Every finding on record at North River Health Campus

Based on observation, interview, and record review, the facility failed to ensure skin injuries did not happen during routine care for 1 of 3 resident's reviewed for ADL (activities of daily living) care. A resident received skin shearing during care. The deficient practice was corrected on July 15, 2026, prior to the start of the survey, and was therefore past noncompliance. Finding includes: On 7/28/26 at 9:41 a.m., Resident B's clinical record was reviewed. Diagnoses included but were not limited to, central cord syndrome at unspecified level of cervical spinal cord, arthrodesis status, spinal stenosis, cervical region, wedge compression fracture of fifth lumbar vertebra, subsequent encounter for fracture with routine healing. An admission Minimum Data Set (MDS) assessment dated [DATE], indicated cognition intact, toileting dependent (helper completed the activities for the resident), roll left and right, dependent, skin- surgical wound, no pressure ulcers on admission. Resident B was admitted to the facility on [DATE]. Care plans were reviewed and included, but were not limited to: Skin integrity at risk for skin breakdown r/t (related to) Foley catheter placement, need for assistance with mobility, ADL's toileting, hygiene, positioning off of pressure areas, altered skin integrity d/t (do to) shearing, start date 7/6/26. Approach included but was not limited to, avoid shearing skin during positioning, turning, and transferring, treatments/preventative treatments as or when ordered, start date 7/6/26. Resident has shearing injury: L) buttock & R buttock, start date 7/15/26. Approach included but was not limited to, treatment per MD order. July 2026 physician's orders were reviewed and included but were not limited to: order set WC (wound care) preventative - apply foam dressing coccyx (be sure to cover both areas) change every 5 days. Special instructions: change PRN (as needed) with soiled, once a day every 5 days, 6:30 p.m- 11:00 p.m., order date 7/13/26. Order set WC preventative - observe dressing to coccyx every shift. May peel back and view area to monitor if area has opened, twice a day, 6:00 a.m.- 10:00 p.m., order date 7/13/26. Incontinence care- cleanse skin with personal cleanser and apply protective ointment/cream as needed after each incontinence episode twice a day, 6:00 a.m.- 6:00 p.m., 6:00 p.m.- 6:00 a.m., order date 7/3/25. Progress notes were reviewed and included but were not limited to:7/13/26 at 5:13 p.m., Primary Etiology: Other friction injuryLocation:: L side coccyxLength: 1.6Width: 9Depth: 0Exudate: No ExudateTissue Type: Partial ThicknessDebridement Type: No Debridement Type 7/13/26 at 5:15 p.m., Primary Etiology: Other friction injuryLocation:: R side coccyxLength: 1Width: 3.8Depth: 0Exudate: No ExudateTissue Type: Partial ThicknessDebridement Type: No Debridement Type 7/13/26 at 5:16 p.m., This nurse called to room via hall staff member. Coccyx noted to have purple, red areas to each side. Measurements entered into wound management and skin progress note. The following treatment was recommended by WCC (wound care certification) - apply skin prep to area, periwound and cover with Allevyn Life Sacral dressing- change every 5 days and PRN if becomes soiled or dislodged. LAL(low air loss) mattress applied this day, resident and staff were encouraged to use podus boots while resident is in bed. Use draw sheet for all transfers to prevent friction. NHT(nursing home triage) notified and new orders received for liquacell 30 ml daily X 1 month. Orders transcribed. 7/14/26 at 3:43 p.m., IDT/New onset edema/blister to right medial heel/friction injury to bil(bilateral) buttocks: .[Resident B] has also experienced friction injures to bil buttocks. Areas are elongated length wise across her buttocks (much longer on the left than on the right) and there are areas with what appears to be blood blisters. Areas treated with skin prep and covered with a foam dressing for protection .Education to be done with team regarding shearing injuries .On 7/29/26 at 9:22 a.m., LPN 2 was observed to do a treatment/dressing change to Resident B's shearing wounds to her bilateral buttocks. LPN 2 indicated the wounds were due to shearing, she believed either from staff removing a brief, or pulling Resident B up in bed, education had been done with staff. On 7/29/26 at 9:49 a.m., the DON indicated she thinks Resident B's skin injury was shearing from removing sheets or a brief, you could see a line across buttocks like something had rubbed, reinforcement was done with staff about using draw sheets and what causes friction injuries. On 7/29/26 at 12:24 p.m., the Administrator provided the standard operating procedure for turning and repositioning with a review date of 12/16/24. The procedure guide included but was not limited to: Overview: to identify residents who are unable to turn and reposition themselves or those requiring assistance to reposition while in bed and assist with turning and repositioning as needed to maintain skin integrity, decreased pain, and maintain proper body alignment .2. Turning and repositioning is not routinely documented as this a normal nursing standard of practice that will be performed in accordance with the resident's care plan . 5. Proper turning techniques and body mechanics should be utilized to prevent injury to the resident and care giver . The deficient practice was corrected by July 15, 2026 after the facility implemented a systemic plan that included the following actions: In-service to all nursing staff regarding the Friction Injury Policy. Completed an audit of resident care to ensure turning and repositioning being completed properly to prevent friction injuries. Began the additional audits as follows: 5 random residents and audit will be completed 3 times a week for one month, weekly for one month, every other week for one month, and then monthly for three months. This citation related to Intake 3094983. 410 IAC (Indiana Administrative Code) 3.1-37(a)

Based on observation, interview, and record review, the facility failed to ensure proper storage and labeling of medication for 3 of 3 medication carts observed. Loose pills, employee drinks, and unlabeled medications were observed in the medication carts. (Medication Cart 200 Hall, Medication Cart 300 Hall, Medication Cart 400 Hall) Findings include: 1. On 5/6/26 at 9:00 A.M., the following loose pills and unlabeled medications were observed in the 200 Hall Medication Cart:2 medium-sized orange pills 1 blue capsule 1 small white oval bill1 bottle of eye drops with no open date 2. On 5/6/26 at 9:10 A.M., the following unlabeled medications and food were observed in the 300 Hall Medication Cart:1 open can of soda4 bottles of cough medicine with no open date1 bottle of antacid pills with no label or open date 3. On 5/6/26 at 9:20 A.M., the following unlabeled medications were observed in the 400 Hall Medication Cart:1 tube of ointment with no open date1 bottle of lactulose with no open date1 bottle of nasal spray with no open date2 bottles of extra strength acetaminophen with no open date2 bottles of cough medicine with no open date1 bottle of antacid pills with no label or open date1 bottle of antacid pills with no open date During an interview on 5/6/26 at 9:15 A.M., Registered Nurse (RN) 3 indicated she should not have had the drink in the medication cart. She also indicated that the medications should have a label and an open date. During an interview on 05/12/26 9:08 A.M., the Director of Nursing (DON) indicated there should be no employee food in the medication carts. Medications should have a label and an open date. On 5/11/26 at 10:50 A.M., the Regional Support Nurse provided a current Medication Storage in the Facility policy, dated 11/2028. The policy indicated .outdated, contaminated, and deteriorated medications, and those in containers that are cracked, soiled, or without secure closures are immediately removed from inventory and disposed of according to medical procedures .a date opened sticker will be placed on medications . medications are kept in closed and labeled containers .separate from fruit juices, applesauce, and other food used for administrating medications .other food .is not stored there . 410 Indiana Administrative Code (IAC) 16.2-3.1-25(j)

Based on observation, record review, and interview, the facility failed to provide infection control practices during 2 of 2 insulin administrations. The rubber injectable port for insulin was not cleaned prior to placing the needle on the insulin pen. (Resident 68, Resident 37) Findings include:1. On 5/8/26 at 6:45 A.M., Licensed Practical Nurse (LPN) 2 was observed not using an alcohol swab to prepare the rubber injectable port of a Lantus pen prior to placing the needle on the pen to administer insulin to Resident 68. 2. On 5/8/26 at 11:49 A.M., Registered Nurse (RN) 3 was observed not using an alcohol swab to prepare the rubber injectable port of a Lispro pen prior to placing the needle on the pen to administer insulin to Resident 37. During an interview on 5/11/26 at 9:36 A.M., the Regional Support Nurse indicated the rubber injectable ports of the insulin pens should be prepped with an alcohol swab prior to placing a needle on the pen. On 5/11/26 at 10:46 A.M., the Administrator provided a current insert for Kwik-Pen Insulin dated 7/2023. The instructions indicated .wipe the port with an alcohol prep . 410 Indiana Administrative Code (IAC) 16.2-3.1-18(b)(1)

Based on observation, record review, and interview, the facility failed to ensure insulin was properly administered for 1 of 2 residents observed for insulin administration. The insulin pen was not primed before administration. (Resident 68)Finding includes:On 5/8/26 at 9:10 A.M., Licensed Practical Nurse (LPN) 2 was observed administering insulin to Resident 68. LPN 2 attached the needle to the Glargine insulin pen, dialed the pen to 32 units, and administered the insulin. LPN 2 did not prime the pen prior to administering the insulin to Resident 68. On 5/8/26 at 9:30 A.M., Resident 68's clinical record was reviewed. Diagnoses included, but were not limited to, diabetes mellitus.Physician orders included, but was not limited to: Insulin glargine 100 units per milliliter (unit/mL) Injectable Solution (long acting insulin) - 32 units subcutaneously (SQ) twice a day, dated 5/5/26. During an interview on 5/11/26 at 9:36 A.M., the Regional Support Nurse indicated that insulin pens should be primed with two units of insulin prior to dialing in the amount needed. On 5/11/26 at 10:46 A.M., the Administrator provided a current insert for Kwik-Pen Insulin dated July/2023. The instructions indicated . prime the pen with 2 units .if you do not prime before each injection, you may give too much or too little insulin . 410 Indiana Administrative Code (IAC) 16.2-3.1-35(g)(1)

Based on observation, record review, and interview, the facility failed to revise a residents care plan after a change in condition occurred for 1 of 2 residents reviewed for fall resulting in major injury. (Resident 8) Finding includes:On 5/7/26 at 1:44 P.M., Resident 8's clinical record was reviewed. Diagnosis included, but was not limited to, hypotension.A Quarterly Minimum Data Set (MDS) Assessment, dated 2/4/26, indicated Resident 8 was cognitively intact, required supervision for bathing and toileting, and was independent in transfers.The most recent Significant Change MDS Assessment, dated 4/22/26, indicated Resident 8 was moderately cognitively impaired and required substantial assistance (staff does more than half of the work) for bathing, toileting, and transfers. Care plan included, but was not limited to:Resident at risk for falling related to impaired mobility, history of syncope, atrial fibrillation, pulmonary fibrosis; Start date 11/15/24Interventions included, but were not limited to:Encourage proper footwear; Start date 11/15/24Provide nonskid footwear; Start date 11/15/24A nursing progress note, dated 4/4/26 at 10:12 A.M., indicated Resident 8 sustained a fall while attempting to self-toilet. The resident was sent to the emergency room (ER) with injury to her left temple, left upper arm, left hip, and left knee.During an observation on 5/8/26 at 1:42 P.M., Resident 8 was lying in bed awake with black tube socks on that were not non-skid. During an interview on 5/12/26 at 10:19 A.M., the Regional Support Nurse indicated Resident 8's fall care plan intervention should have been revised after the resident's change in condition due to the resident no longer walking. On 5/12/26 at 10:15 A.M., the Administrator provided a policy titled Comprehensive Care Plan Guideline, dated 12/13/24, that indicated Comprehensive care plans need to remain accurate and current.410 Indiana Administrative Code (IAC) 16.2-3.1-35(d)(2)(B)

Based on observation, interview, and record review, the facility failed to treat residents with dignity for 1 of 1 random observations. Staff members stood up to feed a resident and had personal conversations in the dining area with residents present. (Resident 3) Finding includes:On 5/6/25 at 11:46 A.M., Certified Nurse Aide (CNA) 5 was observed feeding Resident 3 lunch in the restorative dining area. CNA 5 was standing up. At 11:50 A.M., CNA 6 took over feeding Resident 3. CNA 6 was standing up. At that time, CNA 5 and CNA 6 engaged in conversation about the difficulties of their job and how burnt out they were.On 5/7/26 at 12:39 P.M., Resident 3's clinical record was reviewed. Diagnoses included, but were not limited to, Alzheimer's disease and dysphagia.The most current Quarterly Minimum Data Set (MDS) Assessment, dated 4/15/26, indicated Resident 3 was assessed by staff to have severe cognitive impairment and was dependent on staff (staff does all the work) for eating.A care plan conference was completed on 2/10/26 with the resident's representative in attendance. The care plan was reviewed. A risk for malnutrition care plan, dated 2/22/24, included an intervention to assist with meals as needed.A profile care guide, dated 2/22/24, included an intervention to assist with eating as needed.During an interview on 5/11/26 at 10:22 A.M., CNA 7 indicated that staff should sit down next to the resident while assisting them to eat. Staff were not supposed to stand over the residents for dignity reasons.On 5/12/26 at 10:15 A.M., the Administrator provided an undated Your Rights and Protections as a Nursing Home Resident policy that indicated You have the right to be treated with dignity and respect.410 Indiana Administrative Code (IAC) 16.2-3.1-3(a)

Based on observation, record review, and interview, the facility failed to ensure residents received supervision and consistent implementation of interventions to prevent a fall for 1 of 1 residents reviewed for accidents related to falls. Fall interventions were not consistently implemented. (Resident 15) Findings include: On 3/19/25 at 9:35 A.M., during a random observation of Resident 15 transferring from a wheelchair to a shower chair by Certified Nurse Aide 5 (CNA) and CNA 6, the wheelchair was observed lacking a Dycem (Anti-slip mat) in the seat. On 3/18/25 at 10:26 A.M., Resident 15's clinical record was reviewed. Diagnoses included, but were not limited to, Alzheimer's disease with late onset and Dementia with unspecified severity. The Current Annual Minimum Data Set (MDS) assessment dated [DATE] indicated that Resident 15 was severely cognitively impaired. Resident 15 was dependent on transferring, hygiene, and dressing. Current physician orders included, but were not limited to, using a Dycem to the wheelchair twice a day from 6:00 A.M. to 10:00 A.M. and 6:00 P.M. to 10:00 P.M. dated 6/21/24. An Interdisciplinary (IDT) note dated 3/17/25 at 12:24 P.M., indicated Resident 15 had a fall on 3/14/25 while leaning forward trying to pick things off the floor when he toppled out of the chair. The note indicated that a Dycem was in place. A Quarterly Resident First Meeting dated 2/21/25 indicated Resident 15 was a high fall risk. The most recent care plan indicated the resident was a high fall risk related to altered/impaired mobility and impaired cognition. Interventions included, but were not limited to: Dycem to wheelchair cushion dated 6/24/24 and keep personal items and frequently used items within reach dated 2/22/24, the care plan was last reviewed by staff on 3/3/2025. During an interview on 3/19/25 at 9:35 A.M., CNA 5 indicated that there should be a Dycem in place for the resident. During an interview on 3/21/25 at 8:30 A.M., the Regional Support Nurse indicated that the care plan should be followed and updated after each fall. On 3/21/25 at 9:15 A.M., the Regional Support Nurse provided a current policy Fall Management Program Guidelines reviewed on 12/17/24. The policy indicated .the resident care plan should be updated to reflect any new or change in interventions . 3.1-45(a)(2)

Based on observation, interview, and record review, the facility failed to ensure the implementation of enhanced barrier precaution (EBP) during a random observation for 1 of 1 resident with a permcath dialysis catheter while changing linen. (Resident 15) Finding includes: During a random observation on 4/18/24 at 10:02 A.M., Resident 15's room was identified as following the Enhanced Barrier Precautions. Two CNAs (Certified Nurse Aides) were observed entering Resident 15's room with a Hoyer lift and did not apply PPE (personal protective equipment). The resident was observed to be ready for the transfer with the lift pad in position. While in the resident's room, the CNAs did not have PPE on before or after transferring the resident to a wheelchair. The two CNAs were also observed to change the soiled bed linens and apply new linens. During an interview on 4/19/2 at 9:01 A.M., Resident 15 indicated staff did not wear PPE when doing transfers. During an interview on 4/19/24 at 9:04 A.M., RN (Registered Nurse) 3 indicated the staff wore PPE when doing anything that involved direct contact when residents were on enhanced barrier precautions. On 4/19/24 at 12:49 P.M., Resident 15's clinical record was reviewed. Diagnoses included, but were not limited to, other complications of vascular dialysis catheter and end stage renal disease. The most recent Quarterly MDS (Minimum Data Set) Assessment, dated 2/26/24, indicated the resident was cognitively intact. The resident was dependent for mobility, transfer, and dressing. Physician orders included, but were not limited to: Staff to use enhanced barrier precautions d/t (due to) central line, wearing a gown and gloves at minimum during high-contact care activities twice a day, dated 4/15/24. The current care plan indicated the resident had a central line and required enhanced barrier precautions (EBP) during high-contact care related to presence of this line. Interventions included, but were not limited to, risk for transmission of infection will be minimized with use of enhanced barrier precautions, to don/doff and dispose of PPE systematically and appropriately, per policy, and utilize gown and gloves per EBP policy during high contact ADL (Activities of Daily Living) care (e.g. dressing, showering/bathing, hygiene, transfers, toileting/changing briefs) and during linen changes. On 4/19/24 at 1:15 P.M., the Clinical Support Nurse provided a current Enhanced Barrier Precautions (EBP) Standard Operating Procedure policy, dated 4/1/24, that indicated . Enhanced Barrier Precautions will be in place during high-contact activities for residents with the following conditions .all residents with indwelling medical devices .high-contact activities include but are not limited to .morning and evening ADL care . 3.1-18(b)(2)

Based on observation, interview, and record review, the facility failed to ensure resident records were accurate for 2 of 2 residents reviewed for pressure ulcers and 1 of 1 residents reviewed for dental. (Resident 43, Resident 101, Resident 47) Findings include: 1. On 4/17/24 at 8:42 A.M., Resident 43's clinical record was reviewed. Diagnoses included, but were not limited to, paraplegia and morbid obesity. The most recent Admission Minimum Data Set (MDS) Assessment, dated 2/14/24, indicated that Resident 43 was cognitively intact, was at risk for pressure injuries, and had no unhealed pressure injuries. A care plan, initiated 2/29/24, indicated the resident had a pressure area to the bottom of the left lateral foot and to the gluteal fold. Physician orders included, but were not limited to: Weekly skin assessment: 0=no impairment, 1=new impairment, 2=old impairment, once a day on Mondays, dated 2/09/24 Cleanse left buttock with soap and water. Apply wound gel to wound bed and cover with dry dressing. May change PRN (as needed) if soiled, once a day, dated 3/21/24 Triad Wound Dressing paste - one application topically, twice a day, dated 3/22/24 Wound 1: A Wound Management Detail report indicated a pressure ulcer was identified on the bottom of the resident's left lateral foot on 2/28/24 at 5:25 P.M The wound was unstageable (full thickness tissue loss in which the base of the ulcer cannot be confirmed because the wound bed is obscured by slough and/or eschar), measured 1.9 cm (centimeters) by 2.8 cm, and skin was light purple/green and intact. A wound management detail report, dated 3/7/24 at 7:18 P.M., indicated the pressure ulcer on the resident's left foot was unstageable, measured 1.9 cm by 2 cm, and had necrotic tissue. A progress note, dated 3/14/24 at 11:55 A.M., indicated the pressure ulcer on the resident's left foot continued to show improvement, the purple was fading, with a scant amount of fluid noted under the dermis that appeared to be reabsorbing, and no signs or symptoms of infection. A wound management detail report, dated 3/14/24 at 6:52 P.M., indicated the pressure ulcer on the resident's left foot was unstageable, measured 1.8 cm by 2 cm, and had necrotic tissue. A wound management detail report, dated 3/21/24 at 9:57 P.M., indicated the pressure ulcer on the resident's left foot was unstageable, measured 1.9 cm by 2 cm, and had necrotic tissue. A progress note, dated 3/23/24 at 10:12 A.M., indicated the resident had a bruised area on bottom L [left] foot. A wound management detail report, dated 3/29/24 at 1:59 P.M., indicated the pressure ulcer on the resident's left foot was unstageable, measured 1.9 cm by 2 cm, and had necrotic tissue. A wound management detail report, dated 4/5/24 at 9:17 A.M., indicated the pressure ulcer on the resident's left foot was unstageable, measured 1.9 cm by 2 cm, and had necrotic tissue. A wound management detail report, dated 4/11/24 at 9:22 A.M., indicated the pressure ulcer on the resident's left foot was unstageable, measured 1.9 cm by 2 cm, and had epithelial tissue. Wound 2: A progress note, dated 3/21/24 at 11:08 A.M., indicated . Assessed BLE [bilateral lower extremities]. Remains with purple area to bottom of left foot. Improved from last assessment fading in color . Noted open area to left buttock. 6.8x5.4<0.1 irregular rashy [sic] dry peeling edges open red with slight bleeding. Notified [name of provider] new order received Cleanse daily apply wound gel and cover with foam dressing. Wound nurse eval [evaluation] treatment effectiveness of treatment. A progress note, dated 3/22/24 at 2:31 P.M., indicated MASD [moisture associated skin damage] noted to bilateral gluteal folds. Areas cleansed and triad paste applied. A progress note, dated 3/27/24 at 12:53 P.M., indicated treatment done to area on buttocks. Area is healing peri-wound is pink in color. A wound management detail report indicated a pressure ulcer was identified on the left lower buttocks/thigh (gluteal fold) on 3/29/24 at 2:00 P.M The wound was unstageable, measured 3.5 cm by 3.2 cm, and had granulation tissue. A wound management detail report, dated 4/5/24 at 9:14 P.M., indicated the pressure ulcer on the resident's gluteal fold was unstageable, measured 3.4 cm by 3.2 cm, and had epithelial tissue. The entry was created on 4/17/24 at 9:17 A.M. A progress note, dated 4/11/24 at 7:24 A.M., indicated Resident leaving for appointment in [name of city]. Will return this evening. A wound management report dated 4/11/24 at 9:19 A.M., indicated the pressure ulcer on the resident's gluteal fold was unstageable, measured 3.4 cm by 3.1 cm, and had epithelial tissue. The entry was created on 4/17/24 at 9:21 A.M. A progress note, dated 4/11/24 at 7:37 P.M., indicated Resident has returned from LOA [leave of absence]. A progress note, dated 4/15/24 at 3:07 P.M., indicated Left foot red intact skin improved almost healed. Moisture associated damage to Buttock has improved. The March 2024 TAR (Treatment Administration Administration) indicated a weekly skin assessment had been completed: 3/4/24 - old impairment 3/11/24 - no impairment 3/18/24 - no impairment 3/25/24 - buttocks The April 2024 TAR indicated a weekly skin assessment had been completed: 4/1/24 - no impairment 4/8/24 - old impairment 4/15/24 - no impairment On 4/17/24 at 11:02 A.M., Certified Nurse Aide (CNA) 11 indicated Resident 43 did not have a dressing covering the wound on her buttocks for at least the past week. On 4/17/24 at 11:04 A.M., Licensed Practical Nurse (LPN) 17 indicated Resident 43 did not have a dressing and Triad paste was used. The wound order for the dry dressing needed to be discontinued. She further indicated if a staff member saw a new wound, they would put in an event and she would check those events daily and assess the new wound at that time. She indicated that the resident was in [name of city] on 4/11/24 and the wound assessment, dated 4/11/24, was completed on 4/10/24 and was dated 4/11/24 in error. She indicated the assessments were entered into the resident's medical record on 4/17/24 because she was behind in putting information into the EHR (electronic health record). On 4/18/24 at 9:39 A.M., the Clinical Support Nurse indicated Resident 43's wounds should have been documented as MASD and not unstageable pressure ulcers. The resident had 1 wound on her buttocks and 1 wound on her left foot and that the wounds in the progress notes, skin assessments, and wound management reports referred to those wounds. She indicated the wound on Resident 43's bottom was chronic and would come and go. She indicated the wound on the resident's left foot was not nor ever was necrotic. She indicated the wound nurse was new and was confusing bruised tissue with necrotic tissue. She further indicated the skin assessments should reflect the wound detail management reports, and she was unsure why the nurse was charting there was no impairment when there was. 46758 2. On 4/17/24 at 2:00 P.M., Resident 101's clinical record was reviewed. Diagnoses included, but were not limited to, unspecified displaced fracture of first cervical vertebra and anterior displaced Type II dens fracture. The current Admission MDS Assessment, dated 4/11/24, indicated Resident 101 was moderately cognitively impaired and needed partial to modified assistance to perform toileting, transferring, and mobility. The MDS Assessment indicated Resident 101 also had an unstageable pressure ulcer. Physician's orders included, but were not limited to: Observe L (left) plantar for any changes, notify MD (medical doctor) if any changes are noted, twice a day, dated 4/17/24. Weekly skin assessment once a day, dated 4/4/24. L plantar skin prep q (every) shift, twice a day, dated 4/17/24. Care plans included, but were not limited to: Resident has a pressure ulcer to left bottom of foot. The goal was that the resident ulcer would heal without complications. Interventions included, but were not limited to, assess and record the condition of the skin surrounding the pressure ulcer, observe and report signs of infection (localized redness, swelling, tenderness .), and weekly skin assessment, measurement, and observation of the pressure ulcer and record, dated 4/5/24. On 4/17/24 at 12:46 P.M., the Regional Support Nurse provided Resident 101's Wound Management Detail Report. The observation, dated 4/4/24, indicated the observed pressure wound measured 0.5 cm by 0.5 cm and was located on the bottom of the left plantar foot. The wound was unstageable in the deep tissue. The tissue was necrotic with well-defined wound edges and the surrounding skin was pink and normal. The observation dated 4/12/24 indicated the pressure wound measured 0.7 cm by 0.5 cm and was located on the bottom of the left plantar foot. The wound was unstageable in the deep tissue. The tissue was necrotic with well-defined wound edges and the surrounding skin was pink and normal. During an interview on 4/18/24 at 9:34 A.M., the Regional Support Nurse indicated she had seen the wound and it was not necrotic but was blanchable. The person who had been putting in the assessment was new and had put in the wrong entry. It should not be labeled as necrotic. It was more like a bruise. 48057 3. During an observation on 4/15/24 at 01:19 P.M., Resident 47 was observed having both missing and broken teeth in the oral cavity. On 4/16/24 at 10:06 A.M., Resident 47's clinical record was reviewed. Resident 47 was admitted on [DATE]. Diagnoses included, but were not limited to, Chronic Obstructive Pulmonary Disorder (COPD), acute and chronic respiratory failure with hypoxia, and type 2 Diabetes Mellitus. The most recent Admission MDS Assessment, dated 3/39/24, indicated Resident 47 was cognitively intact, required limited assistance of 1 staff member for transfers and mobility, and had broken or missing teeth. Current care plans included, but were not limited to: Resident is at risk for malnutrition R/T (related to) no natural teeth or dentures (edentulous), dated 4/1/24. An admission observation, dated 3/23/24 at 3:32 P.M., indicated no oral cavity issues and was not selected for any oral cavity indications including missing or broken teeth, dentures, or edentulous. During an interview on 4/17/24 at 10:05 A.M., the MDS Coordinator indicated the care plan contained incorrect information and was marked in error, was not sure why the admission assessment stated Resident 47 had no oral decays and confirmed Resident 47 did have missing and broken teeth. During an interview on 4/19/24 at 12:58 P.M., the Clinical Support Nurse indicated there was no policy related to documentation, and stated it was company policy to document accurately and timely. 3.1-50(a)(2)

Based on observation, record review, and interview, the facility failed to ensure oxygen equipment was properly labeled and oxygen was administered as ordered for 1 of 2 residents reviewed for respiratory care. (Resident 47) Finding includes: During an observation on 4/15/24 at 1:19 P.M., Resident 47 was observed sitting in a chair in her room with no oxygen being administered. There was an unplugged oxygen concentrator on the opposite side of the room. There was no date or initials observed on the humidification bottle, oxygen tubing, or oxygen tubing bag. During an observation on 4/16/24 at 8:48 A.M., the oxygen concentrator was observed turned off. There was no date or initials observed on the humidification bottle, oxygen tubing, or oxygen tubing bag. There was a portable oxygen concentrator, not in use, attached to the back of Resident 47's wheelchair; there were no dates on the oxygen tubing. On 4/16/24 at 10:06 A.M., Resident 47's clinical record was reviewed. Resident 47 was admitted on [DATE]. Diagnoses included, but were not limited to, Chronic Obstructive Pulmonary Disorder (COPD), acute and chronic respiratory failure with hypoxia, and bronchopneumonia. The most recent Admission MDS (Minimum Data Set) Assessment, dated 3/39/24, indicated Resident 47 was cognitively intact, required limited assistance of 1 staff member for transfers and mobility, and was receiving oxygen therapy. Current active physician orders included, but were not limited to: Oxygen at 2L (liters) per nasal cannula continuous, dated 4/1/24. Change oxygen tubing monthly, once a day on the 1st of the month, dated 4/1/24. Current care plans included, but were not limited to: Resident has potential for complications, functional and cognitive status decline related to respiratory disease; Administer oxygen per MD (medical doctor) order, dated 3/25/24. During an interview on 4/17/24 at 09:01 A.M., Registered Nurse (RN) 9 stated that oxygen tubing was changed weekly, and the oxygen tubing was placed in the bag with the resident's name and current date. When the tubing was not in use the equipment was placed in the bag. A current oxygen administration policy was requested on 4/19/24 and was not provided. 3.1-47(a)(6)

Based on interview and record review, the facility failed to ensure the MDS (Minimum Data Set) assessment was completed accurately for 1 of 1 residents reviewed for restraints. (Resident 27) Finding includes: On 4/15/24 at 2:23 P.M., a family member indicated restraints had never been used on Resident 27 that she was aware of. On 4/16/24 at 11:00 A.M., Resident 27's clinical record was reviewed. Diagnoses included, but were not limited to, dementia and anxiety disorder. The most recent Quarterly MDS Assessment, dated 2/16/24, indicated Resident 27 had severe cognitive impairment, had no behaviors, and that physical restraints were used less than daily during the 7-day look back period. The clinical record lacked care plans, orders, assessments, and progress notes related to the use of physical restraints. On 4/17/24 at 9:35 A.M., the MDS Coordinator indicated that restraints used less than daily was marked in error on the 2/16/24 Quarterly MDS Assessment. She further indicated the facility did not use restraints on any resident. On 4/19/24 at 10:51 A.M., the Administrator indicated the facility follows the RAI (Resident Assessment Instrument) manual for guidance on coding MDS Assessments.

Based on observation, interview, and record review, the facility failed to ensure infection control practices and standards were maintained in 3 of 6 residents observed for care and 1 random observation. Staff did not change gloves from dirty to clean tasks during incontinence care and a catheter bag was observed dragging the floor. (Resident 5, Resident 29, Resident 13, Resident 195) Findings include: 1. On 1/17/23 at 9:10 A.M., RN (Registered Nurse) 21 was observed to provide catheter care to Resident 5. RN 21 wore gloves and used a peri-wipe to cleanse the skin in the folds of the resident's groin and around his pubis, after which she used the same wipe to cleanse the opening to his urethra, which was red. She then disposed of the wipe and her gloves in a plastic trash bag and removed it from the room. 2 .On 1/17/23 at 1:49 P.M., Resident 29's catheter leg bag was observed to be draining cloudy yellow urine. CNA 1 came in to straighten out the pillow case that was wrapped around the resident's right leg and secured with elastic bands. She took the pillow case off his leg and laid it on the floor, then got new elastic bands and wrapped the same pillow case around his leg and placed a new leg bag. At that time, Resident 29 indicated it burned when he urinated. CNA 1 did not acknowledge Resident 29's remark about burning on urination. 38770 3. On 1/18/23 at 9:57 A.M., CNA (Certified Nurse Aide) 3 and CNA 5 were observed to perform incontinence care for Resident 13. CNA 3 washed her hands and donned (put on) a pair of gloves. CNA 5 washed her hands with a 4 (four) second lather, and donned gloves. CNA 3 then closed the resident's blinds, and touched the bed control to raise the bed and lower the head of the bed. Both CNA 3 and CNA 5 then removed the blankets from the resident. CNA 3 then opened the cabinet door by the bed, obtained a clean brief and a package of incontinence wipes, and laid them on the bed. CNA 5 removed the soiled brief, and CNA 3 removed an old dressing from the resident's coccyx before cleaning the resident with the incontinence wipe. After cleaning the resident, CNA 3 placed her gloved hands on the resident's legs to assist with turning from side to side to place the new brief. CNA 3 then replaced the package of wipes in the cabinet, and touched the bed control to lower the bed. CNA 3 and CNA 5 then removed their gloves. No glove changes were observed during care. CNA 3 then washed her hands with a 6 (six) second lather, and CNA 5 washed her hands with an 11 second lather. During an interview at that time, CNA 3 indicated hands should be washed for 20 to 30 seconds. 4. On 1/19/23 at 9:37 A.M., during a random observation, Resident 195 was observed sitting in a wheelchair by the 400 Hall nurses station. A catheter bag was observed under the wheelchair resting on the floor. At that time, the resident indicated he was waiting on transportation. PT (Physical Therapist) 7 was observed speaking with the resident, then went to his room, obtained a jacket, and brought it back to assist the resident with putting it on. The driver for the transportation was then observed to push the resident's wheelchair down the hall with the catheter bag dragging the floor. Staff did not address the catheter bag. During an interview on 1/23/23 at 10:17 A.M., the IP (Infection Preventionist) indicated if and when a resident's catheter bag was observed on the floor, staff should pick it up. A current catheter care policy, dated 12/1/2021, was provided on 1/23/23 and indicated Keep drainage bag be covered with an appropriate device .may utilize drainage bags that have a built-in cover, i.e. The Fig Leaf .Cover needs to be replaced when it becomes soiled, urinary drainage bags are to be changed as ordered or as needed .Urinary drainage bags and catheter tubing should be kept from touching the floor surface On 1/23/23 at 9:37 A.M., a current hand hygiene policy, dated 2/9/17, was provided and indicated Health Care Workers shall use hand hygiene at times such as . Before/after having direct physical contact with residents . Wash well for 15-20 seconds, using a rotary motion and friction 3.1-18(b) 3.1-18(l)

Based on observation, interview, and record review the facility failed to ensure food was prepared in a sanitary manner. Staff was observed with hair not completely covered by a hairnet for 1 of 1 meal preparations observed. Staff fed residents with bare hands, and reached over a resident's plate of food to assist another resident during 2 of 2 dining observations. (Dietary 12, Resident 16, Resident 17) Findings include: 1. On 1/19/23 during lunch preparation at 11:15 A.M., Dietary 12 was observed in the food preparation area of the kitchen pouring ketchup into containers. Her hair was not contained in the hairnet, hair was exposed and loose at the forehead area. 45933 2. During an observation on 1/17/23 from 12:04 P.M. to 12:32 P.M., the following was observed: Certified Nurse Aide (CNA) 3 reached over Resident 17's plate of food to assist Resident 16 with cutting her food. CNA 3 then reached over Resident 17's plate with her right hand to help Resident 16 obtain food on her fork. CNA 3 walked over to clean Resident 16's hands with a white paper towel. CNA 3 then performed hand hygiene for a 9 (nine) second lather. CNA 3 reached over Resident 17's plate to adjust Resident 16's plate, then reached over Resident 17's plate with her right arm to provide Resident 16 her drink. CNA 3 walked over to clean Resident 16's hands with a white paper towel. CNA 3 then performed hand hygiene for an 8 (eight) second lather. CNA 3 then reached over Resident 17's plate to provide Resident 16 her drink. During an interview on 1/23/23 at 8:47 A.M., CNA 1 indicated if she was helping 2 (two) residents, she would sit in the middle of the two residents in order to not reach over the resident's food to assist. 35733 3. On 1/19/23 at 9:46 A.M., CNA 1 was observed to pick up a piece of toast with her bare hand and feed it to Resident 17. That was observed to be done twice while CNA 1 was feeding Resident 17 breakfast. On 1/23/23 at 8:47 A.M., CNA 1 indicated that gloves should be worn to touch food , not bare hands when feeding a resident. During an interview on 1/23/23 at 11:50 A.M., the Dietary Manager indicated that hair was to be completely covered by a hairnet. On 1/23/23 at 1:17 P.M., Clinical Support 32 indicated the facility does not have a policy indicating to not reach over a resident's plate to feed another resident, but staff should not reach over another resident's food to assist another resident. At that time, the Clinical Support 32 indicated staff were not supposed to touch food with bare hands when assisting residents to eat, the facility did not have a policy regarding this. A current policy Yellow Lines/Hair Restraint Policy dated 12/31/18 provided by Nurse 14 on 1/23/23 at 11:30 A.M., indicated: Entering food production areas . requires the proper use of hair restraints to prevent the chance of hair contaminating food for the consumption. No one is permitted in these areas without the proper hair-restraint equipment being worn . 1. All [name of facility] team members are required to follow signage and wear proper hair restraint equipment such as hair nets . before entering food production areas. 3.1-21(i)(2) 3.1-21(i)(3)

Based on observation, interview, and record review, the facility failed to ensure residents that were self administering medications were assessed for capability to self administer medications for 2 of 2 residents observed with medications in their rooms. (Resident 24, Resident 37) Findings include: 1. On 1/17/23 at 8:55 A.M., Resident 24 was observed sitting in her chair with a bedside table next to her that had a clear medicine cup with 2 (two) capsules in it. Resident 24 indicated she did not know what the capsules were. At that time, Qualified Medication Aide (QMA) 22 indicated Macrobid and a multivitamin was in the medicine cup, and Resident 24 did not self administer medications. On 1/18/23 at 1:19 P.M., Resident 24's clinical record was reviewed. Diagnosis included, but were not limited to, anxiety and depression. The most recent quarterly Minimum Data Set (MDS) assessment on 12/30/22, indicated Resident 24 was severely cognitively impaired. Current physician orders included, but were not limited to, Macrobid 100mg (milligrams) oral twice a day, dated 1/13/23 (to be given between 6:00 A.M. and 10:00 P.M. and again from 6:00 P.M. to 10:00 P.M.) and Multivitamin 0.25mg oral once a day, dated 12/8/22 (to be given from 6:00 A.M. to 10:00 A.M). Current physician orders lacked an order to self administer medications, or to keep medications in room. Resident 24's record lacked any care plans related to self administration of medications or storage of medications in room. Resident 24's record lacked any self administration of medication assessments. During an interview on 1/20/23 at 10:33 A.M., Licensed Practical Nurse (LPN) 23 indicated Resident 24 required staff to be in the room when receiving medications. 2. On 1/17/23 at 1:04 P.M., Resident 37 was observed sitting in a chair with a bedside table next to him with a bottle that was labelled glucose pills. On 1/19/23 at 8:45 A.M., Resident 37's clinical record was reviewed. Diagnoses included but were not limited to, acidosis and metabolic acidosis. A current quarterly MDS assessment dated [DATE] indicated the resident was mildly cognitive impaired. He was independent with eating and toileting, and needed supervision with dressing, mobility,an dressing. Resident 37 lacked a physician's order for glucose pills and self administration of such pills. Resident 37 lacked a current care plan for the use of glucose pills. Resident 37 lacked a self medication assessment. During on interview on 1/20/23 09:03 A.M., Nurse 6 indicated she was not aware that resident had glucose pills until they were taken away from him. On 1/23/23 at 10:07 A.M., a current Medication Administration General Guidelines policy, revised 11/18 was provided and indicated .The person who prepares the dose for administration is the person who administers the dose .The resident is always observed after administration to ensure that the dose was completely ingested . 3.1-11(a)

Based on observation, interview, and record review, the facility failed to ensure the resident received necessary respiratory care and services in accordance with professional standards of practice for 1 of 1 residents reviewed for respiratory care. (Resident 197) Findings included: On 1/17/23 at 10:40 A.M., Resident 197 was observed with a CPAP (continuous positive airway pressure) machine on the bedside table. On 1/18/23 at 10:41 A.M., Resident 197's clinical record was reviewed. The resident was admitted on [DATE]. Diagnoses included, but were not limited to, COPD (chronic obstructive pulmonary disease) and sleep apnea. Resident 197's record lacked a current physician's order for use of a CPAP machine. A personal possessions inventory form, dated 1/6/23, listed a CPAP machine. During an interview on 1/20/23 8:25 A.M., Resident 197 indicated his wife maintained the care of the CPAP machine such as filling the water. During an interview on 1/20/23 8:46 A.M., CNA (Certified Nurse Aide) 10 indicated care for a CPAP machine should have been located on the resident's MAR (medication administration record), as well as the CNA computer screen. CNA 10 indicated that Resident 197 lacked that notice. During an interview on 1/23/23 at 11:44 A.M., Clinical Support 32 indicated the facility did not have a policy for the use of CPAP machines. 3.1-47(a)(6)

Based on interview and record review, the facility failed to ensure staff COVID-19 vaccination medical exemptions specified a clinically recognized contraindication for 1 of 2 staff medical exemptions reviewed, and the policy lacked additional precautions related to being unvaccinated. (Staff 10) Finding includes: On 1/17/23 at 2:13 P.M., Staff 10's medical exemption was reviewed. The medical exemption, signed 5/16/22, indicated Staff 10 should not receive the COVID-19 vaccine related to multiple neurological issues. During an interview on 1/20/23 at 10:35 A.M., Staff 10 indicated she had a medical exemption and is required to wear a surgical mask as an additional precaution. At that time, Staff 10 was observed working on the resident unit. On 1/23/23 at 9:15 A.M., a current Covid-19 Health Care Staff Vaccination policy, revised 9/28/22, was provided and indicated .Senior Clinical Staff reserves the right to seek clarification from the employee for medical statements not reflecting the Centers for Disease Control (CDC) recognized contraindications Must always wear a well-fitting face mask (loop or N95), regardless of whether they are providing direct care to a resident . The policy lacked the specific contraindication to receiving the vaccine and additional precautions for unvaccinated individuals. 3.1-18(b)

Based on observations, record review and interview, the facility failed to adequately supervise and implement specific interventions for 2 of 3 residents who were reviewed for falls. Resident B had multiple falls with one resulting in the surgical hardware to dislocate and Resident C had a fall that resulted in a fracture. ( Resident B, Resident C) Findings include: 1. During the initial tour on 9/15/21 at 8:35 a.m., the Director of Nursing (DON) indicated Resident B had multiple falls in the facility and one had resulted in an emergency room visit due to her hip replacement hardware popping out of place. Resident B was observed lying in her bed at the time of the tour. During a review of Resident B's clinical record on 9/15/21 at 9:10 a.m., it indicated Resident B was moderately cognitively impaired. Resident B's diagnoses included, but were not limited to, [CONDITION(S)], heart failure, non-displaced intertrochanteric fracture of left femur, subsequent encounter for closed fracture with routine healing, periprosthetic fracture around internal prosthetic left hip joint, periprostetic [CONDITION(S)] of internal prosthetic left hip joint, toxic effect of other metals, accidental. The Admission MDS (Minimum Data Set) assessment, dated 9/4/21, indicated Resident B required extensive assistance of two staff with bed mobility, transfers, dressing, toileting, hygiene, and required physical help in part of bathing. Resident B had two or more falls since admission on 8/28/21 and had orthopaedic surgery to repair, but not replace joints and other major orthopaedic surgery. Resident B's care plans included, but were not limited to, Resident demonstrates altered behaviors including hallucinations. Interventions included, but were not limited to, monitor resident's mood and behavior with all hands on care and contacts, psychiatric services as needed, redirect as needed, notify physician of behavioral changes. Start date 9/3/21, no revisions noted. Resident demonstrates cognitive impairment. Interventions included, but were not limited to, encourage resident to participate in her plan of care and ADLs (activities of daily living), encourage resident to make choices in care as she is able, medications as ordered, refer to physician with significant changes in cognitive functioning, reorient and redirect resident as needed. Start date 9/3/21, no revisions noted. Resident at risk of falling related to cobalt toxicity and hip replacement. Interventions included, but were not limited to, call don't fall sign on walker (added 9/2/21), offer assistance with toileting frequently throughout the night (added 9/1/21), assure the floor is clear of liquids and foreign objects (added 8/31/21), encourage and assist resident to assume a standing position slowly (added 8/31/21), keep call light in reach (added 8/31/21), keep personal items and frequently used items in reach (added 8/31/21), parameter mattress (added 8/31/21), provide non-skid footwear (added 8/31/21), bed in lowest position at all times (added 8/30/21), therapy evaluation as needed (added 8/31/21), assist resident with transfers as needed (added 8/31/21). Start date 8/30/21. Resident B's orders indicated, 9/4/21 Weight bearing as tolerated with assistive device (walker) with posterior hip precautions 9/9/21 Call don't' fall reminder sign on walker as visual reminder 9/9/21 Bed in lowest position at all times, intervention bed position check added 8/30/21 9/10/21 Offer assistance with toileting frequently throughout the night, intervention added 9/1/21 Resident B's events indicated, 8/28/21 7:47 p.m.- Unwitnessed fall No injury noted. Complaints of left hip pain. No new intervention noted. 8/30/21 8:15 p.m.- Unwitnessed fall No injury noted. Complaints of left hip pain. Intervention: bed in lowest position. 8/31/21 2:50 a.m.- Unwitnessed fall No injury noted. Complaints of left hip pain. New intervention: parameter mattress. 9/1/21 10:33 p.m.- Unwitnessed fall No injury noted. Complaints of left hip pain. New intervention: toilet frequently throughout the night. 9/2/21 6:30 p.m.- Unwitnessed fall No injury noted. Complaints of left hip pain. New intervention: call don't fall sign on walker Progress notes indicated, but were not limited to, 08/28/21 at 5:49 p.m.- Resident arrived at facility via ambulance. Family waiting here for arrival. Resident was transferred to bed by emergency medical personnel. Resident was tearful when arrived, stated, I am scared. Family stated that resident has had increased confusion. Attempts made to console, effective. Resident is alert with confusion, able to voice wants. Skin is warm and dry. Lung sounds clear bilaterally, no cough or shortness of breath noted. SpO2 at 98%. Respirations at 18, relaxed. Pulse 98 regular. Bruising noted to bilateral upper extremities and bilateral hands due to intravenous access. Foley catheter in place, urine appears cloudy, sediment noted in tubing. Permcath noted to upper R chest, dressing is dry and intact, dated today. Resident complains of discomfort to upper left thigh. Surgical incision healing, no open areas, redness noted to distal end of incision. No other skin issues noted. Family at bedside and knowledgeable with residents condition. 8/29/21 12:20 a.m.- Recorded as Late Entry on 08/30/21 at 12:23 a.m.- Resident was very anxious at the beginning of the shift, hollering for help, very confused. As the night went on, Resident rested in bed until 4:30 a.m., again started hollering for help. Staff was able to easily direct her back to bed and she went back to sleep. Resident does complain of pain, states Tylenol helps. Foley catheter in place and draining cloudy yellow urine. 8/30/21 12:23 a.m.- Foley catheter removed around 4:00 p.m. Resident has voided 3 times with each occurrence voiding more. Resident continues to be anxious with legs shaking in bed. Resident has become stronger and is able to transfer with assist of 1 this night. 8/30/21 11:49 p.m.- Nurse heard resident yelling at 8:15 p.m., Help me, I've fallen. Nurse entered resident's room and resident was sitting on buttocks almost to the door with legs stretched out in front of her. Resident was wearing non-skid socks. Resident stated at this time that she had slid off of side of bed and had crawled from that spot to where she was sitting to get some help. Nurse assessed resident and there was no redness or bruising noted at the time of the fall. Resident had no outward or inward rotation of hips. Bilateral hand grasp was weak. Neuro checks were within normal limits. Vital signs were stable. Resident visibly upset. Nurse and aide spent time with resident and she was calm when nurse and aide left resident's room. No complaints of pain or discomfort related to fall at this time, but has complained of pain related to previous hip injury. Resident notified daughter of fall as daughter called facility. Physician and DON notified. 8/31/21 4:08 a.m.- Resident hit call light and as nurse approached room could hear resident saying that she had fallen out of bed. Resident noted to be sitting on buttocks next to bed facing with legs out in front of her away from closet. Resident stated that she had rolled out of bed when she had turned over because these beds are too narrow. Resident stated that her left hip was hurting, but she had rolled out of bed on to it. No noted redness or bruising, no inward or outward rotation of the area during any of neuro checks which were within normal limits. Vital signs stable. Resident had been incontinent prior to fall as bed was wet. Lines changed, resident toileted, and placed back in bed. Physician, DON, and daughter notified. 8/31/21 5:52 a.m.- Resident was complaining of pain early in the shift, but rested quietly between 9:30 p.m. when pain medication was administered and 2:50 a.m., when resident rolled out of bed. Resident was complaining of pain at that time, but during the frequent neuro checks stated that she was feeling better and had no complaints after 30 minutes. Spoke with resident about the narcotics related to falling and increased confusion. Resident agreed and did not request more pain medication after second fall. 8/31/21 11:13 a.m.- Resident complaining of pain in left hip. Resident's family concerned. Call placed to physician and orders received for X-ray of left hip. [MEDICATION(S)] (anti-anxiety medication) orders clarified. [MEDICATION(S)] 0.5 mg (milligrams) once daily as needed and at bedtime, as needed. 8/31/21 3:19 p.m.- Care Conference: met with daughter and son for admission care conference. Resident and family plan for her to return home following services. Therapy goals and progress discussed. All medication questions answered. Family asking for call light attendant and mats be placed on either side of the bed. Resident's husband passed away a year ago, family state resident is still grieving. Family also asking about a PET scan, facility to reach out to physician. Will continue to monitor and intervene as needed. 9/02/21 6:30 p.m.- Recorded as Late Entry on 9/04/21 at 12:58 p.m. Dietary aid summoned this nurse to room after observing resident on the floor of her bathroom. Upon entering the room resident noted sitting on the bathroom floor with pull up down around ankle. Small bowel movement noted in toilet with urine on the floor. Walker noted next to sink. Resident did not have footwear on at time of assessment. Resident denied any pain or discomfort. No visible sign of injury noted. No change in range of motion. Resident assisted up to walker and ambulated with assist from bathroom to wheelchair. Resident brought to common area for close observation due to impulsiveness and repeated falls. 9/02/21 7:30 p.m.- Recorded as Late Entry on 9/04/21 at 1:04 p.m. Resident noted up out of wheelchair ambulating with unsteady gait. Reminded that she is to ask for assistance with ambulation. Resident stated she needed to go to the bathroom. Assisted to bathroom at this time with no results. Resident taken to Legacy (locked dementia) unit on the Assisted Living unit at this time for more 1:1 monitoring. Daughter updated of resident continuous attempts to get up unassisted and short term placement on Legacy until ready for bed, daughter voiced understanding and in agreement. 9/03/21 5:00 a.m.- Recorded as Late Entry on 9/04/21 at 1:13 p.m. Resident stated she was tired and ready for bed around 9:45 p.m. Resident assisted from Legacy unit to her room and transferred to bed. Resident denied any pain or discomfort. Resident slept through the night without difficulty until at this time when she woke up with complaints of pain to left hip. PRN (as needed) [MEDICATION(S)] (pain medication) given as ordered for pain. Offered resident ice pack for more immediate relief and resident declined. 9/03/21 11:15 a.m.- Resident on follow up due to fall. Resident has had 4 falls since 8/30/21. Resident continues to be impulsive, short term memory deficits noted. Complaints of left hip pain to SSD (Social Services Director), nursing aware. Will continue to monitor and intervene as needed. 9/03/21 12:58 p.m.- Physician called and informed of recent fall. New orders received for X-ray to right hip. Also requested side rails for residents safety. 9/03/21 3:20 p.m.- X-ray tech was here to complete image requested. Image on screen showed significant displacement of left hip was noted. Physician called, new order to be sent to emergency room immediately. Daughter was called and is in route to facility to inform resident for needed support. 9/03/2021 3:42 p.m.- Ambulance service called for transport to hospital. Daughter is here and explaining to resident the need for transport. Nurse was also present for explanation. Resident tearful. Pain medication was administered prior to known need for transfer. Awaiting for ambulance to arrive. 9/05/21 12:38 a.m.- Resident arrived at facility at 7:30 p.m. via ambulance, accompanied by daughter. Arrived on stretcher, alert and oriented. Transferred to bed by 2 emergency personnel and and 1 staff assist. Resident is WBAT (weight bearing as tolerated) with assistive device, posterior hip precautions, and has wedge cushion between bilateral lower extremities. Resident denied any pain upon admission. Vital signs stable. Lungs clear, bowel sounds active, respirations even and unlabored. Bedtime meds given per orders. 9/05/21 1:39 a.m.- Resident resting in bed since returning from the hospital. PRN [MEDICATION(S)] given with HS (bedtime) meds per daughter's request. Resident denied any pain upon admission. Resident also starting [MEDICATION(S)] (antibiotic) BID (twice daily) for abnormal urinalysis. 9/05/21 2:10 p.m.- Resident alert and oriented x 4 this date, no confusion noted. Daughter sat with resident throughout day. Resident has had some discomfort but stated that is is tolerable, PRN pain medication administered as ordered. Resident able to stand and pivot without difficulty. Wedge is placed while in bed. Resident's mood is pleasant. Appetite is good. Call light is within reach, low bed position and parameter mattress in place. 9/09/21 10:24 a.m.- IDT note: Resident noted to have slid off the bed trying to transfer self. Root cause: Transferring Immediate Intervention: Staff assisted resident back to bed Intervention: Bed in lowest position Resident has cobalt toxicity and has increased confusion with delusions and agitation at times. Will continue to monitor with all safety measures in place. 9/09/21 10:31 a.m.- IDT note: Resident noted to roll out of the bed stating the bed was too narrow. Resident has some confusion related to cobalt toxicity. Intervention: Parameter mattress Will continue to monitor with fall preventions in place. 9/10/21 9:51 a.m.- IDT note: Resident noted to have some left hip pain since admission. She has had a recent hip repair with cobalt toxicity. Pain medications given per orders and keeping pain under control. Resident has had increased confusion and agitation with multiple falls in a week. Urinalysis was gathered and started on antibiotic for [CONDITION(S)]. Will continue to monitor through antibiotic therapy. 9/15/21 4:30 p.m.- Resident's daughter was called today regarding new medication for cobalt poisoning diagnosis. Explained to her that pharmacy did not have the medication in stock due to it being a non-used drug, but is in the process of getting it for resident. Daughter voiced understanding and that she knows that it is not used often. She also voiced that she understands her mom is not cognitively intact like she used to be and that the cobalt poisoning caused from her metal on metal hardware in hip is the cause. Daughter stated that she is planning on discharging her mother on Saturday with 24/7 care at home. 9/16/21 7:44 a.m.- Staff alerted nurse that resident had a phone conversation with daughter in room regarding orthopaedic appointment scheduled for today. Call placed with daughter regarding this appointment. Stated that she was going to reschedule appointment due to resident stating she felt like she pulled a muscle and did not feel like going today. Nurse informed daughter of the importance of keeping said appointment to ensure proper treatment and healing. Daughter stated that she was going to call the office at 8 a.m. to request a different time. Waiting on return call from daughter to move forward with appointment. 9/16/21 9:35 a.m.- Spoke with physician's office regarding resident's refusal to go to orthopaedic appointment scheduled this date. Updated on daughter's request to reschedule. 9/16/21 12:00 p.m.- Resident continued to complain of pain to left hip and new order received for X-ray to left hip and pelvis. X-ray tech already at facility and notified of new order. Upon completion of X-ray, left hip noted to be dislocated. Call placed to physician's office and order received to transport resident to emergency room for evaluation and treatment. Ambulance service notified. Residents daughter notified and stated would meet mother at emergency room . Report called to hospital. X-ray report faxed to orthopaedic office. 2. During the initial tour on 9/15/21 at 8:45 a.m., the DON indicated Resident C had a fall that resulted in a fracture. Resident C was noted in her room, lying in bed with non-skid sock on. During a review of Resident C's clinical record on 9/15/21 at 9:53 a.m., it indicated Resident C was moderately cognitively impaired. Resident C's diagnoses included, but were not limited to, [CONDITION(S)], non-Alzheimer's dementia. Resident C's Quarterly MDS, dated [DATE], indicated Resident C required extensive assistance of 2 staff with ADLs and total dependence with bathing. Resident C had no falls since her admitted [DATE]. During a review of Resident C's care plans, they indicated, Resident demonstrates altered behaviors including delusions. Interventions included, but were not limited to, monitor resident's behaviors with all hands on care and contact, observe for behavioral triggers and causal relationships to medical changes with all hands on care and contact, psych services as needed. Start date 9/10/21. No revisions noted. Resident has impaired cognition with associated short term memory impairment and risk for confusion, disorientation, altered mood, impaired and/or reduced safety awareness related to dementia. Interventions included, but were not limited to, assess the degree of hearing ability, impulsive behavior, and decrease in visual perception, calm resident if signs of distress develop, determine if decisions made by res endanger the resident or others, intervene if necessary, give feedback to resident when inappropriate decisions are made. Start date 8/23/21, no revisions noted. Resident demonstrates visual losses. Interventions included, but were not limited to, arrange and assist with optometry appointments as needed, encourage to wear glasses as needed. Start date 5/3/21, no revisions noted. Resident demonstrates hearing loss. Interventions included, but were not limited to, communicate with resident in a clear, concise manner, hearing aids as indicated, refer to audiologist as needed, refer to speech therapy for evaluation of need for communication device as needed. Start date 5/3/21, no revisions noted. Resident requires staff assist to complete ADL tasks completely and safely. Interventions included, but were not limited to, allow resident sufficient time to complete all or parts of task, do not rush resident, encourage resident to do as much as safely possible for self, observe for deterioration in ADL abilities and report if occurs, therapy eval and treat as needed. Start date 4/28/21, no revisions noted. Resident is at risk for falls related to weakness, dementia, [CONDITION(S)], [CONDITION(S)]. Interventions included, but were not limited to, offer toileting frequently throughout the night (added 9/4/21),encourage resident to assume standing position slowly, ensure the floor is free of liquids and foreign objects, keep personal items and frequently used items within reach, provide non-skid footwear, staff to assist resident with transfers as needed, therapy eval and treat as needed. Start date 4/28/21. Resident C's orders indicated, but were not limited to, 4/14/21 Assist of 2 staff with transfers and walking 9/8/21 Offer toileting frequently throughout the night Resident C's events indicated, 9/4/21 6:07 a.m. Unwitnessed fall. Injury: Complaints of hip and shoulder pain. Fractured pelvis ramus. New intervention: offer toileting frequently throughout the night Progress notes indicated, but were not limited to, 9/04/21 5:20 a.m.- The resident's spouse, her roommate, pulled the emergency cord out of wall. RN entered room to find resident on the floor, laying on her right side, head under the furnace. Resident complained of right hip and shoulder pain. Resident stated she hit head on metal part of bedside table. No bleeding noted. Neuro checks within normal limits. RN called physician and received order to send to emergency room for evaluation. Called daughter and left message to return call. Spouse called daughter and nurse gave update of incident. Resident stated she was trying to toilet her self after watching her husband return from the room next door after having an affair. Resident had been sleeping in her recliner because she did not want to sleep near spouse. Call light was within reach at the time and resident was wearing house shoes. 911 called and ambulance left facility at 6 a.m. 9/04/21 2:21 p.m.- Resident to be discharged from hospital. Mobility service to transport resident from hospital back to facility. Family aware. Report stated that resident had a fracture to pelvic ramus and a [CONDITION(S)] that was treated with IV [MEDICATION(S)] (antibiotic). 9/04/21 6:18 p.m.- Resident returned from hospital. Daughters arrived to facility prior to resident. Packet received from daughter. New orders from hospital discharge orders for [MEDICATION(S)] (antibiotic) 100 mg PO (by mouth) BID (twice daily) x 5 days, [MEDICATION(S)] 1 gram IV administered at emergency room . Physician saw resident at the hospital and is aware. Resident alert and able to voice wants and needs. Resident does complain of hip discomfort, hospital finding noted; Fractured pelvis ramus. Small bruise noted to right elbow, no discomfort to this area noted. Resident currently lying in bed, refused evening meal, had meal at hospital. No other complaints at this time. 9/05/21 1:34 a.m.- Resident resting in bed this night after returning from the hospital. PRN [MEDICATION(S)] (pain medication) given for pain. Resident is being checked Q2 (every 2) hours. Neuro checks resumed x 72 hours. Neuro check within normal limits. Resident started [MEDICATION(S)] BID for [CONDITION(S)]. Tolerating at this time. 9/06/21 12:43 p.m.- Nurse spoke with resident's daughter. Daughter stated she spoke with her father, and he told her that her mother was in bed. She asked how the resident was doing and if she would be getting up. Nurse placed daughter on hold and went to resident's room. Nurse asked resident if she was in pain and resident denied. Nurse asked if resident would like to get out of bed and the resident declined. Nurse spoke with daughter and explained that the resident voiced no when asked if resident wanted to get up. Daughter stated she would like to feed the resident lunch and asked if the nurse would tell the resident and see if that would motivate the resident to get up. Nurse and CNA went to resident's room and resident did say she would get up. Three CNAs and nurse assisted resident from bed to wheelchair, and then the wheelchair to recliner. Resident did grimace with pain during transfers. 9/07/21 3:45 p.m.- Resident on follow up due to fall. No signs or symptoms of psychosocial distress noted related to fall at this time. Neuro checks within normal limits. Care plans and interventions reviewed. Will continue to monitor and intervene as needed. 9/07/21 4:01 p.m.- Resident having increased pain. Call placed to physician and orders received to change [MEDICATION(S)] order to TID (three times daily) PRN. Resident's daughter notified. 9/08/21 12:11 p.m.- IDT Note: Residents' spouse alerted nursing of resident being on floor after attempting to transfer from recliner. Root Cause: Resident was responding to toileting needs. Immediate intervention: Resident sent to emergency room for evaluation. Care plan reviewed upon return and new intervention in place to offer toileting frequently throughout the night. 9/08/2021 1:47 p.m.- Resident returned from appointment with Ortho group. Pelvis fracture ok for WBAT (weight bearing as tolerated). Continue physical therapy. Follow up appointment 3-4 weeks for recheck of pelvis. During an interview with the DON on 9/15/21 at 8:35 a.m., she indicated Resident B had multiple falls since admission related to her increased confusion due to her cobalt toxicity. She indicated she was difficult to redirect and would attempt to transfer and ambulate without assistance. She had a short term memory loss and would quickly forget to use her call light or to ask for assistance. She further indicated the daughter and son would stay with most of the day, but did not always notify staff when they left, so they would not know to check on her when she was in her room, which is what happened on her last fall. During an interview with CNA 2 on 9/16/21 at 1:58 p.m., she indicated Resident B was very confused and impulsive and had very poor safety awareness. She had notified the nurse several times of increased confusion and complaints of pain from Resident B. She did not feel the nurse took the resident's pain seriously, and did not assess her appropriately, as it took several day before the physician was notified and an X-ray was requested. She further indicated she did not feel the facility had adequate staffing to ensure increased supervision with Resident B, as she had 4-5 falls in one week. She was unable to check on her as often as she felt she should due to having too many residents to care for on the unit. She indicated Resident C had delusions about her husband and a resident across the hall, and would become extremely agitated and difficult to redirect. She had notified the nurse she needed something to calm her down prior to her fall, but the nurse did not go to assess her. She indicated she waited for her husband to use the restroom and then lifted her lift chair to stand and that is when she fell . She indicated she needed more supervision, but there was not enough staff. During an interview with the Corporate Clinical Support on 9/16/21 at 12:55 p.m., she indicated Resident B had just left for the emergency room for a dislocation of her hip hardware. Indicated she did not have a fall, was just lying in bed. They had to cancel her ortho appointment. She was aware she was very confused due to her cobalt toxicity and agreed she probably needed more supervision to prevent falls since she was so impulsive and had a lack of safety awareness. She indicated the daughter had been in the room with the resident prior to her last fall and staff was unaware she had left, so had not gone into the room to check on her. She indicated Resident C's fall was her first fall in the facility, and acknowledged she did have cognition deficits, but did not feel the fall could have been prevented. During a review of the current policy, Fall Management Program Guidelines, dated 5/31/17, provided by the Corporate Clinical Support on 9/16/21 at 1:41 p.m., indicated, .strives to maintain a hazard free environment, mitigate fall risk factors and implement preventative measures .Identified risk factors should be evaluated for the contribution they may have to the resident's likelihood of falling. Care plan interventions should be implemented that address the resident's risk factors. Should the resident experiencing a fall the attending nurse should complete the Fall event. This includes an investigation of the circumstances surrounding the fall to determine the cause of the episode, a reassessment to identify possible contributing factors, interventions to reduce risk of repeat episode and a review by the IDT to evaluate thoroughness of the investigation and appropriateness of the interventions .the resident care plan should be updated to reflect any new or change in interventions. Nursing staff will monitor and document continued resident response and effectiveness of interventions for 72 hours. Discuss risks and interventions with resident and/or responsible party and communicate interventions during shift report. This Federal tag relates to Complaints IN 221 and IN 704. 3.1-45(a)

Based on record review and interview, the facility failed to follow the policy and procedure for receiving and returning medications received from two residents' home and returned the medications to the wrong resident's family for 2 of 2 residents who had their personal medications delivered to the facility. The facility failed to inventory the medication for each resident. The facility returned the medication to the wrong resident in a sample of 6 residents reviewed for medication management. (Resident B, Resident C) Findings include: 1. During a review of Resident B's clinical record it indicated Resident B was admitted to the facility on [DATE] and was discharged on [DATE]. Resident B's diagnoses included but were not limited to, [CONDITION(S)] cyst of popliteal space, right knee, [CONDITION(S)], [CONDITION(S)], history of pulmonary embolism. Resident B was severely cognitively impaired. A review of Resident B's care plans indicated, 3/1/21 Resident plans to return to previous living environment after successful completion of her rehab program. Goal: Return home with daughter. Interventions included, but were not limited to, arrange for DME (durable medical equipment) as needed upon discharge, arrange for follow up services and appointments as needed, discharge planning upon admission and weekly thereafter, refer to home health care as needed. During an interview with Resident B's representative on 3/22/21 at 8:45 a.m., they indicated Resident B was admitted to the facility on [DATE] and they dropped off home medications to the facility when filling out admission paperwork that morning. Resident B was to be admitted later that evening. They indicated the medications were in a bag and were handed off to the Customer Service Specialist, non-medical personnel. On 2/23/21 they received a call from the facility that they needed to pick up the medications because the resident was on Medicare and the facility would not be using the medications. Resident B's representative indicated they picked up the medications from the facility on 2/24/21. She further indicated she did not open the bag or look at the medications until 3/17/21, when the home health nurse was there to perform the in home admission paperwork. At that time, while reconciling Resident B's medications several packets of medications with Resident C's name on them were found in the bag with Resident B's medications. Resident B's representative noted this to the home health nurse. The medications were never administered to Resident B. Resident B's representative indicated they dropped Resident C's medications off to the (local sheriff's office 1). Resident B's representative indicated the following medications with Resident C's name on them were found in the bag, Medications dated 2/22/21 3 p.m.- [MEDICATION(S)] (used to treat nerve pain) 800 mg (milligrams) 8 p.m. [MEDICATION(S)] sodium ( used to treat constipation) 100 mg [MEDICATION(S)] ( used to treat [CONDITION(S)]) 2.5 mg [MEDICATION(S)] (used to treat overactive bladder) 5 mg, take 1/2 tablet [MEDICATION(S)] 3 mg Medications dated 2/23/21 7 a.m. amlodopine (used to treat high blood pressure) 10 mg [MEDICATION(S)] sodium 100 mg [MEDICATION(S)] 2.5 mg [MEDICATION(S)] 800 mg [MEDICATION(S)] ( used to treat heartburn and gastroesophageal reflux disease) 40 mg [MEDICATION(S)] ( anti-depressant) 100 mg spirolactone ( diuretic) 50 mg trazadone ( anti-depressant) 100 mg, 2 tablets Vitamin C (supplement) 500 mg [MEDICATION(S)] 5 mg, take 1/2 tablet 3 p.m. [MEDICATION(S)] 800 mg [MEDICATION(S)] 5 mg, take 1/2 tablet 8 p.m. [MEDICATION(S)] sodium 100 mg [MEDICATION(S)] 2.5 mg [MEDICATION(S)] 800 mg [MEDICATION(S)] 3 mg [MEDICATION(S)] 5 mg, take 1/2 tablet Medications dated 2/24/21 7 a.m. amlodopine 10 mg [MEDICATION(S)] sodium 100 mg [MEDICATION(S)] 2.5 mg [MEDICATION(S)] 800 mg [MEDICATION(S)] 40 mg [MEDICATION(S)] 100 mg spirolactone 50 mg trazadone 100 mg, 2 tablets Vitamin C 500 mg [MEDICATION(S)] 5 mg, take 1/2 tablet 3 p.m. [MEDICATION(S)] 800 mg [MEDICATION(S)] 5 mg, take 1/2 tablet Medications dated 2/25/21 7 a.m. amlodopine 10 mg [MEDICATION(S)] sodium 100 mg [MEDICATION(S)] 2.5 mg [MEDICATION(S)] 800 mg [MEDICATION(S)] 40 mg [MEDICATION(S)] 100 mg [MEDICATION(S)] 5 mg, take 1/2 tablet During an interview on 3/22/21 at 1:40 p.m. with the Home Health Nurse, she indicated she was in Resident B's home on 3/17/21 performing an in home admission. She indicated that during the medication reconciliation the resident's family member indicated there were medications with a different resident's name on them in the bag with Resident B's medications. She indicated she did not see the medications with the other resident's name on them, but the family member indicated she was going to contact the facility since she had picked them up from the facility. The Home Health Nurse reported this to her supervisor. During an interview on 3/22/21 at 1:50 p.m., LPN 1 indicated the facility did not accept medications from home for Medicare stay residents. She indicated Resident B was on a Medicare stay and the medications were sent back up front with the Customer Service Specialist to be returned to Resident B's family. She was unsure when they were picked up, and was unsure what medications were in the bag. No inventory was ever made of the medications that were dropped off, and it was not checked by nursing prior to being returned to Resident B's representative. During an interview on 3/22/21 at 2:11 p.m. with RN 1, she indicated the facility is not to accept medications from home when a resident is on a Medicare stay. If they are unable to get the medications from the pharmacy, they can pull them from the EDK (emergency drug kit) or contact the back up pharmacy. During an interview with the Director of Nursing on 3/22/21 at 2:13 p.m., she indicated they do not ask residents to bring medications from home unless they are private pay, and only in special circumstances. They are able to get medications from the back up pharmacy, the first dose machine, or they call pull from the EDK. During an interview with the Director of Nursing on 3/22/21 at 2:30 p.m., she indicated an incident did occur last week with Resident B's daughter being sent home with Resident C's medications. She indicated the Administrator kept a soft file regarding the incident. Resident B's grandson had called the Administrator on 3/17/21 to tell him that Resident C's medications were sent home with his mother. He refused to bring them to the facility or say what the medications were. Resident B was supposed to be coming to the facility for a respite stay, but ended up in the hospital and came to the facility on a Medicare stay instead. The Customer Service Specialist had called Resident B's family about the respite stay and asked her to bring her medication, but forgot to call her before the Medicare stay and tell her the facility no longer needed her medications. They were brought into the facility on the morning of her admission and the Customer Service Specialist brought them to the nurses' station. The nurses told her but the nurses told her they would not need them. The medications never made it to the medication cart. The family was called to pick up the medications and she did on 2/24/21, but she didn't open them until her mother discharged . She noticed they had the wrong medications on 3/17/21 when the home health nurse was reconciling the medications. She had her son call the Administrator and he told them to bring them in, but they refused. The Administrator had to get the corporate legal department involved. He was told by corporate to call the grandson back and give him a chance to return the medications, if not to call the police. The Administrator contacted the (local sheriff's office 2) and they called the grandson, but he still refused to return the medications unless the Attorney General told him to. They were made aware by Resident C's family that Resident B had contacted them to join a lawsuit against the facility, but he refused to do so. He was already aware of the incident, as the Administrator had contacted him on 3/17/21 to tell him what had happened. Audits were completed, but no medications were found to be missing in the facility's inventory, and Resident B never took Resident C's medications, and Resident B never missed any doses of her medications. During a review of the incident summary on 3/23/21 at 10:40 a.m., provided by the Director of Nursing on 3/23/21 at 8:00 a.m., a timeline indicated, On 3/17/21 at 12:15 p.m. the Administrator received a call from Resident B's grandson indicating that Resident B's representative was sent home with Resident C's medications on 2/24/21. He was upset and indicated he had contacted the Attorney General, police, Medicare, and ISDH (Indiana State Department of Health). The Administrator apologized and indicated he would look into it and call him back. The Administrator discussed it with the Director of Nursing, Assistant Director of Nursing, and notified the Regional Vice President and Regional Nurse Consultant. 12:30 p.m.- A medication audit was done on Resident C and the medication cart on the hall. (Name of Pharmacy) was notified. Interviews were conducted with the Customer Service Specialist, as well as the nurses who discharged the resident. No narcotics found to be missing. Resident B's family was called back by the Administrator to clarify exactly where the medications were found. He stated 8 (eight) doses of medications were found in a box in the bag his mother picked up. A home health nurse witnessed it. (Name of home health care agency) was contacted by the Administrator. The Director of Operations initiated an investigation. The home health nurse stated when doing the in home admission the resident's daughter indicated she had found some medications that did not belong to her mother and that Somebody is getting fired, we've gotten somebody fired everywhere she's been. The family would not allow the home health nurse to see the medications upon request. Resident C's family was alerted of incident and a concern form was completed. 5 p.m.- The (local sheriff's office 2) was contacted. Deputy (name withheld). He called back at 6:50 p.m. and said Resident B's family refused to return the medications or give any information. The Deputy indicated he would file a theft charge as a record of the incident. On 3/18/21, Resident C's representative was in discussion with the Director of Nursing discussing discharge options for Resident C. He indicated he had been contacted by Resident B's family and was asked to join in on a lawsuit against the facility. He said they got his information from a family member's Facebook page. He explained she was very pushy, but he indicated he did not want to be involved in a lawsuit. People make mistakes and if they have medications that don't belong to them they should throw them away or bring them back. During a review of witness statements on 3/23/21 at 8:45 a.m., they indicated the following, 3/17/21 LPN 1: The Customer Service Specialist brought a white plastic bag to the 400 nurses' station and indicated they were Resident B's medications. Indicated she told her that they were not needed because the resident was on a Medicare stay and that the daughter could take them home. They were never put in the medication cart, the Customer Service Specialist took them back with her up front. 3/17/21 Customer Service Specialist: Indicated she talked to the daughter of Resident B prior to admission because the resident was initially going to come in as a respite stay. So in the beginning I told [Resident B's family] that she would need to bring in her own medications. Resident B then ended up in the hospital and came in on a Medicare stay vs a respite. On the day of admission she came in to fill out paperwork and brought in a bag of medications. Resident B was scheduled to be transferred from hospital later that evening around 6 p.m. After meeting with Resident B's representative I took the medications to the nurse ( LPN 1). LPN 1 informed me that we wouldn't need her home medications because she is Medicare. She kept the bag and I told her that I would call Resident B's representative to pick them up. I am unsure if I went back that day or the next morning to retrieve the bag of medications, but when I did, the medications were in a white plastic bag tied up, and I handed them to the door attendant (non-medical) in the front lobby to keep, until Resident B's representative picked them up. On 3/17/21, the following inservices were completed with all nursing staff, Discharge/Discharge instructions Medication Administration Guidelines-5 rights Narcotic count Disposal of Controlled drugs Disposal of Non Controlled drugs During an interview on 3/22/21 at 3:05 p.m. with a Deputy at (local sheriff's office 1), he indicated Resident B's representative brought the medications for Resident C into the office. He indicated the medications were placed into an evidence bag, but he explained to them that since it did not occur in his jurisdiction that he would be unable to do anything with the investigation. He confirmed the medications did belong to Resident C. He indicated he had been in contact with (local sheriff office 2) and they indicated it was a civil matter. During an interview on 3/23/21 at 8:45 a.m. with LPN 2, she indicated the facility was not to accept home medications if a resident was on a Medicare stay. She indicated they did accept them at times if a resident was private pay, and in that case they were brought to the nurses' station. She denied knowing of a procedure to check in or out home medications, except for at discharge. During an interview on 3/23/21 at 12:04 p.m. with the Regional Nurse Consultant and Director of Nursing, they indicated an audit was completed on 3/17/21 of Resident C's medications and the hall medication cart. No medications were found to be missing. The Director of Nursing indicated Resident C transferred from another facility and thought they may have sent medications with her. She was unable to provide an inventory of medications sent from the other facility. During an interview on 3/23/21 at 12:30 p.m. with the Administrator, Regional Nurse Consultant, and Director of Nursing, they indicated they do not know for sure if Resident B was sent home with another resident's medications since the audit did not find any missing medications and the representative refused to return the medications to the facility. The Administrator indicated he contacted (local sheriff's office 2) and they did contact Resident B's family to obtain the medications, but were unable to retrieve them. The representative told the deputy they would only turn them over if ordered to do so by the Attorney General. The Administrator indicated Resident B's representative refused to give the names of the medications that were sent erroneously. During an interview on 3/24/21 at 8:01 a.m. with the Customer Service Specialist, she indicated she had contacted Resident B's family a few weeks prior to her 2/22/21 admission because they were expecting her for a respite stay. She told Resident B's family to bring in her medications since they do not provide medications when a resident is on a respite stay. A week or so later, Resident B ended up in the hospital and was admitted to the facility on [DATE] for a Medicare stay. The Customer Service Specialist indicated she did not think to call the family back to tell them that they no longer needed to provide her medications. Resident B's representative came in on the morning on 2/22/21 to fill out admission paperwork and brought in a bag of home medications. Resident B was not expected to arrive at the facility until later that evening. At that time, the Customer Service Specialist took the bag of medications, without opening the bag or verifying contents, to the nurses' station on the 400 hall. She handed the bag to LPN 1. LPN 1 informed the Customer Service Specialist that they could not accept the medications because the resident was on a Medicare stay. She indicated she left the bag at the nurses' station and went back to her office. She is unsure if she called Resident B's representative that day or the next morning to come and pick up the medications. She went back and obtained the bag of medications either that day or the next morning and took it to the office. On the morning of 2/24/21 she handed the bag to the health screener at the door to hand off to Resident B's representative when they arrived. Resident B's representative picked up the medications on 2/24/21, but she did not have a signature to verify it was picked up or an inventory to verify what medications were in the bag. She was unsure what was in the bag, as it was tied up. She does believe it was the same bag that was dropped off on 2/22/21. 2. During the initial tour on 3/22/21 at 10:15 a.m., Resident C was observed lying in her bed watching television. Resident C indicated she had not left the facility since her admission. During a review of Resident C's clinical record on 3/22/21 at 11:30 a.m., it indicated Resident C was admitted to the facility on [DATE] and still currently resides in the facility. Resident C's diagnoses included but were not limited to, [CONDITION(S)], [CONDITION(S)], [CONDITION(S)], [CONDITION(S)], and Type II diabetes mellitus. Resident C was cognitively intact. A review of Resident C's care plans indicated, 2/26/21 Resident plans to return to previous living environment after successful completion of her rehab program. Interventions included, but were not limited to, discharge planning upon admission and weekly thereafter, arrange for follow up services and appointments as needed. Current physicians orders and Medication Administration Record (MAR) indicated that Resident C continued to receive the medications that had been given to Resident B's family. Those drugs included the following: [MEDICATION(S)], [MEDICATION(S)] sodium, [MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)], amlodopine, [MEDICATION(S)], [MEDICATION(S)], spirolactone, trazadone, and Vitamin C. During a review of the resident concern form on 3/22/21 at 8:50 a.m., dated 3/17/21, indicated there was a medication concern with Resident C. The Administrator called the spouse and notified him that medications were accidentally sent home with another resident. He was made aware staff was unable to verify what medication it was and there was an investigation taking place. During a review of the current policy, Disposal of Medications and Medication Related Supplies, revised 11/18, provided by the Director of Nursing on 3/22/21 at 2:44 p.m., it indicated, Medications are sent with the resident upon discharge from the facility only under conditions that protect the resident and assure compliance with applicable state laws .If medications were brought into the facility by a resident or responsible party and not returned or destroyed , the facility personnel returns these medications to the resident and documents return of the medications to the resident or responsible party .These medications and quantities are also listed on the Medication Release Form, or on a copy of the form used to document receipt when the medications were originally received. During a review of the current policy, Medication Ordering and Receiving from Pharmacy, revised 11/18, provided by the Regional Nurse Consultant on 3/24/21 at 8:40 a.m., indicated, Medications brought into the facility by a resident or responsible party are used only upon written order by the resident's attending physician, after the contents are verified, and if the packaging meets the facility's guidelines. Unauthorized medications are not accepted by the facility .A staff member as permitted by regulation: Received medications delivered to the facility and documents the delivery of the medication in the medical record .These delivery/receipt records are retained as required .Medications not ordered by the resident's physician, or unacceptable for other reasons, are returned to the responsible party or designated agent. If unclaimed the medications are disposed of in accordance with facility medication destruction/disposal procedures. This Federal tag relates to Complaint IN 890. 3.1-25(m) 3.1-25(s)

Based on observation, interview, and record review, the facility failed to ensure infection control measures were implemented to prevent the spread of Covid-19 for 2 of 4 nursing units observed. PPE (Personal Protective Equipment) was not donned and doffed per infection control recommendations and N95 masks were not secured. (room [ROOM NUMBER], room [ROOM NUMBER], LPN 1, QMA 1, 100 Unit, Red Unit) Findings include: On 11/20/20 at 10:17 A.M., the Red (Covid -19 positive ) unit was observed while touring the facility with the DON, she indicated that one staff member was assigned to that unit, QMA 1. On 11/20/20 at 11:32 A.M., the Red (Covid-19 positive) Unit was observed. QMA 1 was observed to be in an isolation gown, mask, gloves, and a face shield standing outside of room [ROOM NUMBER]. QMA 1 was observed to be holding an electronic tablet. QMA 1 walked from the far end of the hall to the front of the hall and then back to the far end and entered room [ROOM NUMBER]. QMA 1 was observed to exit room [ROOM NUMBER] and enter room [ROOM NUMBER]. QMA 1 was not observed to donn a clean isolation gown or gloves. At that time, the Administrator approached and was queried whether a resident resided in room [ROOM NUMBER]. The Administrator indicated he was unsure and would have to check. The Administrator returned and indicated there were residents in room [ROOM NUMBER], room [ROOM NUMBER], and room [ROOM NUMBER]. The Nurse Consultant approached at that time and indicated the guidance was unclear about extended gown use on the Red Unit and it would certainly be appropriate to wear a gown into multiple resident rooms if there was a safety issue. QMA 1 was observed to exit room [ROOM NUMBER]. QMA sat the dirty electronic tablet on top of the isolation cart holding clean PPE, walked to the outside of room [ROOM NUMBER], and removed her gloves and isolation gown. QMA 1 sanitized her hands, donned clean gloves, and cleaned the electronic tablet. On 11/20/20 at 11:50 A.M., LPN 1 was observed to be sitting at the 100 Hall nurses' desk. LPN 1's N95 bottom mask strap was hanging below her chin, not secured at the base of her neck. The N95 did not have a secure seal around LPN 1's mouth and nose. On 11/20/20 at 11:54 A.M., RN 1 indicated facility staff had been inserviced on donning and doffing PPE (Personal Protective Equipment). RN 1 indicated staff donned a clean isolation gown for every resident encounter and was supposed to doff the isolation gown and gloves before exiting resident rooms. On 11/20/20 at 12:10 P.M., QMA 1 was observed on the Red Unit. QMA 1 exited room [ROOM NUMBER] with an isolation gown and gloves on. QMA 1 walked down to room [ROOM NUMBER] and removed her gloves and isolation gown. QMA 1 performed hand hygiene. QMA 1 was observed to donn gloves and an isolation gown. As QMA 1 donned her isolation gown, her face shield was pulled down around her neck. QMA 1 pulled her face shield back to the proper place around her forehead, tied the back of the isolation gown, and entered room [ROOM NUMBER]. QMA 1 was not observed to clean the face shield after adjusting the face shield position and no hand hygiene was observed after touching the face shield. On 11/20/20 at 12:15 P.M., LPN 1 was observed to be sitting at the 100 Unit nurses' desk. LPN 1 indicated that to donn PPE, an isolation gown is donned first and then gloves. LPN 1's N95 bottom mask strap was hanging below her chin, not secured at the base of her neck. The N95 did not have a secure seal around LPN 1's mouth and nose. LPN 1 indicated she was unable to get the strap secured due to her hair and was about to go get another N95 mask. On 11/20/20 at 12:34 P.M., the Administrator provided the current COVID-19 Guidelines for Contact/Droplet Precautions policy, revised 7/29/20. The policy included, but was not limited to: All staff entering and exiting room will follow proper contact/droplet precautions, with PPE donned (gown, gloves, mask, eye protection) and doffed/disposed of following infection control policies. Place reusable gown in designated receptacle inside resident room. Place disposable PPE in trash receptacle. On 11/20/20 at 12:45 P.M., the DON indicated she had spoke to QMA 1 who indicated she had changed her gown and gloves between resident rooms and was donning and doffing PPE in the appropriate order. 3.1-18(b)(1)

Based on observation, interview, and record review, the facility failed to ensure residents received supervision and assistance to prevent accidents for 1 of 2 residents reviewed for falls. Supervision and effective fall interventions were not in place for a resident with eight (8) falls within the past 3 months, which resulted in the resident receiving a compression [MEDICAL CONDITION] (lumbar level one) vertebra. (Resident 5) Findings include: On 7/17/19 at 10:18 a.m., Resident 5 was observed to be sitting in a wheelchair in the main lobby with a family member. The resident's family member indicated the resident had several falls recently and was legally blind. The family member indicated the resident was able to self propel in the wheelchair and had been receiving therapy recently. The clinical record for Resident 5 was reviewed on 7/18/19 at 1:37 p.m. [DIAGNOSES REDACTED]. A quarterly MDS (Minimum Data Set) assessment, dated 5/8/19, indicated the resident had severe cognitive impairment. A care plan, initiated 12/6/17 and reviewed/revised on 7/17/19, indicated the resident was at risk for falling related to impaired cognition, weakness, balance, [MEDICATION NAME] degeneration, hard of hearing, hypertension, [MEDICAL CONDITION], pain, and medications. Interventions included, but were not limited to, the following: Dycem to recliner cushion, start date 7/11/19. Alarming floor mat on floor next to bed or chair dependent resident position, start date 6/28/19. Engagement of activity of preference in evening hours approximately 3:00 p.m., start date 6/28/19. Dycem to wheelchair cushion, start date 6/19/19. Offer to toilet upon rising before/after meals at bedtime and prn (as needed), start date 6/19/19. Offer to lie resident down in afternoon for nap, start date 5/31/19. Pad alarm to chair, start date 5/31/19. Pad alarm to bed, start date 5/20/19. Empty catheter bag before meals, HS (hour of sleep) and prn, start date 5/10/19. Alarm to bathroom door to alert staff of resident entering bathroom, start date 12/20/18. Ensure resident is wearing gripper socks when not wearing shoes, start date 11/29/18. Offer to toilet or to bed q (every) 1 (one) hr (hour) from 6:00 p.m.-10:00 p.m., start date 7/17/18. Keep bed in lowest position, start date 7/6/18. Staff to round frequently to check on toileting needs in early a.m. and assist resident when they are ready, start date 6/13/18. Keep call light within reach, start date 12/6/17. Keep personal items and frequently used items within reach, start date 12/6/17. Provide non-skin footwear, start date 12/6/17. Staff to assist resident with transfers x 1 person, start date 12/6/17. physician's orders [REDACTED]. Activity orders: transfer with assist of one, start date 6/5/19, discontinued 7/3/19. Activity orders: transfer with assist of two person, start date 7/3/19. Alarm to bathroom door. Check placement and function twice a day, start date 6/5/19. Alarming floor mat alarm to exit side of bed. Check placement and function twice a day, start date 6/5/19. Alarming floor mat alarm when in recliner. Check placement and function twice a day, start date 6/27/19. Anti-roll back device to wheelchair. Check placement and function twice a day, start date 6/5/19. A lumbar spine x-ray, dated 6/21/19, indicated the resident had severe T12 and mild L1 compression, new from 4/3/18. The clinical record lacked documentation of the lumbar spine x-ray from 4/3/18. A progress note, dated 4/21/19 at 7:39 p.m., indicated the resident was on the floor in their bathroom on their right side. The note indicated the resident had a skin tear above the right elbow. The note lacked any fall interventions that were in place prior to the fall. A progress note, dated 5/7/19 at 5:35 a.m., indicated the resident was yelling for help and was found on their knees in front of the wheelchair in front of the closed bathroom door. The resident indicated they needed to use the restroom. The progress note lacked any further interventions present prior to the fall. A progress note, dated 5/18/19 at 1:33 a.m., indicated the resident's bed alarm was going off. The note indicated the resident was found to be sitting on the floor beside their bed. The note indicated the resident stated they were trying to get into their recliner and fell . The note indicated the resident was encouraged to push the call light when needing help. The progress note lacked any further interventions present prior to the fall. A progress note, dated 5/18/19 at 4:00 p.m., indicated a visitor had notified the nursing staff the resident was in the floor. The note indicated the resident had placed the tab alarm inside of their shirt to avoid the alarm going off, The note indicated the resident forgot to call for assistance and got out of the chair and fell to the floor. The progress note lacked any further interventions present prior to the fall. A progress note, dated 5/20/19 at 4:45 p.m., indicated the resident was found lying in the floor with their pants down, their shirt up and their brief off. The resident indicated they were trying to go to bed and fell over a bicycle, referring to their wheelchair. The resident complained of pain in the right hip. The progress note lacked any further interventions present prior to the fall. A progress note, dated 5/25/19 at 7:30 a.m., indicated the resident's alarm was sounding and when staff entered the resident's room, the resident was observed sitting on the floor on their buttocks. The progress note lacked any further interventions present prior to the fall. A progress note, dated 6/18/19 at 4:29 p.m., indicated the resident was noted to be on the floor in their room. The note indicated the resident was on their hands and knees when the nurse arrived to the room. The resident indicated they were trying to get to the bathroom. The note indicated the alarms on the bathroom door and the wheelchair pad alarm were sounding. The note further indicated the resident had proper footwear on. The note further indicated the resident was very shaky when ambulating with 4 (four) staff members back to the wheelchair. The progress note lacked any further interventions present prior to the fall. A progress note, dated 6/18/19 at 7:10 p.m., indicated the resident bathroom alarm sounded and the resident was noted to be supine on the bathroom floor. The call light was within reach but not on prior to the fall. The resident was assisted to stand and into the wheelchair. The resident sustained [REDACTED]. The progress note lacked any further interventions present prior to the fall. A progress note, dated 6/22/19 at 9:25 a.m., indicated the resident was sent to the hospital for back pain. An x-ray indicated the resident had a compression fracture of L1 and T12 and the resident had increased pain since the fall on 6/18/19. A progress note, dated 6/23/19 at 11:14 a.m., indicated the facility received a call from the hospital of the CT scan of the [MEDICATION NAME] and lumbar without contrast combo report which indicated the acute compression fractures of T12-L2 with approximately vertebral body height loss at the level of T12. No retropulsion and central canal compromise. A progress note, dated 6/23/19 at 1:39 p.m., indicated the facility received a phone call from the nurse at the hospital indicating the T12 fracture was an old fracture but the L1 fracture was acute (new). A progress note, dated 7/5/19 at 2:38 p.m., indicated the resident was found on floor in the room in front of their recliner. The note indicated the resident had slid out of the recliner. The note indicated the call light was within reach and the pad alarm was in the recliner under the resident and the floor alarm was in place. The progress note lacked documentation of the alarms sounding or the call light being on. On 7/22/19 at 10:45 a.m., the Director of Nursing (DON) indicated the resident had many interventions in place. The DON indicated the facility should document the interventions in the clinical record. The current facility, dated 5/31/17, obtained from the Administrator on 7/23/19 at 10:30 a.m., indicated the facility strived to maintain a hazard free environment with intensive efforts directed toward minimizing or preventing injury. 3.1-45(a)