6/28, 6/30. July dates not documented: 7/4, 7/5, 7/6, 7/8, 7/10. Weights were reviewed and included, but were not limited to: 12/1/23- 133 7/1/24- 127 8/1/24- 132 Progress notes included, but were not limited to: 10/2/23 1:29 P.M., Sig [significant] change RD [registered dietician] review: This 62 yo [year old] female with multiple recent hospitalization s r/t [related to] chf, fluid overload. Res [resident] noted with hx [history] +3 pitting edema to BLE [bilateral lower extremities], feet. Has order for daily weights .will continue with daily weights to monitor weight trends. RD available. The clinical record did not contain refusals on the dates not documented. On 8/28/24 at 8:31 A.M., the DON (Director of Nursing) indicated there was not a unit manager at that time, it looked like someone was not monitoring, and the weights got missed for different reasons. On 8/28/24 at 10:57 A.M., the Administrator indicated there was not a specific policy for following physician orders, but it was the expectation of the facility that staff follow orders. 3.1-37(a)

Based on interview and record review, the facility failed to ensure residents dependent on staff for ADL (activities of daily living) were showered for 2 of 2 residents reviewed for ADL care. (Resident 33 and Resident Q) Findings include: 1. On 8/21/24 at 2:21 P.M., Resident 33 indicated that she did not get showers, and that staff only give her bed baths. She further indicated that she didn't feel clean. On 8/22/24 at 1:41 P.M., Resident 33's clinical record was reviewed. Diagnoses included, but were not limited to, hypertensive chronic kidney disease and diabetes mellitus. The most current Quarterly MDS (Minimum Data Set) Assessment, dated 8/9/24, indicated Resident 33 was cognitively intact, required substantial to maximal assistance of staff (staff does more than half) for bathing, and had no rejection of care. An Assistance with ADLs care plan, dated 6/2/24, indicated for staff to assist with bathing as needed per resident preference. Offer showers two times per week, partial bed bath in between. A Preferences for Customary Routine and Activities assessment, dated 8/9/24, indicated it was very important for the resident to choose between a tub bath, shower, bed bath, or sponge bath, and the resident was most used to showers. On 8/27/24 at 10:00 A.M., a current shower schedule was reviewed. Resident 33 was scheduled to receive showers on Tuesdays and Fridays during the day. On 8/28/24 at 12:00 P.M., the Director of Nursing (DON) provided bathing performed from 6/1/24 through 8/23/24; Resident 33 received 2 showers in June, no showers in July, and 2 showers in August. 2. On 8/21/24 at 9:58 A.M., Resident Q indicated she was supposed to get showers twice a week, but she was lucky if she got cleaned up once a week. She indicated that her hair only got washed when she took a shower so she washed her hair every time she got a shower because the showers were so far apart. She further indicated staff didn't offer to set up supplies for her to perform oral care every day. On 8/23/24 at 10:09 A.M., Resident Q's clinical record was reviewed. Diagnoses included, but was not limited to, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, irritable bowel syndrome with diarrhea, and generalized anxiety disorder. The most current Significant MDS (Minimum Data Set) Assessment, dated 6/13/24, indicated Resident Q was cognitively intact, required partial to moderate assistance of staff (staff does less than half) for bathing, and had no rejection of care. An Assistance with ADLs care plan, dated 6/8/22, indicated for staff to assist with bathing as needed per resident preference. Offer showers two times per week, partial bath in between. Prefers showers in the evening. A Preferences for Customary Routine and Activities assessment, dated 6/13/24, indicated it was somewhat important for the resident to choose between a tub bath, shower, bed bath, or sponge bath, and the resident was most used to showers. On 8/27/24 at 10:00 A.M., a current shower schedule was reviewed. Resident Q was scheduled to receive showers on Wednesdays and Saturdays during the day. On 8/28/24 at 12:00 P.M., the Director of Nursing (DON) provided bathing performed from 6/1/24 through 8/23/24; Resident Q received 8 showers in June, 4 showers in July, and 1 shower in August. On 8/28/24 at 12:27 P.M., the Administrator indicated residents got 2 showers a week and could request more. On 8/28/24 at 1:57 P.M., Clinical Support 5 indicated there was no shower/ADL policy and that the facility followed the Resident [NAME] of Rights. At that time, the policy Resident [NAME] of Rights, revised 12/17, was provided and indicated The resident has the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the Community . The resident has the right to be treated with consideration, respect and recognition of their dignity and individuality. 3.1-38(a)(2)(A) 3.1-38(a)(3)(B) 3.1-38(b)(2) 3.1-38(b)(3)

Based on interview and record review, the facility failed to ensure care plan conferences were completed for 3 of 3 residents reviewed for care plan conferences. (Resident M, Resident N, Resident Q) Findings include: 1. On 8/26/24 at 2:35 P.M., Resident M's clinical record was reviewed. Diagnoses included, but were not limited to, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, diabetes mellitus, generalized anxiety disorder, and depression. The most current Quarterly Minimum Data Set (MDS) Assessment, dated 7/5/24, indicated Resident M was cognitively intact and was dependent on staff for toileting, and required substantial to maximal assistance of staff (staff does more than half) for bed mobility and bathing. The clinical record lacked documented care plan conferences between 5/9/23 and 11/6/23. 2. On 8/21/24 at 1:59 P.M., Resident N indicated he did not have care plan meetings to discuss his care. On 8/22/24 at 11:33 A.M., Resident N's clinical record was reviewed. Diagnoses included, but were not limited to, chronic kidney disease, diabetes mellitus, and depression. The most current Annual Minimum Data Set (MDS) Assessment, dated 8/8/24, indicated Resident N was cognitively intact and was independent for all ADLs (Activities of Daily Living). The clinical record lacked documented care plan conferences between 6/23/23 and 2/5/24. 3. On 8/21/24 at 10:04 A.M., Resident Q indicated she did not have any care plan meetings until recently. On 8/23/24 at 10:09 A.M., Resident Q's clinical record was reviewed. Diagnoses included, but was not limited to, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, irritable bowel syndrome, and generalized anxiety disorder. The most current Significant Change Minimum Data Set (MDS) Assessment, dated 6/13/24, indicated Resident Q was cognitively intact and required partial to moderate assistance of staff (staff does less than half) for bed mobility, transfers, and bathing. The clinical record lacked documented care plan conferences between 7/25/23 and 2/5/24. On 8/27/24 at 12:10 P.M., the Social Services Director indicated that she was unable to find documented care plan conferences for Resident M between 5/9/23 and 11/6/23, for Resident N between 6/23/23 and 2/5/24, and for Resident Q between 7/25/23 and 2/5/24. Care plan conferences were completed quarterly and as needed. On 8/29/24 at 10:51 A.M., the Administrator provided an IDT (Interdisciplinary Team) Comprehensive Care Plan policy, revised 8/2023, that indicated The care plan review may be conducted face to face, via phone conference, video conference, or through written communication per resident and/or representative preference. Care plan problems, goals, and interventions must be reviewed and revised by the interdisciplinary team periodically and following completion of each MDS assessment. 3.1-35(d)(2)(B)

Based on observation, record review, and interview, the facility failed to ensure staff performed proper hand hygiene and disinfection of equipment during 2 of 2 random observations of resident care. (Resident 9) Findings include: 1. On 8/23/24 at 6:45 A.M., CNA (Certified Nursing Aide) 18 and CNA 4 were observed performing peri care for Resident 9. CNA 18 had gloves on and touched the nightstand and bedside table. CNA 4 turned Resident 9 to the right side and removed the soiled brief. CNA 18 cleaned Resident 9's buttocks with wipes and placed the soiled brief in a plastic bag. After placing the soiled brief in the plastic bag and without changing gloves, CNA 4 placed barrier cream on the resident's buttocks and positioned a new brief. CNA 4 donned new gloves without sanitizing or washing hands, applied cream to scrotal area with same gloves, and attached a clean brief. CNA 18 and CNA 4 did not change gloves before touching and placing clean clothes on Resident 9. CNA 4 removed gloves and placed the Hoyer pad under Resident 9 without hand sanitizing and proceeded to touch controls. CNA 18 touched the Hoyer Lift with soiled gloves and lowered the resident into his Broda chair. CNA 18 removed gloves and did not sanitize hands before straightening the sheets. CNA 18 placed soiled linen and trash into plastic bags, and did not sanitize hands. After Resident 9 was placed in Broda Chair, the Hoyer Lift was placed in hallway outside of room and was not cleaned. 2. On 8/23/24 at 7:05 A.M., LPN (Licensed Practical Nurse) 27 took a blood pressure of 143/71 on Resident 9 and put it on the medication cart. She did not clean the equipment after using it on the resident. During an interview on 8/23/24 at 11:50 A.M., Clinical Support 5 indicated hand hygiene should be done before applying gloves. Once gloves were applied things should only be touched that were needed to complete tasks. Gloves should be changed before and after peri care. Equipment should be cleaned in between residents. On 8/29/24 at 10:55 A.M., the Administrator provided a current Hand Hygiene policy, revised 12/2021. The policy indicated .health care professionals should use an alcohol-based rub for the following reasons: before moving from work on a soiled body site to clean body site on the same resident .after contact with body fluids, immediately after glove or PPE (Personal Protective Equipment) removal . On 8/29/24 at 10:56 A.M., the Administrator provided a current policy Standard and Transmission-Based Precautions (Isolation) policy, revised 4/24/24. The policy indicated . standard precautions refer to infection prevention practices that apply to all residents .change gloves during care and perform hand hygiene if hands move from a contaminated site to a clean site .shared equipment should be cleaned and disinfected in-between each resident use . 3.1-18(b) 3.1-18(l)

Based on interview and record review, the facility failed to ensure staff were qualified to administer insulin to residents for 3 of 6 residents reviewed for insulin. Qualified Medication Aides (QMAs) who were not insulin certified, administered insulin to residents and held insulin without a physician order or notification of nursing staff. (Resident N, Resident M, and Resident Q) Findings include: 1. On 8/26/24 2:35 P.M., Resident M's clinical record was reviewed. Diagnosis included, but was not limited to, diabetes mellitus. The most current Quarterly Minimum Data Set (MDS) Assessment, dated 7/5/24, indicated Resident M was cognitively intact and received insulin during the 7-day look back period. Physician orders included, but were not limited to: insulin lispro (a fast-acting insulin) - insulin pen; 100 unit/mL (units per milliliter) - give 10 units subcutaneous three times a day. Notify MD (Medical Doctor) if blood glucose is below 70 mg/dL (milligrams per deciliter) or above 400 mg/dL, dated 8/27/22. The February 2024 MAR (Medication Administration Record) indicated: QMA 8 administered insulin lispro to Resident M on 2/24/24 at 8:00 A.M. The March 2024 MAR indicated: QMA 8 administered insulin lispro to Resident M on 3/2/24 at 5:00 P.M. and 3/3/24 at 8:00 A.M. The April 2024 MAR indicated: QMA 8 administered insulin lispro to Resident M on 4/3/24 at 5:00 P.M. and 4/11/24 at 5:00 P.M. QMA 12 administered insulin lispro to Resident M on 4/5/24 at 5:00 P.M., 4/24/24 at 5:00 P.M., and 4/25/24 at 5:00 P.M. The May 2024 MAR indicated: QMA 8 administered insulin lispro to Resident M on 5/10/24 at 5:00 P.M. The August 2024 MAR indicated: QMA 12 held Resident M's insulin lispro for a blood glucose of 105 mg/dL. The physician was not notified. There was no documentation that a nurse was notified or that the resident was assessed by a nurse. 2. On 8/22/24 at 11:33 A.M., Resident N's clinical record was reviewed. Diagnosis included, but was not limited to, diabetes mellitus. The most current Annual Minimum Data Set (MDS) Assessment, dated 8/8/24, indicated Resident M was cognitively intact and received insulin during the 7-day look back period. Physician orders included, but were not limited to: insulin glargine (a long-acting insulin) - insulin pen; 100 unit/mL (units per milliliter) - give 45 units subcutaneous every 12 hours, dated 12/28/23. Insulin aspart (a rapid-acting insulin) - insulin pen; 100 unit/mL - give 12 units subcutaneous at bedtime. Notify MD (Medical Doctor) if blood sugar is below 50 mg/dL (milligrams per deciliter) or greater than 400 mg/dL, dated 6/2/23. Insulin aspart (a rapid-acting insulin) - insulin pen; 100 unit/mL - give 15 units subcutaneous three times a day. Notify MD if blood sugar is below 50 mg/dL or greater than 400 mg/dL, dated 6/3/24. The February 2024 MAR (Medication Administration record) indicated: QMA 8 administered insulin glargine to Resident M on 2/24/24 at 8:00 A.M. The March 2024 MAR indicated: QMA 8 administered insulin glargine to Resident M on 3/3/24 at 8:00 A.M. QMA 12 held Resident M's insulin glargine on 3/31/24 at 8:00 P.M. for a blood sugar of 95 mg/dL. The physician was not notified. QMA 8 administered insulin aspart to Resident M on 3/28/24 at 8:00 P.M. QMA 12 held Resident M's insulin aspart on 3/31/24 at 8:00 P.M. for a blood sugar of 85 mg/dL. The physician was not notified. There was no documentation that a nurse was notified or that the resident was assessed by a nurse. The April 2024 MAR indicated: QMA 8 administered insulin glargine to Resident M on 4/5/24 at 8:00 A.M. and 4/17/24 at 8:00 P.M. QMA 8 held Resident M's insulin glargine on 4/6/24 per nursing measure. The physician was not notified. There was no documentation that a nurse was notified or that the resident was assessed by a nurse. QMA 8 administered insulin aspart to Resident M on 4/17/24 at 8:00 P.M. The May 2024 MAR indicated: QMA 8 administered insulin glargine and insulin aspart to Resident M on 5/9/24 at 8:00 P.M. QMA 12 held Resident M's insulin glargine and insulin aspart on 5/13/24 for a blood sugar of 103 mg/dL. The physician was not notified. There was no documentation that a nurse was notified or that the resident was assessed by a nurse. The July 2024 MAR indicated: QMA 6 administered insulin glargine to Resident M on 7/13/24 at 8:00 P.M. 3. On 8/23/24 at 10:09 A.M., Resident Q's clinical record was reviewed. Diagnosis included, but was not limited to, diabetes mellitus. The most current Significant Change Minimum Data Set (MDS) Assessment, dated 6/13/24, indicated Resident Q was cognitively intact and received a hypoglycemic medication during the 7-day look back period. Physician orders included, but were not limited to: insulin degludec (an ultralong-acting insulin) - insulin pen; 100 unit/mL (units per milliliter) - give 10 units subcutaneous at bedtime, dated 7/18/24. The July 2024 MAR (Medication Administration Record) indicated: QMA 12 held Resident Q's insulin degludec on 7/22/24 at 8:00 P.M. for a blood sugar of 130 mg/dL (milligrams per deciliter), 7/28/24 at 8:00 P.M. for a blood sugar of 100 mg/dL, 7/29/24 for a blood sugar of 108 mg/dL, and 7/30/24 for blood sugar low. The physician was not notified. There was no documentation that a nurse was notified or that the resident was assessed by a nurse. On 8/27/24 at 2:30 P.M., employee records were reviewed. QMA 8, QMA 12, and QMA 6 were not insulin certified. In a handwritten statement dated 5/16/24, QMA 8 indicated it was [QMA 8's] understanding that [former Director of Nursing] said she had communicated with [Clinical Support 7] and that as long as my nurse was present [QMA 8] could give insulin . On 8/23/24 at 9:47 A.M., the Administrator, the Director of Nursing (DON), Clinical Support 7, and Clinical Support 5 indicated QMA 8 pushed boundaries and believed she was able to practice outside out her scope of practice because she was a nursing student. Corporate policy did not allow QMAs to administer insulin even if they were certified to do so. On 8/28/24 at 9:45 A.M., Clinical Support 5 indicated the nurse could have told QMA 12 and QMA 8 to hold insulin. The QMA should have documented that the nurse told her to hold it in the Not Administer Notes, but she didn't. She further indicated that she was unsure what the parameters for holding insulin were since none were listed. She indicated it would depend on the comfort level of the nurse, and the physician should have been notified if insulin with no hold orders was held. On 8/29/24 at 8:39 A.M., the DON indicated that even though nursing staff had been provided education on insulin there was still a need for more education. QMAs should not be assessing or holding insulin and should be clear in their documentation that a nurse was consulted. On 8/23/24 at 10:04 A.M., the Administrator provided a QMA Parameters and Scope of Practice policy, revised 7/26/19, that indicated The QMA shall document in a resident's clinical record all medications that the QMA personally administered. The QMA shall not document in a resident's clinical record any medication that was administered by another person or not administered at all (Medication, refusal, not available, etc.) . The following tasks shall NOT be included in the QMA scope of practice: Administer medication by the injection route, including the following: . Subcutaneous route . Complete any type of nursing assessment. This citation relates to complaint IN00435599. 3.1-35(g)(2)

Based on observation, interview, and record review, the facility failed to post accurate actual hours worked for licensed and unlicensed nursing staff directly responsible for resident care per shift daily for 5 of 7 days during the annual survey period. Finding includes: During an observation on 8/23/24 at 12:33 P.M., a posted nurse staffing data sheet, dated 8/23/24, was observed on the main desk. The sheet included, but was not limited to, the following information: Census, total number of staff for each shift and total hours of each shift for CNA (Certified Nurse Aide), LPN (Licensed Practical Nurse), and RN (Registered Nurse). The sheet indicated that 9.5 unlicensed nursing staff worked the day shift but did not specify which half of the shift the staff worked. During an observation on 8/26/24 at 3:20 P.M., a posted nurse staffing data sheet, dated 8/26/24, was observed on the main desk. The sheet included, but was not limited to, the following information: Census, total number of staff for each shift and total hours of each shift for CNA (Certified Nurse Aide), LPN (Licensed Practical Nurse), and RN (Registered Nurse). The sheet indicated that 5.5 licensed nursing staff worked the day shift but did not specify which half of the shift the staff worked. On 8/28/24 at 1:58 P.M., the Administrator provided a copy of posted nurse staffing sheets for dates 8/21/24, 8/22/24, 8/23/24, 8/26/24, and 8/27/24. Each of these dates did not reflect actual hours worked. At that time, the Administrator indicated she was unable to tell by looking at the posted nurse staffing sheet which half of the shift was worked. On 8/29/24 at 10:51 A.M., the Administrator provided a Posted Nurse Staffing Data and Retention Requirements policy, revised 7/2023, that indicated The facility must post the following information at the beginning of each shift . total number and actual hours worked by the following categories of licensed and unlicensed nursing staff .

Based on interview and record review, the facility failed to provide ADL (activities of daily living) care for 3 of 3 resident's reviewed for bathing. Bathing was not provided to residents. ( Resident B, Resident C, Resident D ) Finding includes: 1. On 1/29/24 at 9:50 a.m., Resident B indicated his showers are lacking, he has had a few bed baths, staff helped him change his diaper and get dressed that morning so he could go to therapy. Resident B indicated staff handed him his deodorant and he put it on, but did not wash him including using wipes on his bottom. Resident B indicated when was at home he took two showers a day. On 1/29/24 at 11:24 a.m., Resident B's clinical record was reviewed. Diagnoses included, but were not limited to, acute metabolic acidosis, chronic obstructive pulmonary disease, hypertensive heart disease with heart failure. Resident B was admitted to the facility on [DATE]. An admission MDS (Minimum Data Set) assessment, dated 12/21/23, indicated Resident D's cognition was intact, shower-dependent, personal hygiene - dependent. Care plans were reviewed and included, but were not limited to: Resident requires assistance with ADL's including bed mobility, transfers, eating and toileting related to: weakness, decreased mobility, incontinence, fall risk, advanced age, hypertensive heart disease w/heart failure, bradycardia, acidosis, hypokalemia, hypomagnesemia, BPH w/lower urinary tract symptoms et obstructive uropathy, retention of urine, alcohol dependence, alcoholic hepatitis, COPD, adult failure to thrive, HTN, A-FIB, anemia, HLD, depression, hereditary and idiopathic neuropathy, GERD, DX constipation. Approach included, but was not limited to, assist with bathing as needed per resident preference. Offer showers two times per week, partial bath in between .start date 12/20/23. Current shower sheets were reviewed and Resident B was scheduled to receive showers on Sunday and Wednesday evening shift. Shower days for December 2023 were: 12/20, 12/24, 12/27, 12/31 Shower days for January 2024 were: 1/3, 1/7, 1/10, 1/14, 1/17, 1/21, 1/24, 1/28, 1/31 Point of care history for bathing was reviewed and contained the following for December 2023 and January 2024: 12/18- PBB (partial bed bath) 12/20- shower 12/21- PBB 12/26- PBB 12/27- PBB 1/2- PBB 1/4- PBB & CBB (complete bed bath) 1/8- shower 1/10- PBB 1/11- shower 1/12- PBB 1/17- CBB 1/18- PBB 1/25- shower 1/26- CBB Shower report sheets for December 2023 and January 2024 were reviewed. Shower sheets included an area for staff to initial two times reattempts for shower, a signature box for resident to sign if they refused shower. 12/27- refused shower, not initialed by staff for reattempts, not signed by resident 12/20 - shower 1/3- CBB 1/6- refused shower- initialed by staff 2 attempts, not signed by resident 1/8- shower 1/10- refused shower, not initialed by staff or signed by resident, comments : wants shower @ 5 am -:30 (1/11/24) am going to ask that PT give shower due to morning rush 1/17- refused shower signed by resident for refusal 1/24- refused shower x 3 not initialed by staff or signed by resident 1/26- CBB No bathing refusals were in the clinical record for the days with no bathing documented. 2. On 1/29/24 at 12:36 p.m., Resident C's clinical record was reviewed. Diagnoses included, but were not limited to, Parkinson's disease, type 2 diabetes mellitus with diabetic poluneuropathy, unilateral primary osteoarthritis of left knee. A quarterly MDS (Minimum Data Set) assessment, dated 1/16/24, indicated Resident C's cognition was intact, shower/bathe self- supervision or touching assist. Care plans were reviewed and included, but were not limited to: [name] requires assistance with ADL's including bed mobility, transfers, eating and toileting related to weakness, decreased mobility, incontinence at times, Parkinson's disease without dyskinesia, DM 2 w/diabetic polyneuropathy, HTN, HLD, hypothyroidism, chronic pain syndrome, depression, insomnia, mononeuropathy of bilateral lower limbs, BPH, constipation, allergic rhinitis, dysphagia, osteoarthritis left knee. Approach included, but was not limited to, assist with bathing as needed per resident preference. Offer showers two times per week, partial bathing in between, start date 10/26/23. On 1/29/24 at 1:11 a.m., Resident C indicated they got their showers and bathing most of the time, but not always, shower days were Monday, Wednesday, and Friday. Current shower sheets were reviewed and Resident C was scheduled to receive showers Monday, Wednesday, and Friday day shift. Shower days for December 2023 were: 12/1, 12/4, 12/6, 12/8, 12/11, 12/13, 12/15, 12/18, 12/20, 12/22, 12/25, 12/27, 12/29 Shower days for January 2024 were: 1/1, 1/3, 1/5, 1/8, 1/10, 1/12, 1/15, 1/17, 1/19, 1/22, 1/24, 1/26, 1/19, 1/31. Point of care history for bathing was reviewed and contained the following for December 2023 and January 2024: 12/2- PBB 12/3- PBB 12/4- shower 12/7- PBB 12/9- PBB 12/11- shower 12/14- PBB 12/15- shower 12/16- shower 12/18- PBB 12/24- PBB 12/25- shower 12/31- PBB 1/3- shower 1/8- PBB 1/12- shower 1/13- PBB 1/15- shower 1/17- shower 1/26- PBB 1/29- PBB Shower report sheets for December 2023 and January 2024 were reviewed. Shower sheets included an area for staff to initial two times reattempts for shower, a signature box for resident to sign if they refused shower. 12/4- shower 12/6- shower 12/9- shower 12/11- left blank not singed by staff 12/14- shower 12/15- shower 12/18- shower 12/20- shower 12/25- shower 12/28- shower 1/3- shower 1/5- shower 1/8- left blank not signed by staff 1/12- shower 1/15- shower 1/17- shower 1/22- shower 1/27- shower No bathing refusals were in the clinical record for the days with no bathing documented. On 1/30/24 at 10:00 a.m. a facility concern/grievance form dated 1/5/24 for Resident C was reviewed and included the following: Nature of concern: Resident states he is only getting 1 shower a week. He states he use to get 3 a week on the other unit. Department Head review and action: Spoke to resident about showers, explained when he switched rooms the shower days are 2 x a week. Writer also explained if he would like 3 x a week for showers I can update the shower sheet so he can have 3 a week. Writer also stated we would speak with staff about showers. 3. On 1/30/24 at 9:50 a.m., Resident D indicated they did not get their shower last night, staff will mark refusals, but they just don't wake them up, sometimes they get a shower the next day. Resident D indicated staff did not wash them today only dressed them. On 1/30/24 at 10:18 a.m., Resident D's clinical record was reviewed. Diagnoses included, but were not limited to, chronic obstructive pulmonary disease, spinal stenosis, lumbosacral region, spinal stenosis, cervical region, contracture right shoulder, contracture right elbow. A quarterly MDS (Minimum Data Set) assessment, dated 12/8/23, indicated Resident D's cognition was intact, shower/bathe self- partial moderate assistance. Care plans were reviewed and included, but were not limited to: Resident requires assistance with ADL's including bed mobility, transfers, eating and toileting related to: weakness, decreased mobility, impaired balance, impaired mobility to BUE et BLE, incontinence, fall risk, .spinal stenosis, contracture right shoulder/left elbow/right hand .Approach included, but was not limited to, assist with bathing as needed per resident preference. Offer showers two times per week in the AM, partial bath in between. Current shower sheets were reviewed and Resident D was scheduled to receive showers on Monday and Thursday night shift. Shower days for December 2023 were: 12/4, 12/7, 12/11, 12/24, 12/18, 12/21, 12/25, 12/28 Shower days for January 2024 were: 1/1, 1/4, 1/8, 1/11, 1/15, 1/18, 1/22, 1/25, 1/29 Point of care history for bathing was reviewed and contained the following for December 2023 and January 2024: 12/4 CBB 12/5- CBB 12/7- CBB 12/11-CBB 12/16- PBB 12/17- PBB 12/20- PBB 12/23- PBB 12/31- CBB 1/1- PBB 1/7-PBB 1/8- PBB 1/12- CBB 1/22- CBB 1/25- PBB 1/29- PBB Shower report sheets for December 2023 and January 2024 were reviewed. Shower sheets included an area for staff to initial two times reattempts for shower, a signature box for resident to sign if they refused shower. 12/4- comments: was charted that her bath was already done, not signed by staff or resident 12/8- CBB 12/11- written by staff: BB morning before she gets up. Not signed by staff or resident 12/15- Comments: refused, no initialed by staff for reattempts, not signed by resident 1/11- CBB 1/12- CBB 1/16- CBB 1/21- CBB 1/22- CBB No bathing refusals were in the clinical record for the days with no bathing documented. A anonymous interview indicated when a shower is done, the CNA fills out a shower sheet, the nurse looks at it to ensure it was done, if a shower is refused by the resident, staff are supposed to attempt again, let the nurse know, and have the resident sign the shower sheet for refusal, they believe staff sometimes are signing that a resident refuses a shower when the resident didn't refuse. On 1/30/24 at 12:18 p.m., CNA 1 indicated is a resident refuses a shower, staff are supposed to reattempt twice and sign the sheet, tell the nurse, have the resident sign for refusal on the third attempt. On 1/30/24 at 12:35 p.m., the DON indicated the facility does not have a specific policy on bathing or ADL's. On 1/30/24 at 12:40 p.m., the DON provided the current policy on resident rights with an original date of 11/15. The policy included, but was not limited to: In accordance with this right to dignity and respect, residents are entitled to all of the freedoms and privileges of any other citizen .(20) Residents have the right to be suitably dressed at all times and given assistance when needed in maintaining body hygiene and good grooming . This citation relates to Complaint IN00426893. 3.1-38(b)(2)

Based on observation, interview, and record review, the facility failed to ensure accurate and complete documentation was recorded on the EMAR (Electronic Medication Administration Record) for 5 of 7 residents reviewed for medications. Medications were not documented as given. ( Resident D, Resident E, Resident F, Resident H, Resident J) Finding includes: On 10/13/23 at 9:30 a.m., the clinical record was reviewed for resident's chosen for medication review. The following medications were not documented as given on the dates listed: Resident D: 8/23/23 - clonazepam 0.5 mg oral three times a day 6:00 a.m., 3:00 p.m., 11:00 p.m. The 11:00 p.m. dose was not documented as given. 8/23/23- hydrocodone-acetaminophen 7.5 mg -325 mg oral three times a day 6:00 a.m., 3:00 p.m., 11:00 p.m. The 11:00 p.m. dose was not documented as given. Resident E: Rezvoglar KwickPen (insulin glargine-agir) insulin pen; 100 unit/ml(milliliter) (3 ml); amount to administer 10 units subcutaneous at bedtime. The following dates were not documented as given: 8/8/23, 8/13/23, 8/19/23, 8/28/23, 9/17/23, 9/29/23. 9/8/23- hydralazine 25 mg amt: 75 mg oral three times a day 8:00 a.m., 2:00 p.m., 8:00 p.m. The 8:00 a.m. dose was not documented as given. 9/29/23- metoprolol tartate 25 mg amt; 12.5 mg oral special instructions hold for HR less than 60 beats/hour twice a day 7:00 a.m.- 11:00 a.m., 7:00 p.m.- 10:00 p.m. The p.m. dose was not documented as given. 9/29/23- sodium chloride 1,000 mg amt; 1 gram oral twice a day 7:00 a.m.-11:00 a.m., 7:00 p.m.- 10:00 p.m. The p.m. dose was not documented as given. Resident F: 10/8/23- senna 8.6 mg (milligram) amt: 17.2 mg oral twice a day 7:00 a.m.- 11: 00 a.m., 7:00 p.m.- 11:00 p.m. The p.m. dose was not documented as given. 10/8/23- tizanidne 2 mg oral twice a day 7:00 a.m.-110:00 a.m., 7:00 p.m.- 11:00 p.m. The p.m. dose was not documented as given. Resident H: 10/8/23- Lantus Solostar U-100 insulin (insulin glargine) insulin pen; 100 unit/ml (3 ml)k; amt: 45 units subcutaneous special instructions : notify MD if blood glucose < 60 or > 400 at bedtime 9:00 p.m. 10/8/23- lisinopril 20 mg oral twice a day 7:00 a.m.- 11:00 a.m., 7:00 p.m.-11:00 p.m. The p.m. dose was not documented as given. 10/8/23- medroxyprogesterone 2.5 mg amount to administer 5 mg oral three times a day 8:00 a.m., 2:00 p.m., 8:00 p.m. The 8:00 p.m. dose was not documented as given. 10/8/23- melatonin 5 mg oral at bedtime. 10/8/23- trazodone 50 mg oral at bedtime. 10/8/23- zoloft (sertraline) 25 mg oral at bedtime. 10/8/23- metoprolol succinate extended release 24 hr; 100 mg oral twice a day 7:00 a.m.- 11:00 a.m., 7:00 p.m.- 11:00 p.m. The p.m. dose was not documented as given. 10/8/23- metformin 1,000 mg oral twice a day 7:00 a.m.-11:00 a.m., 7:00 p.m.- 11:00 p.m. The p.m. dose was not documented as given. Resident J: 10/8/23- atorvastatin 20 mg oral at bedtime. 10/8/23- budesonide suspension for nebulizer; 0.5 mg/ml ; amt: 1 vial; inhalation twice a day 7:00 a.m.- 11:00 a.m., 7:00 p.m.- 10:00 p.m. The p.m. dose was not documented as given. 10/8/23- colace (docusate sodium) capsule 100 mg oral at bedtime. 10/8/23- Eliquis (apixaban) 5 mg oral twice a day 7:00 a.m.- 11: 00 a.m., 7:00 p.m.- 10:00 p.m. The p.m. dose was not documented as given. 10/8/23-formoterol fumarate solution for nebulization; 20 mcg (microgram /2 ml; amount to administer 1 vial; inhalation twice a day 7:00 a.m.- 11:00 a.m., 7:00 p.m.- 10:00 p.m. The p.m. dose was not documented as given. 10/8/23- hydrocodone- acetaminophen 7.5- 325 mg; oral three times a day 8:00 a.m., 2:00 p.m., 8:00 p.m. The 8:00 p.m. dose was not documented as given. 10/8/23- loratadine 10 mg oral at bedtime. 10/8/23- metaprolol tartrate 25 mg oral three times a day 8:00 a.m., 2:00 p.m., 8:00 p.m. The p.m. dose was not documented as given. 10/8/23- polyethylene glycol 3350 powder; 17 gram/dose oral at bedtime. 10/8/23- tamsulosin 0.4 mg oral at bedtime. 10/8/23- triamcinolone acetonide cream 0.025 % amount to administer : thin layer; topical twice a day 7:00 a.m.- 11:00 a.m., 7:00 p.m.- 11:00 p.m. The p.m. dose was not documented as done. On 10/11/23 at 10:19 a.m., the interim DON indicated the facility had been having an issue with medications being documented as given on the EMAR. The Administrator indicated nurses are supposed to be documenting on the EMAR when medications are given. On 10/11/23 at 10:38 a.m., LPN 1 indicated medications given are supposed to be signed off as given on the EMAR. On 10/10/23 the interim DON provided a document titled Med Pass with CareAssit eMAR. The document included, but was not limited to: Administration compliance report- every nurse must run this report at the end of their shift. This report will show all orders/tasks that have been missed. If this report is blank than all orders/tasks have been administered/satisfied as scheduled. On 10/12/23 at 12:20 p.m., the Administrator provided the current policy dose preparation and medication administration with a revision date of 1/1/22. The policy included, but was not limited to: .document necessary medication administration/treatment information (e.g.; when medications opened, when medications are given, injection site of a medication, if medications are refused, PRN medications, application sight) on appropriate forms . This Federal tag relates to Complaint IN00416094. 3.1-50(a)(1)

Based on observation, interview, and record review, the facility failed to ensure each resident received supervision and consistent implementation of interventions to prevent falls for 1 of 3 residents reviewed for falls. Resident 31 had a fall that resulted in a fracture to right femur. (Resident 31) Finding includes: During an interview on 5/21/23 at 11:14 A.M., Resident 31's spouse indicated Resident 31 had fallen several times and recently had a fall that resulted in sutures and staples. He was concerned that the falls resulted from a lack of staffing on the unit. He indicated he had been to management several times with the concern, and was told that Resident 31's falls could have been prevented if there was more staff. He indicated during the most recent fall, the CNA (Certified Nurse Aide) had left all the residents on the hall to get report from another CNA in another hall. At that time, Resident 31 was in her room and had gotten up by herself to walk toward the door. Her alarm was sounding, but because of the lack of staff on the unit, they did not get to her until she was on the floor in the doorway. On 5/23/23 at 8:48 A.M., Resident 31's clinical record was reviewed. Diagnosis included, but were not limited to, Alzheimer's disease, dementia, anxiety, and psychotic disorder. The most recent quarterly MDS (minimum data set) Assessment, dated 4/17/23, indicated Resident 31 was severely cognitively impaired, required extensive assistance of two staff for bed mobility and transferring, extensive assistance of one staff for toileting, and had experienced one fall since admission with no injury. A current falls care plan, dated 2/1/19, included the following interventions: Resident to be laid down after she is done eating prior to removing hall trays, dated 5/8/23. Resident activity to use hands, dated 12/16/22. Velcro shoes, dated 9/19/22. Resident to be at afternoon activities, dated 9/10/22. Floor mat with alarm. Check placement and function every shift, dated 6/2/21. Offer resident to speak with husband on the phone when she appears anxious, dated 11/20/20. Encourage resident to lay down in the afternoon, dated 10/14/20. Bed against the wall, dated 4/19/20. Non-skid socks at bedtime, dated 3/31/20. Visual reminder to the call light, dated 12/9/19. Call light in reach, dated 10/23/19. Personal items in reach, dated 10/23/19. Fall events included the following: Fall 1 9/10/22 at 3:12 P.M. Resident was sitting in her wheelchair in the dining room prior to the fall, got up out of her wheelchair, and fell . The fall was unwitnessed by staff. All staff were in other resident's rooms assisting them. The fall event indicated all fall interventions were in place and effective at that time, and would continue to monitor. An IDT (Interdisciplinary Team) meeting, dated 9/12/23, indicated fall was witnessed, and the new intervention would be to have the resident attend afternoon activities. The falls care plan was updated with new intervention on 9/10/22. Fall 2 9/16/22 at 2:27 P.M. Nurse was notified by staff that resident was sitting in the hall on the floor. Resident 31 was observed sitting on buttocks with legs outstretched. A wheelchair was observed behind her. Fall was witnessed. The fall event indicated resident was bent down to mess with her shoes, and fell out of the wheelchair. The immediate intervention was to shorten the cord on the tabs alarm. The clinical record lacked an IDT meeting related to the fall. The falls care plan was updated with intervention Velcro shoes on 9/19/22. Fall 3 12/15/22 at 1:50 P.M. Nurse was notified by staff that resident was in the floor in the dining room. Resident 31 was observed laying on her back with her legs extended out. Resident 31 had a small red area above her right ear. Fall was unwitnessed. The fall event indicated the resident had been trying to stand up and staff would assist her back down in her chair. An IDT meeting, dated 12/16/22, indicated the new intervention would be to shorten the alarm string (completed on previous fall), and redirect to activity to use her hands. The falls care plan was updated with intervention for resident activity to use hands on 12/16/22. Fall 4 4/2/23 at 6:01 P.M. Resident was attempting to transfer self in the dining room from her wheelchair to another chair. Staff heard a chair scoot across the floor and then heard the alarm sounding. Resident 31 slid to the floor before staff could reach her. Fall was witnessed. The immediate intervention was to lay resident down in bed. An IDT meeting, dated 4/4/23, indicated the new intervention would be to place resident in bed after finishing dinner. Fall 5 5/7/23 at 6:30 P.M. Nurse was notified by staff that resident was on the floor. Resident was observed outside of room [ROOM NUMBER] with an alarm clip attached to her back. Resident 31's wheelchair was noted alarming in room [ROOM NUMBER]. At 6:00 A.M. the following day, a CNA notified the nurse that the resident was crying and grabbing at her right hip and right leg while attempting to assist her out of bed. An x-ray was ordered and showed an acute, displaced right femoral neck fracture (hip fracture). Resident 31 was sent to the ER (emergency room ) for treatment. An IDT meeting, dated 5/8/23, indicated the new intervention would be to have antithrust cushion to the wheelchair, and resident to be laid down after she is finished eating prior to removing hall trays. The care plan was updated 5/8/23 to include lying the resident down after meals before removing hall trays, but lacked any new intervention related to an antithrust cushion to the wheelchair. A radiology report, dated 5/8/23, indicated Resident 31 had a current fracture of the right femoral neck with displacement of the distal fragment. On 5/23/23 at 9:11 A.M., Resident 31 was observed sitting in the common area in a Broda chair during an exercise activity. A blanket was observed over her lap, and her feet were up. There was no hand activity observed in her lap or hands. On 5/23/23 at 1:32 P.M., Resident 31 was observed sitting in the dining area with her spouse. Resident was observed in a Broda chair with a blanket over her. There was no hand activity observed in her lap or hands. On 5/24 23 at 8:55 A.M., Resident 31 was observed in the dining area with a robe on. There was no hand activity observed in her lap or hands. During a continuous observation on 5/25/23 from 7:39 A.M. until 9:10 A.M., the following was observed: Resident 31 was observed sitting at a table with 2 other residents. She was observed sitting in a regular wheelchair facing the wall from across the table. An activity cloth was observed in her lap, but the resident was unaware of it, not acknowledging or touching it. A food cart was brought to the unit at 7:51 A.M. After all residents had finished the meal, CNA 25 and Activities 35 were observed to remove dishes and trays, and load the food cart. The food cart was taken out of the dining area at 8:54 A.M. At that time, CNA 25 and CNA 31 assisted another resident to their room. The food cart was taken off of the unit at 8:56 A.M. At 8:59 A.M., CNA 25 and CNA 31 assisted another resident into her wheelchair and into their room. At that time, CNA 25 indicated to CNA 51 in the hall all of the residents that needed assisted to their rooms, but did not mention Resident 31's name. At 9:10 A.M., QMA (Qualified Medication Aide) 33 asked Resident 31 if she wanted to go to exercises. The resident indicated she did, and QMA wheeled her down the hall. During an interview on 5/25/23 at 9:15 A.M., CNA 25 indicated she used her own judgement related to keeping Resident 31 up after meals or assisting to lay down. She indicated because she was awake more, she liked to keep her up between breakfast and lunch. During an interview on 5/25/23 at 10:15 A.M., the DON (Director of Nursing) indicated an IDT meeting should have been conducted after each fall or accident. She indicated she was aware that a meeting was not documented after Resident 31's 9/16/22 fall, and thinks they may have completed one, but forgot to save it in the computer. During an interview on 5/25/23 at 11:05 A.M., RN (Registered Nurse) 23 indicated Resident 31 used to have a pull tab alarm that was currently discontinued. She indicated staff tries to keep her near at all times and engaged in some sort of activity. RN 23 indicated discontinuing the pull tab alarm had contributed to her falls, and she needed to have it again. She indicated though it did not prevent falls, staff was able to get to her before she fell with the alarm. During an interview on 5/25/23 at 11:19 A.M., the DON indicated the pull tab alarm was discontinued when the resident returned from the hospital after the most recent fall on 5/7/23 because upon her return, she was in a Broda chair. She indicated now that she was in a regular wheelchair, they were still discussing the need for the pull tab alarm to be reinstated. On 5/25/23 at 7:28 A.M., a current Fall Management Policy, revised 8/2022, was provided and indicated It is the policy of [company name] to ensure residents residing within the facility receive adequate supervision and or assistance to prevent injury related to falls . The care plan will be reviewed and updated, as necessary 3.1-45(a)

Based on observation, interview, and record review, the facility failed to maintain resident's dignity for 1 of 4 residents observed for incontinence care, and 1 of 2 observations of a meal. (Resident 62, Cottage Dining Room-Resident 41, Resident 75, Resident 70, Resident 31) Findings include: 1. On 5/23/23 at 9:51 A.M., CNA (Certified Nurse Aide) 25 and QMA (Qualified Medication Aid) 54 were observed to assist Resident 62 with incontinence care. During care, CNA 25 indicated At least he didn't get naked today. I shouldn't talk too soon. After checking Resident 62's brief, QMA 54 asked CNA 25 Are we going to need a new diaper?. After care was performed, CNA 25 indicated staff should respect resident dignity by speaking with the resident while performing care, explain what they were doing, and try to ease the resident. 2. On 5/25/23 at 8:13 A.M., breakfast was observed in the Cottage Dining Room of the dementia unit. At that time, there were 11 residents seated in the dining room. CNA 25 was observed speaking loudly to Therapist 41 about the residents sitting in the dining room. CNA 25 indicated that Resident 62 was ok yesterday, then he was acting up during lunch. CNA 25 then indicated Resident 41 was ok about 90% of the time and was easier to give showers than the other residents. Therapist 41 indicated to CNA 25 that Resident 75 was so cute while sitting across from the resident. CNA 25 spoke to Therapist 41 from across the room about a conversation her and Resident 70 had the previous day. Therapist 41 then got up and walked to CNA 25 where they both discussed Resident 31's medications, behavior, and other medical status while CNA 25 was assisting Resident 31 to eat. During an interview on 5/25/23 at 10:16 A.M., the DON (Director of Nursing) indicated staff should not talk to other staff members while assisting residents to eat or in the dining room with other residents. Staff should only be attentive to the resident they were attending. On 5/25/23 at 7:28 A.M., a current Resident Rights policy, revised 11/2016, was provided and indicated All staff members recognize the rights of residents at all times and residents assume their responsibilities to enable personal dignity, well being, and proper delivery of care 3.1-3(a)

Based on interview and record review, the facility failed to ensure a resident's complaints of leg and hip pain was adequately assessed, resulting in contractures, unrelieved pain, hospitalization , and surgery to remove a dislocated prosthesis, for 1 of 5 residents reviewed for pain control, in a sample of 10. Resident B Findings include: 1. The closed clinical record of Resident B was reviewed on 8/18/14 at 2:00 P.M. [DIAGNOSES REDACTED]. A resident care plan, dated 8/28/13 and with a long term goal date of 10/21/14, indicated: "Problem: Potential for pain related to disease process, [MEDICAL CONDITION]. Approach: Notify MD if pain is unrelieved and/or worsening. Observe for changes in day to day activities. Observe for non verbal signs of pain: changes in breathing, vocalizations, mood/behavior changes...." Physician orders, dated July 2014, included the following: 1/10/14 [MEDICATION NAME] 7.5 mg-325 mg every 6 hours as needed for pain, 1/10/14 Tylenol 325 mg Take 2 tablets every 4 hours as needed for pain, 5/29/14 [MEDICATION NAME] 5-325 mg Take 2 tablets twice daily 8:00 A.M. and 4:00 P.M. A "Therapy Assessment" Screening form, dated 4/9/14 at 11:42 A.M., indicated: "Reason for screen...nursing referral...Hygiene, Extensive Assist, Decline; Bed mobility, Dependent, Decline; Transfers, Dependent, Decline; Walking, Dependent, Decline...ADL (activities of daily living) - has the resident had a decline in ADL's...Yes - bed mobility...Does the resident have ROM (range of motion) that is impaired putting the resident at high risk for skin breakdown, poor hygiene or pain, Yes- BLEs (bilateral lower extremities)...Recommendation, Physical Therapy Eval (evaluation)." A Physical Therapy Plan of Care, dated 4/14/14, indicated: "This therapist performed quarterly screen this resident (sic). Pt (patient) demo (demonstrated) significant decline in overall mobility, BLE contracture, and severe pain during movement. PT (physical therapy) is appropriate to improve ROM, decrease pain in order to improve bed mobility and w/c (wheelchair) positioning. Therapy necessity: Therapy necessary for contracture and pain...Medical History...recent left hemiarthroplasty (hip replacement)...Precautions:...pain to BLE >LLE during movement...Pain Intensity: 9/10...Effect of Pain on Function, severe effect on function...ROM...L (left) knee extension limited to -50 degrees to neutral...L hip abducted to -29 to neutral...Current Level of Function, Patient demonstrates PROM (partial range of motion) of L LE (lower extremity) adduction -29 degrees with complaints of pain...." A nursing Weekly Summary, dated 4/15/14 at 2:38 P.M., included: "Pain, In last 7 days have pain medications been administered, Yes; Ask resident: Have you had pain or hurting at any time in the last 5 days? Yes; Ask resident: Please rate the intensity of your worst pain over the last 5 days, Unable to answer; Ask resident: How much of the time have you experienced pain or hurting over the last 5 days? Unable to answer; Resident makes vocal complaints: i.e. ouch, that hurts, stop...." A Minimum Data Set (MDS) assessment, dated 4/25/14, indicated the resident scored a 14 out of 15 for cognition, with 15 indicating no memory impairment. The resident exhibited "Inattention" and "Disorganized thinking" as "Behavior present, fluctuates." The resident required extensive assistance of two+ staff for transfer and hygiene, and did not ambulate. A "Functional Limitation in Range of Motion" was coded as "No Impairment" for either the upper extremities or lower extremities. The MDS assessment indicated the resident received a scheduled pain medication regime in the previous 5 days, and did not receive a PRN (as needed) pain medication. The resident received non-medication interventions for pain. The Pain Assessment Interview indicated the resident was unable to answer if she had pain. "Indicators of Pain or Possible Pain in the last 5 days" indicated the resident had "Vocal complaints of pain." A Physical Therapy note, dated 5/4/14, indicated, "Resident refuses PT treatment this date. Resident states that she 'doesn't want to be tortured.' Resident to be d/c'd (discontinued) from PT secondary to refusals and no progress this time." An Occupational Therapy (OT) Plan of Care, dated 5/7/14, included: "Pt referred to skilled OT for w/c positioning d/t (due to) Nsg (nursing) staff trying to encouraged (sic) sitting up with pt c/o pain in w/c...Pain Intensity, 10/10...The patient refusing to utilize abductor pillow between legs for increased positioning seated in w/c...The patient exhibits BLE (bilateral lower extremities) internal rotation...Note: Changing and maintaining body position functional limitation, current status has been documented based on pt c/o (complaints of) pain 'all over' 10/10...Pt presents with L LE internal rotation and hips thrusted. To trial different w/c's to increase positioning and decrease pain...." An OT note, dated 5/7/14 at 2:50 P.M., indicated, "...Pt. c/o B LE pain immediately upon sitting in w/c. Pt educated on just getting up from bed and B LE tight cause pain...Pt wanting leg rests d/t pain. Pt presents with good posture but L LE internal rotation. Pt refused abductor pillow. Pt seated in w/c x 1 hour with request to get out and try different w/c...Pt set-up with different regular 18 in w/c...only seated x 30 min before c/o w/c being too small and crying to get out...." Additional OT notes included: 5/8/14: "...Pt refusal to get in chair multiple times this date...." 5/9/14: "Pt refusal to get up this date with multiple attempts...." A nursing Weekly Summary, dated 5/10/14 at 10:39 A.M., included: "Pain, In last 7 days have pain medications been administered, Yes; Ask resident: Have you had pain or hurting at any time in the last 5 days? Yes; Ask resident: Please rate the intensity of your worst pain over the last 5 days, Unable to answer; Ask resident: How much of the time have you experienced pain or hurting over the last 5 days? Unable to answer; Resident makes non-verbal sounds that may indicate pain: i.e. crying, whining, gasping, moaning or groaning; Resident makes vocal complaints: i.e. ouch, that hurts, stop...Over the past five days have you limited your day to day activities because of pain? N/A (not applicable)...." OT notes continued: 5/12/14: "Pt refusal to get up in w/c this date with multiple attempts...." 5/15/14: "Pt max x 2 transfer to chair...Pt immediately c/o pain and requesting to get out. Encouraged pt to trial for a day or a few hours. Pt stated, 'Why are you trying to punish me? You're trying to punish me...." 5/16/14: "Res (resident) noted to have increased confusion and disorientation...Res. reported having a 'broken leg,' reported to nsg'ing (sic)...." 5/19/14: "...Patient refusing to get up from bed d/t pain, nursing notified." 5/22/14: "...Pt requesting a wider w/c d/t hips hurting. Educated and explained to pt we have tried wider chair and too wide with 18 in appropriate...." 5/28/14: "Pt increase (sic) behaviors and crying with non-inteligble (sic) speech...." 5/29/14: "Pt refusing original 18 in highback (W/C) stating, 'It's old, I need a new one. I (sic) causes pain in my hip.' Pt set-up with a different 18 in highback...Pt seated in w/c and req repositioning of hips...." 5/30/14: "...Pt refusing to get up in w/c d/t increased B LE pain and 'allowing legs to rest.'...." 6/2/14: "...Patient states she has 'leg pain,' nursing aware....." A nursing Weekly Summary, dated 6/6/14 at 1:31 P.M., included: "Pain, In last 7 days have pain medications been administered, Yes; Ask resident: Have you had pain or hurting at any time in the last 5 days? Yes; Ask resident: Please rate the intensity of your worst pain over the last 5 days, Unable to answer; Ask resident: How much of the time have you experienced pain or hurting over the last 5 days? Unable to answer; Resident makes non-verbal sounds that may indicate pain: i.e. crying, whining, gasping, moaning or groaning, Resident makes vocal complaints: i.e. ouch, that hurts, stop...Resident makes facial expressions: i.e. grimaces, winces, wrinkled forehead, furrowed brow, clenched teeth, Over the past five days have you limited your day to day activities because of pain? N/A (not applicable)...." OT notes continued: 6/10/14: "Patient refused to get up today verbalizing she has a 'broken hip.' Reported to nursing. Patient educated to benefits of getting up from bed daily...." A nursing Progress Note, dated 6/15/14 at 10:36 A.M., indicated, "...Was yelling this am. Leg broke. Wanted to go to hospital. Informed her leg was not broke. Than stated someone was under her pillow...Had routine pain med and anxiety med...." OT notes continued: 6/16/14: "...Patient refused to get up this date d/t her 'broken hip.' Nursing aware...." 6/17/14: "Pt located in bed with c/o leg pain. Report to nursing...continue to c/o LE pain seated in w/c. Pt educated on ROM to work on decreased tightness...." 6/18/14: "Patient located in bed and refusing to get up verbalizing she swallowed 'ammonia' and needs to go to the hospital, reported to nursing. Patient unable to give a number to leg pain...." A nursing Progress Note, dated 6/19/14 at 10:26 A.M., indicated, "...Has been yelling most of am with various complaints. Wanted up. Then complained she was up. Stated it was not her w/c...Wanted foot rest lowered. Stated they were too high...Continued yelling. Refused to eat breakfast...." A OT Discharge Summary, dated 6/27/14, indicated, "Short Term Goals History, Pain, Goal Not Met, The patient reports a pain scale rating of 8/10 (1-10 pain scale measure) for B LE with refusal to received therapy treatment...." Nursing Progress Notes included the following notations: 6/27/14 at 3:14 P.M.: "...Sitting in bed and moaning continuously...Fluids encouraged...moans continuously when attempting to give drink by cup...." 6/28/14 at 6:25 A.M.: "Res has been awake most of noc...Res chanting. States leg is broken...Refused to drink...mumbled speech." 7/2/14 at 7:04 A.M.: "Res has been awake off and on. Quietly chanting. Unable to determine what she was saying...." 7/6/14 at 2:44 P.M.: "...Asked this nurse if she could have her two pain pills while eating lunch. I explained to resident that it was not in compliance with med times to give since she refused this am. PRN pain pill given...." A MDS assessment, dated 7/13/14, indicated the resident scored a 12 out of 15 for cognition, was totally dependent on two + assist for transfer, did not ambulate, and had no impairment in Range of Motion. The MDS assessment indicated the resident received scheduled pain management in the previous 5 days, and did not receive PRN pain medication, nor non-medication intervention for pain. The assessment indicated no pain assessment interview was conducted. Staff assessment of pain indicated the resident had vocal complaints of pain. Nurses notes continued: 7/13/14 at 12:11 P.M.: "...Laying in bed with hand on her face most of am, mouth open and yelling. Was unable to redirect...." 7/18/14 at 10:56 A.M.: "...At first refused meds this am. When told her pain med was included, resident then took all meds...." A nursing Weekly Summary, dated 7/22/14 at 2:17 P.M., included: "Pain, In last 7 days have pain medications been administered, Yes; Ask resident: Have you had pain or hurting at any time in the last 5 days? Yes; Ask resident: Please rate the intensity of your worst pain over the last 5 days, Unable to answer; Ask resident: How much of the time have you experienced pain or hurting over the last 5 days? Unable to answer; Resident makes vocal complaints: i.e. ouch, that hurts, stop...Over the past five days have you limited your day to day activities because of pain? N/A (not applicable)...." 7/22/14 at 2:25 P.M.: "...Turned side to side. Is very resistive to being on side. Still will not allow her feet to be elevated...." 7/27/14 at 6:12 P.M. (sic): "N.O. (new order) recvd (sic) to send pt to (name of hospital) ER for further tx (treatment) and eval...daughters were by the bedside and stated that their mother kept saying she needed to go to hospital and that they felt she may need to go...." A nursing ER flowsheet, dated 7/27/14 at 8:15 P.M., indicated, "Complains of pain /discomfort, Left hip, constant, aching, Pain Rating (0-10) 10, Non Verbal Indicators, moaning...." A hospital physician note, dated 7/29/14, indicated, "(Left) leg contractures (after) (Left) hip prosthesis placement one year ago...Concern for subluxation/dislocation - Ortho consult...." An Orthopedic Consult, dated 7/31/14, included: "Chief Complaint: Left hip pain...She fell approximately 1 year ago resulting in a left femoral neck fracture. She underwent a hemiarthroplasty...she was able to get up and sit in a chair and could walk short distances with her walker; however, she has complained of pain...Then approximately 2-3 months ago they (family) noted that she continued to complain of worsening hip pain with some significant internal rotation of her hip and associated knee contractures. Family states that they discussed this with the nursing facility; however, as far as they know, there were no x-rays or further studies to investigate...During this admission the family requested that the hip be x-rayed due to her ongoing complaints of pain. X-rays showed a left hip dislocation which is believed to be chronic. She then had a CT scan done of the pelvis which shows a dislocation of the left femoral head prosthesis with chronic remodeling of the hip...Physical Examination:...Her right hip is internally rotated. Her left knee overlies the right thigh, and in fact puts a significant amount of pressure into the right thigh. Her knee is flexed to greater than 90 degrees. I was unable to straighten the knee and trying to abduct the hip is also painful for the patient...she appears to be in obvious pain with this hip and deformity...." A hospital surgery note, dated 8/4/14, indicated, "Operative Findings: The patient...with findings consistent with a chronic dislocation of hemiarthroplasty of the left hip. She had developed hip and knee flexion contractures, which were confirmed at the time of surgery. On exposing the left hip at surgery today, evidence of chronic dislocation of the hemiarthroplasty was found. At the acetabulum, there appeared to be complete erosion of the superior dome of the acetabulum...removal of the hemiarthroplasty/femoral component was performed...." On 8/20/14 at 9:25 A.M., during interview with RN # 1, she indicated she took care of Resident B occasionally. She indicated Resident B was "sometimes very difficult," and refused medications and treatments a lot of the time. She indicated the resident had an extensive mental health history, and would have frequent delusions. On 8/20/14 at 9:45 A.M., during interview with MDS staff # 1 and MDS staff # 2, they indicated they obtained their information to complete the resident's MDS by looking at the chart, progress notes, nursing notes, and CNA notes. MDS staff # 2 indicated she also performs ROM on residents, and she felt like Resident B had no impairment in her ROM. On 8/20/14 at 11:20 A.M., during interview with Physical Therapist (PT) # 1, she indicated she was the staff member who assessed Resident B. She indicated she saw the resident from 8/13-11/13, following her left [MEDICAL CONDITION]. She indicated, "At first she could walk, but she slowly declined." She indicated a quarterly screen revealed the resident had declined, and therapy was restarted. She indicated the resident was discharged from therapy because she refused to walk. PT # 1 indicated the resident "would yell out." When questioned if Resident B had any contractures, PT # 1 indicated, "Oh, yes!" PT # 1 demonstrated how the resident's left leg was contractured and rotated over the resident's right thigh. PT # 1 indicated she was unsure if the resident had any x-rays of the left hip. On 8/20/14 at 12:00 P.M., during interview with the Administrator, he indicated he had only been at the facility for 2 weeks, and so was not familiar with this resident. He indicated he would have Medical Records staff search the resident's closed records for any x-rays. He indicated although the resident had a mental health history, her pain should have been followed up on. Documentation of x-rays of the resident's left hip were not provided by survey exit. 2. On 8/21/14 at 1:00 P.M., the Administrator provided the current facility policy on "Pain Management," revised 9/2013. The policy included: "...It is the responsibility of the facility to ensure that each resident is assessed for pain, and the efficacy of pain medication, while keeping the resident as comfortable and pain free as possible...The following guidelines will be used when assessing pain: Interviewable Resident...will be determined based upon the resident's verbal response to the questions on the pain assessment...Non-Interviewable Resident...will be based upon staff observation of non-verbal signs of pain as follows: Non-verbal signs (crying, whining, gasping, moaning...), Vocal complaints of Pain...Facial Expressions...Protective Body Movements or Postures ( bracing, guarding...). A plan of care will be written with the initiation of pain medication and individualized to the resident, addressing potential side effects, limitations due to pain, behavioral symptoms, and alternative pain relief techniques...." This Federal tag relates to Complaint IN 157 3.1-37(a)

Based on observation, interview, and record review, the facility failed to provide supervision for a resident at risk for falls, resulting in a fall with a head injury, for 1 of 3 residents reviewed for falls, in a sample of 6. Resident C Findings include: The clinical record of Resident C was reviewed on 10/2/13 at 3:00 P.M. [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) assessment, dated 6/24/13, indicated the resident scored a 15 out of 15, indicating no memory impairment. The resident required extensive assistance of two+ staff for transfer, walking in the room and corridor, and toilet use. A test for "Balance During Transitions and Walking" indicated the resident was "Not steady, only able to stabilize with staff assistance." A resident care plan, dated 4/1/13, indicated: "Problem, Resident is at risk for fall due to: muscle weakness, hx (history) of falls." The Approaches included: "8/15/13 Use gait belt for ambulation...Therapy screen as ordered and prn (as needed)." A Physical Therapy Progress Note, dated 7/8/13, included: "...The patient is able to safely transfer from bed <> wheelchair requiring stand by assistance (close enough to reach patient if assist needed)...Patient continues to have deficits in BLe (bilateral lower extremities) dorsiflexion which limit ability to ambulate and transfer independently...Continued pt (patient) training required in BLe strength, gait training, transfer training to improve safety in all functional mobility including safe toilet transfers, and ambulation...Precautions:...fatigues quickly; fall risk...." Progress Notes included the following notations: 7/14/13 at 6:32 P.M.: "Resident reports she doesn't feel well...had nausea this AM and emesis x 1...a/o x 3 (alert and oriented to person, place, and time), did report dizziness when sitting up from lying position...." An Event Report, dated 7/15/13, indicated: "7/15/13 11:06 PM, Witnessed fall. Resident stated, 'was standing lost footing.' Resident lying on bathroom floor on her back...Is the resident in pain...Yes - pain at back of head. Did the resident hit her head? Yes...Describe injuries, if any...Noted small contusion to back of head, noted also cut to back of head moderate amount of bleeding present unable to measure...Resident was sent out to (hospital name) E.R. for evaluation...." Progress Notes continued: 7/16/13 at 6:00 A.M.: "Res (resident) had fall with head injury and was sent to (hospital) ER for evel (sic) per orders...res returned at 0050 (12:50 A.M.) and was reassessed and neuro checks continued...res assisted up to toilet w/2 (with two) assist this am - c/o (complained of) 'little dizzy' at first...res c/o back of head being 'sore' and just generally being 'sore all over' this am...2.6 cm area on back of head that was 'gelled' at hospital - hematoma on back of head...." 7/16/13 at 4:21 P.M.: "IDT (interdisciplinary team) RE FALL: Resident lost footing on way back to bed from bathroom with walker. Resident hit head on floor and was sent out for evaluation to (hospital)...IDT recommendation of using gait belt for ambulation." On 10/3/13 at 9:25 A.M., during interview with CNA # 1, she indicated staff is always required to use a gait belt during transfers and ambulation. On 10/3/13 at 10:05 A.M., during interview with CNA # 2, she indicated Resident C required 1 assist with transfer and ambulation, and a gait belt is used. CNA # 2 indicated a gait belt is always used to transfer and ambulate with residents. On 10/3/13 at 11:00 A.M., CNA # 1 was observed transferring Resident C from the wheelchair, and ambulating with her to the bathroom, holding onto a gait belt wrapped around the resident's waist. Resident C ambulated with a walker and CNA # 1's assist. Her gait was slow and halting. On 10/3/13 at 11:15 A.M., Resident C was interviewed. Resident C indicated she fell on "July 15th." Resident C indicated, "I was in the bathroom. (CNA # 3) was in the other room playing on her phone. I started walking from the bathroom to my bed, lost my balance, fell backward and cut my head." Resident C indicated she went to the hospital, and "they glued it back together." Resident C indicated CNA # 3 did not assist her with toileting and a gait belt was not used, because "she was on her phone." Resident C indicated she kept a gait belt in her room, so all staff would use one when ambulating with her. On 10/3/13 at 11:35 A.M., during interview with the Administrator, she indicated the fall event on 7/15/13 was investigated. The Administrator indicated the resident was not actually walking when she fell , and that was why a gait belt was not used. The Administrator indicated she thought CNA # 3 was reminded to use her gait belt, and received a written warning regarding her phone use. The Adminsitrator indicated a strict cell phone policy was put into effect after this incident. On 10/3/13 at 3:00 P.M., the Administrator indicated the facility did not have a policy regarding the use of gait belts. This Federal tag relates to Complaint IN 646. 3.1-45(a)(1)

Based on observation, interview, and record review, the facility failed to ensure a resident with a pressure ulcer received appropriate treatment to the area, in that Santyl, a [MEDICATION NAME] agent, was applied to a Stage II area; and weekly wound assessments were not completed, resulting in a Stage III pressure area on a resident's left hip (Resident D); and failed to ensure resident's skin was assessed at readmission, and treatment restarted to a previous right upper thigh pressure ulcer (Resident C), for 2 of 3 residents reviewed withe pressure ulcers, in a sample of 5. Resident C and D Findings include: 1. On 5/22/12 at 12:40 P.M., during the initial tour, the Assistant Director of Nursing (ADON) indicated Resident D had a wound on his left hip and on the sides of his feet, and was not interviewable. Resident D was observed lying abed on an air mattress at that time. On 5/23/12 at 9:45 A.M., a skin assessment was requested. Physical Therapist Assistant (PTA) # 1 removed a dressing off of the resident's left hip. A pressure area was observed on the hip. The wound bed was covered in yellow slough, and slight redness surrounding the wound. PTA # 1 indicated it was a Stage III wound. PTA # 1 indicated, "It looks cleaner." The clinical record of Resident D was reviewed on 5/23/12 at 10:10 A.M. [DIAGNOSES REDACTED]. A physician's orders [REDACTED]." There was no documentation in the nurses' notes to indicate the reason for the order for a skin treatment. There was no skin assessment sheet for this date to indicate an assessment of the area. A "Pressure Wound Risk Assessment," dated 3/1/12, indicated: "Does the resident have impaired or decreased mobility? 'Yes.' Does the resident slide down in chair or bed? 'Yes'...Does the resident have urinary or bowel incontinence? 'Yes.' Is the resident confused...? 'Yes'...If any answer above is 'Yes,' the resident is at risk for developing skin breakdown...." Nurses Notes, dated 3/4/12 at 1:30 A.M., indicated, "The resident has an open area measuring 2.2 cm x 1.4 cm on his left hip. The MD line was called and an order was received for Allevyn with santyl (a [MEDICATION NAME] agent) changed every day. Will continue to monitor." A physician's orders [REDACTED]. The new one measures 2.0 cm x 1.8 cm. Please use a larger (5 x 5) Allevyn pad to cover both sores and apply Santyl cream. Change each shift and PRN (as needed) for dislodgement." An Interdisciplinary (IDT) Progress Note, dated 3/11/12, indicated, "IDT note R/T (related to) wound on (left) hip. Res. (resident) has 2 areas that have small amount yellow slough. Area (sic) are Stage II. Treatment ordered on [DATE] and change on 3/10/12. Santyl cover (with) allevyn q shift. Res. is on pressure relieving mattress. Up in Broda chair. Res has very bony hips...." An Interdisciplinary Progress Note, dated 3/22/12, indicated, "IDT wound rounds this date. Wound (left) hip wound clean with (no) slough present. 2nd wound is closed...New treatment order for Allevyn change daily until healed...." A Nurses Note, dated 3/22/12 and untimed, indicated, "Area St (stage) 2 on lower (left) hip is closed...area St. 2 on (left) hip is smaller in size, no yellow slough noted. Wound is red. New order (physician), D/C (discontinue) previous treatment. N/O (new order) Allevyn to left hip daily until resolved (sic)...." A physician's orders [REDACTED]. Start Allevyn to wound on (left) hip. Change daily and PRN (as needed) dislodgement/soilage..." A treatment record, dated 3/12, indicated weekly skin assessments were initialed as completed on 3/2, 3/9, 3/16, 3/23, and 3/30. The treatment record indicated: "3/23/12 Allevyn to St. 2 on left hip daily (and) prn soilage," and was initialed as completed 3/23 though 3/31. A Pressure Wound Skin Evaluation Report indicated: "Wound present on admission: 'No,' Date Wound Developed: 3-11-12 (measured), (Left) hip boney (sic) prominence (lower)." Measurements were documented on 3/11 and 3/19. A notation, dated 3/22/12, indicated, "Blanches closed healed." A treatment record, dated 4/12, indicated, "Allevyn gentle 4 x 4 Apply with Santyl once daily to open area on left hip until healed," and was initialed as completed from 4/1 through 4/12. A notation indicated, "DC'd Healed, Rewritten." The same order, including the Santyl, was rewritten on 4/16, and initialed as completed from 4/16 through 4/30. Documentation regarding the resident's left hip wound was lacking from 3/22/12 until 5/4/12. A Wound Skin Evaluation Report indicated, "...(Left) hip, Date 5/4/12, Pressure ulcer, Length 3.5 cm, Width 6.5 cm, Depth 0...Color Black, Drainage minimal...." A physician's orders [REDACTED]." A physician's orders [REDACTED].M., indicated, "Physical therapy evaluate (and) tx (treat)...for E-stim to wound at left hip, MIST 3x/wk to left hip...." The most recent assessment, dated 5/20/12, indicated, "Type, pressure, Length 4.0 in diameter, Depth <0.1, Color black, Drainage, minimal....Encircled area red." On 5/23/12 at 4:15 P.M., during interview with the DON and ADON, the DON indicated she had only been at the facility for 2 weeks, and was unaware of this resident previously. The DON indicated if a pressure ulcer has slough, it would not be a Stage II. The DON indicated herself, the ADON, and Medical Records staff were unable to locate any skin sheets from 3/22/12 until 5/4/12. The DON indicated she did not know if Santyl was being applied to the left hip wound inappropriately. The ADON indicated she thought the left hip wound was healed on 3/22/12, and then reopened on 5/4/12. 2. The closed clinical record of Resident C was reviewed on 5/22/12 at 3:00 P.M. [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) assessment, dated 2/7/12, indicated the resident required total dependence of two + staff for bed mobility, transfer, toilet use, and bathing. The MDS assessment indicated the resident did not have any current pressure ulcers, but was at risk for developing pressure ulcers. A care plan, dated 2/27/12, indicated, "Problem, Resident has impaired skin integrity: rt (right) upper inner thigh." The Approaches included: "Assess wound weekly documenting measurements and description...Observe for signs of infection...3/20/12 PT (physical therapy) for mist therapy to (right) ischial wound and cover (with) allevyn." A physician's orders [REDACTED]. May change allevyn as needed for soilage and dislodgement." A "Summary of Weekly Wound Progress," dated 3/28/12, indicated, "...Short description: right posterior buttocks weekly wound assessment...Size 3.7 cm x 2.6 cm . 0.2 cm...Wound odor slight...Peri wound Intact...." A physician's orders [REDACTED]. (posterior) buttocks...." A "Pressure Wound Skin Evaluation Report" indicated: "Right Isheal (sic) (lower)...4/2/12, Stage II, Length 3.5 ( cm: centimeters), width 2.6 (cm), Depth 0.2 (cm)...Drainage scant...Mist therapy/Allevyn. 4/9/12, Hosp." The resident was transferred to a psychiatric hospital on [DATE], and returned to the facility on [DATE]. Hospital transfer orders included, "[MEDICATION NAME] topically to skin around [MEDICATION NAME] on Rt. (right) thigh 2 times a day." That order was not transcribed to the facility admission orders [REDACTED]. Physician orders [REDACTED]. An admission nursing assessment, dated 4/17/12 at 4:00 P.M., indicated, "Abrasion to (right) buttock." Measurements of the area were lacking. Documentation regarding the resident's right thigh pressure area was lacking until 4/23/12. A "Home Discharge Instruction" sheet, signed by the ADON, indicated, "Wound Tx (treatment) (Right) isheal (sic) apply Allevyn change every 3 days et (and) PRN (as needed)." A treatment record, dated 4/12, indicated, "Weekly Skin Assessments." A box, dated 4/9/12, indicated "Hosp," and boxes dated 4/16 and 4/23 were blank. A hospital history and physical, dated 4/24/12, indicated, "...Chief Complaint(s): Pressure ulcer wound to his right thigh...presents to (hospital) with complaints of a right leg wound. Patient had been living at North Park Nursing Home...He was recently discharged , on 4/23/12...he was at the house, getting him cleaned up and bathed, when he noticed a wound to his right inner thigh. He said the nursing home had told him that there was a small scratch on his right thigh, but there were no wounds. The wound did have a yellowish drainage, with positive odor...Patient does have a right thigh wound that measures 5 centimeters x 7.5 centimeters open wound with a 14 c 9.5 centimeter excoriation...." On 5/23/12 at 2:00 P.M., during interview with the ADON, she indicated when a resident is admitted or readmitted to the facility, a full body assessment should be completed and if there are any areas, a skin sheet should be filled out. On 5/23/12 at 2:40 P.M., during interview with the ADON, she indicated she discussed the discharge instructions with the resident's family on 4/23/12, but was unaware of who wrote the notation regarding the wound treatment of [REDACTED]. On 5/23/12 at 4:15 P.M., the DON indicated she was unable to find skin sheets or further documentation indicating the resident's pressure ulcer was treated from 4/17/12 until 4/23/12 at his discharge. 3. Stages of Pressure Ulcers, AMDA - 2008, included: Stage II: Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink ulcer bed without slough. May also present as an intact or open/ruptured serum filled blister. Note: This stage should not be used to describe skin tears, tape burns, perineal [MEDICAL CONDITION], maceration or excoriation. Stage III: Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. Stage IV: Full thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present on some parts of the ulcer bed. Often includes undermining and tunneling. 4. On 5/23/12 at 2:40 P.M., the Administrator provided the current facility policy on the "Skin Management Program," dated 3/10. The policy included: "...A head to toe assessment will be completed by a licensed nurse upon admission/re-admission and documented on the 'nursing admission assessment.' Alterations in skin integrity will be reported to the physician and family member(s). Physician orders [REDACTED]. All alterations in skin integrity will be documented in one of two skin evaluation reports...The licensed nurse will notify the wound nurse of any alterations in skin integrity. The facility assigned wound nurse will complete a further evaluation of the wounds identified...The care plan will be initiated to include specific alterations in skin integrity...Weekly skin assessments will be completed on all residents with or without alterations in skin integrity and documented on the weekly skin assessment form and/or nursing notes...All alterations in skin integrity will be documented in one of two skin evaluation reports...The IDT (interdisciplinary) team will do rounds on a weekly basis to assess all wounds...." This Federal tag relates to Complaint IN 593. 3.1-40(a)(1) 3.1-40(a)(2)

A. Based on observation, interview and record review, the facility failed to ensure 1 of 9 residents reviewed for falls, in the total sample of 19, was provided assistance devices identified by the plan of care to prevent falls, in that the resident had the wrong alarm in place when he experienced a fall that resulted in a fractured left hip. (Resident B) B. Based on observation, interview and record review, the facility failed to ensure 2 of 8 sampled residents reviewed for elopement risk, in the sample of 19, received supervision and assistance to prevent elopement from a locked unit and/or the facility building, in that Resident F left the building twice without staff knowing and Resident G left the locked Alzheimer's Unit once without staff knowing. Findings include: A.1. During the initial tour, on 11/01/11 at 11:00 A.M., the Social Worker identified Resident B had experienced falls, utilized bed and chair alarms, and was not interviewable. Resident B was observed at that time, lying in bed with a mat on the floor. The clinical record of Resident B was reviewed on 11/02/11 at 10:45 A.M. The record indicated the [DIAGNOSES REDACTED]. An Interdisciplinary Team (IDT) Progress Note, dated 04/06/11, no time, indicated, " reported fall 04/05/11...Fall not witnessed...Res (Resident)states that he got up and put self back to bed. Res c/o (complain of) hip pain...Immediate intervention was to place bed alarm..." An IDT Progress Note, dated 04/12/11 no time, indicated, "Res returned...with new dx (diagnosis) of Right subtrochanteric fx (fracture)...now utilizes bed and w/c (wheelchair) and pad alarms to promote safety and discourage unassisted transfers." A physician's orders [REDACTED]. A Care Plan, dated 04/14/11, indicated Resident B "is at risk for fall..." with interventions that included, but were not limited to, "alarm to bed." A Nurse's Note dated 06/25/11 at 0315 (3:15 A.M.) indicated, "...Resident lying on floor on left side of body...Pull alarm on res was not going off. Found gown in floor along with pull alarm in (sic) floor..." A Fall Circumstance Report, dated 06/25/11 at 0315, indicated, "...heard alarm (roomates (sic) alarm)...pull alarm off in (sic) floor..." An IDT Progress Note, dated 06/25/11, no time, indicated, "...will replace tab alarm with pressure alarm in bed..." During an interview on 11/10/11 at 3:00 P.M., with the DoN, she indicated that Resident B "should have had a pressure pad alarm and he had a tabs alarm when he fell from bed and fractured his left hip." B.1. Resident F's clinical record was reviewed on 11/9/11 at 11:00 a.m. The resident had an Elopement Risk Assessment, dated 6/16/11, indicating the resident was at risk for elopement and had been assigned a security bracelet. The resident had a care plan, dated 6/17/11, for elopement risk. The care plan indicated the resident exited the building on 7/31/11 and 8/27/11. Interventions included, but were not limited to, the following: -Diversional activity if resident is exit seeking-Electronic monitoring bracelet, check function/placement every shift -Involve in group activities of choice -placed on 15 minute checks 7/31/11 -checked wanderguard 7/31/11 -checked doors 7/31/11 -1 on 1 supervision when (up) 8/27/11 -(check) function/placement q shift 8/27/11 -15 min (check) while in bed 8/27/11 -w/c in hallway while in bed 8/27/11 -when (up) go to cottage for programming 8/27/11 Nurses' notes included, but were not limited to, the following: 7/31/11 12:50 p.m. "Reported to this nurse per (name of LPN) that res. was sitting below w/c (wheelchair) ramp in the back parking lot-wanderguard in place (and) in working order - immediately assisted into facility and reported to (name) Social Services (and) (name) DON (Director of Nurses) - Back door not functioning properly - immediately reported to maintenance - BP (blood pressure) 114/68 T (temperature) 97.8 R (respirations) 20 O2 sat (oxygen saturation) 90% on room air - res. placed on 15 min checks. Res. observed in activity room @ 12:40 and heard talking in hallway outside breakroom by housekeepers @ lunch. Dr. (name) notified of occurrence." 8/27/11 12:15 p.m. "Resident outside in parking lot - Last checked @ 1200 - was in Activity Rm. (room) drinking coffee -witnessed per (name) Activity Director (and) (name) Restorative aide - Wanderguard in place on w/c (and) in working order - res. still able to exit facility. - immediately placed one on one - (name) ADON (assistant director of nurses) notified of elopement - Dr. (name) notified. Niece (name) notified of occurrence." IDT (Interdisciplinary Team Progress Notes) notes included, but were not limited to, the following: 8/1/11 (no time) "IDT behavior: Resident exited the building on 7/31/11. Statements from staff states he was last seen at 12:45 p.m. Resident was brought back into facility at 12:50 p.m. by nursing staff. residents vitals taken at this time...Resident placed on 15 min. checks. MD, family notified. Wanderguard in place and working. door alarm did not sound when resident exited building. Resident shows no psychosocial distress or physical injury related to being outside. Door was under consistent supervision. Wanderguard called. Immediate intervention was to fix doors. All resident was accounted for, (sic) all doors were checked along (with) all residents who have wanderguards...all are working." 8/29/11 (no time) "IDT this date R/T (related to) resident exited building on 8/27/11 @12:00 N (noon) (approx) (approximately) was last seen in activity room at 12:00 N was found out side at 12:10 p by Activity Assistant. Res. propels self in w.c. and went across parking lot. Res. was brought back into facility by (name) Activity Director. Was accessed (sic) by charge nurse found to have no injury and VS (vital signs) in normal limits...Res. returned at 12:10 to room and was placed on 1 on 1 supervision with ADNS (assistant director of nursing services). Res. is unable to ambulate and cannot get out of bed without assistance. Res. has alarm pressure pad while in bed. When (up) in wheelchair has wanderguard on at all times. When res. gets (up) from bed will be 1 on 1 monitored until is taken to secure unit. While in secure unit will remain 1 on 1. Labs were ordered by MD, with results being DX (diagnosed ) as UTI (Urinary Tract Infection) - Res. placed on Bactrim DS (antibiotic)...Dr. (name) order that pt. may go to Acute Care Behavior for wandering exit seeking behavior..." The Director of Nurses (DoN) was interviewed, on 11/9/11 at 3:09 p.m., regarding the elopements of the resident. She indicated the elopements were investigated and the facility could not figure out how he got out the door. The wanderguard worked every time it was tested . The wanderguard company did reset the sensitivity after the first elopement. She indicated it was the same weekend staff and the same time of day both times. She indicated a consultant attempted to get through the doors and down the ramp while in a wheelchair and had difficulty. According to the DoN, no one admitted to hearing an alarm on either day. On 11/10/11 at 9:30 a.m., the DoN was queried regarding the wanderguard and how the wanderguard system worked, i.e. how the wanderguard could be turned off if a resident exited the door. At 10:10 a.m. on 11/10/11, the Administrator and DoN indicated the following regarding the current wanderguard system: When a resident with a wanderguard bracelet on approaches a wanderguarded door and gets within 3 feet of the door, the door locks down and an alarm goes off. If a staff person, or a visitor keys in the code into the key pad by the door, the door stays locked, unless the bar on the door is pushed for 15 seconds. If the bar is pushed for 15 seconds, a low beeping sound occurs and the door opens. If a wanderguarded resident goes through the door, a louder alarm occurs. According to the Administrator, who was not at the facility at the time of the events, a loud alarm should have occurred. According to the DoN, no one heard an alarm, according to statements taken at the time of the events. Review of 15 minute check documentation indicated the resident was observed at 12:00 noon by a facility nurse and was found outside in the parking lot of an apartment complex across a dead end street at 12:15 p.m., on 8/27/11. B.2. Resident G's clinical record was reviewed on 11/3/11 at 11:10 a.m. The resident's [DIAGNOSES REDACTED]. The resident had a care plan, dated 1/3/11, for being at risk for elopement due to dementia and wandering. Approaches included, but were not limited to, the following: -Electronic monitoring bracelet, check function/placement every shift -Involve in group activities of choice -Diversional activity if resident is exit seeking -Observe whereabouts The resident had a care plan, dated 9/28/11, for requiring a secured unit related to [DIAGNOSES REDACTED]. The approach was for the resident to reside in Auguste's Cottage (the name of the facility's Alzheimer's Dementia unit). Nurses' notes included, but were not limited to, the following: 9/23/11 2000 (8:00 p.m.) "Exit seeking X 2. Easily redirected (with) 1-1 Compliant (with) care." 9/24/11 1405 (2:05 p.m.) "Continues in et out of others rooms pushing linen carts opening close to more easily redirected..." 9/25/11 0200 (2:00 a.m.) Res. (up) wandering in et out of others rooms, pushing carts about refuses to go to bed." 9/26/11 2000 (8:00 p.m.) Cont. (with) wandering (without) agenda. (up) et (down) hallway pushing barrels of linen. In et out of rooms. Easily redirected..." 9/27/11 2000 "Cont (continues) (with) wandering. Easily redirected..." 10/3/11 1400 (2:00 p.m.) "Res found walking down F hall station 1 (outside of secured unit on a unit on the other side of the building) brought back to unit easily secure care R (right) ankle in place et functioning 15 min (checks) started." On 11/3/11 at 3:10 p.m., Resident G was observed following a physical therapist, who was walking with another resident towards the door exiting the Alzheimer's Dementia Unit. As the resident approached the door, LPN #3 observed the resident and directed him away from the door. The Director of Nursing (DoN) was interviewed, on 11/4/11 at 3:45 p.m., and indicated she was unaware of the resident having wandered off the unit. She indicated the Unit Manager may have taken care of the issue. The DoN and Assistant Director of Nursing (ADoN) indicated, at that time, the wanderguard alarm was not configured to alarm when a resident went through the Alzheimer's Unit doors. The unit was secured due to the use of a key pad to unlock the doors. The doors exiting the facility to the outside were controlled by the wanderguard. They indicated the resident would had to have followed someone out. An IDT (Interdisciplinary Team progress note) note, dated 11/4/11 (no time), indicated the following: "IDT this date R/T (related to) resident walked off unit on 10/03/11, was found just past nurses station on station I. Restorative aide, (name) took hand of resident and walked with him back to unit. Aide reported to (name), Charge Nurse who placed resident on supervision and focus charting for 3 days. Res. was on 15 min (checks) with no other episodes of exit seeking. Team recommends inservice of all Dietary/Housekeeping/Laundry/Therapy, clinical staff on ensuring no resident follows them when exit the cottage (Alzheimer's Dementia Unit)...team recommends sign to be placed on both sides of door stating - 'Attention For safety of our residents please make sure door shuts securely. Never allow a resident to exit cottage with you.'" This federal tag relates to complaint number IN 893. 3.1-45(a)(2)

Based on observation, interview, and record review, the facility failed to ensure two staff assisted a dependent resident to transfer and failed to then supervise the resident while in the bathroom, resulting in a fall; and utilized alarms in place of supervision for a resident at risk for falls, resulting in a fall with a resulting subdural hematoma, for 2 of 4 residents reviewed for falls, in a sample of 6. Residents B and C Findings include: 1. On 9/29/11 at 9:20 A.M., during the initial tour, the Director of Nursing (DoN) and LPN # 1 indicated Resident B had fallen recently, hit her head, and received a "black eye." LPN # 1 indicated Resident B was not interviewable. On 9/29/11 at 11:50 A.M., Resident B was observed sitting up in a wheelchair in her room. A leg brace was observed on the resident's right leg, and the resident was wearing a protective helmet. A clip alarm was attached to the resident. The clinical record of Resident B was reviewed on 9/29/11 at 11:55 A.M. [DIAGNOSES REDACTED]. The resident was admitted to the facility following a fall in which she fractured her ankle. A physician's orders [REDACTED]. Wheelchair for mobility. Care Plan Update, Problem Weakness, difficulty (with) transfers, Poor stand. balance, foot pain...." An admission Minimum Data Set (MDS) assessment, dated 8/30/11, indicated the resident was unable to complete an interview for mental status, had a short-term and long-term memory problem, and required extensive assistance of two+ staff for transfer and toilet use. A test for balance while moving from seated to standing position, moving on and off toilet, and surface-to-surface transfer indicated: "Not steady, only able to stabilize with human assistance." A Fall Risk Assessment, dated 9/8/11, indicated, "...Resident has had a history of [REDACTED].? Yes...Resident has impaired vision? Yes...Resident has [DIAGNOSES REDACTED].? Yes...If any answer above is 'Yes,' the resident is at risk for experiencing a fall. Proceed to care plan with appropriate interventions based upon the risk factor(s)." A Care Plan, dated 8/31/11, indicated a problem of "Resident is at risk for fall due to: Blindness, congenital micrcephalus (sic), and epilepsy." The Approaches included: "Call light in reach, Environmental changes, Personal items in reach, Resident to wear helmet when up in w/c (wheelchair)." An approach, dated 9/16/11, indicated, "Educate staff that resident is to be dressed and undressed while seated on the edge of the bed." A Fall Circumstance Report, dated 9/14/11, included: "(Resident B), Date/Time of fall: 9/14/11 @ 1930 (7:30 P.M.)...Describe what the resident was doing prior to the fall...Sitting on toilet, screaming her 'toe hurts get the nurse.' CNA called for nurse - left resident to get nurse. Instruct (sic) to stay seated. Describe the position of the resident when first observed after fall...Sitting on floor holding head, screaming (and) crying, (Right) leg crossed (beneath) (left) leg...Describe location of the fall...Res (resident) Bathroom...c/o (complains of) 'head hurts'...Describe injuries...Res. hit head on sink when falling, has a hematoma (closed) 3.0 x 3.0 (centimeters) @ 1945 (7:45 P.M.) raised slightly...Resident or witness statement of how fall occurred: Apparently res. slid off toilet while waiting for CNA to get nurse...What intervention(s) was put in to place to prevent another fall? 1. Never leave alone in BR (bathroom). 2. Undress (and) dress in bed -while sitting up." An Interdisciplinary Team (IDT) Progress Note, dated 9/16/11, indicated: "IDT this date for fall of 9/14 @ 1930. Resident being toileted by staff CNA...CNA stepped away to call for nurse. Resident fell hitting head on since receiving hematoma (closed) 3.0 x 3.0. Immediate interventions: Staff education - never leave resident alone in B.R....Take helmet off very last thing before lying down in bed." On 9/30/11 at 9:10 A.M., the DON provided documentation of inservicing she gave the staff regarding not leaving a dependent resident alone on the commode. 2. The closed clinical record of Resident C was reviewed on 9/30/11 at 9:25 A.M. [DIAGNOSES REDACTED]. The resident was readmitted to the facility on [DATE], following a stay on a psychiatric unit. A hospital discharge note, dated 8/29/11, indicated: "...The patient needs assistance with her activities of daily living because of her limited cognitive and physical ability...." The resident was started on Depakote (medication used to treat behaviors) and Ativan (an anti-anxiety medication) while at the hospital. A Care Plan, initially dated 2/8/11 and updated 9/16/11, indicated a problem of "Resident is at risk for fall due to: unsteadiness." The Approaches included: "9/14/11 Room move closer to nurses station, 9/14/11 Assist of 1 when up with walker, 9/14/11 Bed to low position, 9/14/11 Toilet every 2 hours, 8/31/11 Assist of 1 when up, 8/31/11 Pressure alarm in bed and chair, 2/8/11 Call light in reach, 2/8/11 Environmental changes: (blank), 2/8/11 Non skid footwear, 9/16/11 Mat at bedside, 9/13/11 Non skid socks @ all times." Nurses Notes included the following notations: 8/29/11 at 4:30 P.M.: "Returned to facility...Ambulating (with) walker (and) driver of van to new room...." 8/29/11 at 6:15 P.M.: "Heard knocking this nurse went to investigate found resident sitting on floor (with) left knee/leg under (right) knee et (and) bleeding from forehead. Noted large hematoma - Assessed for injury then (assisted) (with) 2 (assist) to loveseat...." The resident was sent to the emergency room at 6:50 P.M. and returned the same night. A Fall Risk Assessment, dated 8/30/11, indicated: "Readmit...Resident has history of falls within the past 3 months? Yes...Resident has [DIAGNOSES REDACTED].? Yes...Resident is confused and/or disoriented? Yes...." A Fall Circumstance Report, dated 8/29/11, included: "...States that she was up to close the door (and) fell . found on floor by door walker tipped over...(Right) shoe off, head bleeding, confused...Describe injuries...Lg (large) Hematoma (with) 3.0 x 0.1 (centimeters) laceration to mid forehead...Resident or witness statement of how fall occurred: Was noted sitting on loveseat (after) ADON (assistant director of nursing) (assisted) her to sitting position (after) finding her up straightening her bed...within 5 min she had fallen...Has the resident been prescribed any new medications within the past 7 days? Depakote sprinkles started 8/26/11...Document any environmental factors observed...: New room, returned to facility @ 1630 (4:30 P.M.) (after) being in hospital for behaviors. What intervention(s) was put in place to prevent another fall?...When returns will be on 15 min checks. Tab alarm...Toilet (every) 2 (hours)." Nurse's Notes continued: 9/5/11 at 12:10 P.M.: "Resident (up) in w/c (wheelchair). Is alert but confused. Call light kept in reach...Tabs alarm on. Has gotten (up) and out of w/c on own x 1 today. Practice discouraged...Will cont to monitor." 9/8/11 at 9:00 P.M.: "...Was attempting to stand several times, lots of 1:1 tonoc (sic), to monitor for safety...." 9/11/11 at 3:00 A.M.: "Resident attempted to get OOB (out of bed) alone a couple of times tonoc (sic) (without) assist. Bed alarm sounded each (time). Resident assisted back to bed. Each time CNA warned resident of dangers of falling...Resident kept talking over the top of CNA et refused to listed...Entire time resident talking in disjointed sentences...Very unsteady when up alone...has some trouble understanding others even when she has hearing aides in." 9/12/11 at 1:00 A.M.: "Resident up out of bed (without) assist...." 9/12/11 at 1:10 A.M.: "Resident up out of bed talking loud voice trying to walk in hallway et open doors of other resting residents...." 9/12/11 at 1:38 A.M.: "Resident up in room (without) assist in loud voice saying get me out of here...brought back to NS (nursing station) for short period of x...." 9/12/11 at 11:00 P.M.: "...Climbing out of bed many times...." A Fall Circumstance Report included: "(Resident C), Date/time of fall: 9/13/11 at 9:00 A.M....Describe the position of the resident when first observed after fall: Lying on (right) side. Head against bathroom wall, pajamas (and) brief (down) around knees...Did resident hit his/her head? Yes...(No) injuries...Resident or witness statement of how fall occurred: (No) witness (and) resident unable to tell what happened. (In different writing) Alarm sounding in bed, gown (with) tabs removed...What intervention was put in place to prevent another fall? Non skid socks even when in bed." A Nursing Note, dated 9/13/11 at 1:20 P.M., indicated, "...Remains on 15 min (checks)...Call light in reach when in room. Often does not use as was case this AM...received order to (decrease) Depakote from total of 1000 mg QD (every day) to 750 mg QD...." A Fall Circumstance Report included the following: "(Resident C), Date/time of fall: 9/14/11/0620 AM...Describe the position of the resident when first observed after the fall: She is side-lying on floor with knees slightly flexed...Describe injuries...Open area above (right) eyebrow...Bruise on periorbital (around eye) area on (right) eye is 5.5 x 2 cm (centimeters), the open area is 3.2 x 1. Bruise on (right) hip is 6 x 6 cm. Resident or witness statement of how fall occurred: Resident is confused (and) disoriented. Her 6 AM pill (name) was just give (sic) 5 mins. prior to fall. Resident heard calling for help. Pressure alarm sound off. The alarm attached to her gown did not sound off because she took the gown off...What intervention was put in to place to prevent another fall? I asked my CNA to stay with the resident while I call MD, Family, (and) DON. Resident was sent to ER. Will move Res to Room closer to Nurses Station." A Nursing Note, dated 9/14/11 at 2:30 P.M., indicated, "Call placed to (hospital). Spoke (with) nurse on ICU. States resident admitted to ICU (room number) (with) subdural bleed (slight)...." A Hospital note, dated 9/14/11, indicated, "...This patient was at the nursing home. Apparently she fell from a standing position. She does not remember the incident but she may not be able to remember anything...X-Rays: 8mm right subdural hematoma...." Hospital discharge instructions, dated 9/16/11, indicated, "...Pt (patient) requires 24 hour supervision and assistance when out of bed...." On 9/30/11 at 2:15 P.M., during interview with the DoN, she indicated the resident had 2 alarms on when she fell on [DATE] and 9/14/11. The DoN indicated on both occasions the resident fell , the pressure alarm sounded, and staff responded to that alarm. The DoN indicated the tabs alarm was attached to the resident's gown, which the resident removed, so the tabs alarm did not sound either time. 3. On 10/3/11 at 1:00 P.M., the Director of Nursing provided the current facility policy on "Fall Management Program," revised 3/10. The policy included: "It is the policy of (corporation) to ensure residents residing within the facility will maintain maximum physical functioning through the establishment of physical, environmental, and psychosocial guidelines to prevent injury related to falls...All new admissions will be considered a fall risk based upon his/her new living arrangements, and his/her reasons for being admitted ...A care plan will be developed at time of admission specific to each resident based upon the results of the fall risk assessment. Charge nurses will communicate the specific care required for each resident to the assigned caregiver on each shift...." This federal tag relates to Complaint IN 310. 3.1-45(a)(2)