Every finding on record at North Woods Village

Based on interview and record review, the facility failed to ensure a comprehensive person-centered care plan was developed and implemented for 2 of 2 residents reviewed for care plans. (Resident 12 and 13)Findings include: 1. The clinical record for Resident 12 was reviewed on 3/16/26 at 1:40 p.m. The diagnoses included, but were not limited to, post-traumatic stress disorder (PTSD), traumatic brain injury, and diabetes mellitus. The clinical record indicated the diagnosis of post-traumatic stress disorder was added to the resident's diagnoses list on 5/2/25. There was no care plan located in Resident 12's electronic record related to post-traumatic stress disorder. During an interview, on 3/19/26 at 11:18 a.m., RN 5 indicated she was not sure what Resident 12's trauma triggers were related to the diagnosis of PTSD, and she would have to look it up on the computer. During an interview, on 3/20/26 at 10:00 a.m., the DON indicated Resident 12 was admitted with a diagnosis of PTSD, and a care plan was not added until 3/17/26 for her trauma and triggers. She did not have a care plan prior to the survey, and she should have had a care plan which addressed these issues. During an interview, on 3/20/26 at 10:09 a.m., the Medical Record nurse indicated she had never seen Resident 12 experience any triggers. The staff would know how to address Resident 12's triggers by looking at the care plan. The CNA would know what kind of triggers the resident had by looking at the CNA care sheet. The care sheet helped the CNAs better care for the residents. The sheet would tell them all the special care needs and triggers the residents would have. 2. The clinical record for Resident 13 was reviewed on 3/16/26 at 4:00 p.m. The diagnoses included, but were not limited to, vascular dementia, schizophrenia, anxiety, depression, psychotic disorder with delusions due to known physiological condition, and post-traumatic stress disorder (PTSD). The clinical record indicated the diagnosis of post-traumatic stress disorder was added to the resident's diagnoses list on 2/10/20. There was no care plan located in Resident 13's electronic record related to post-traumatic stress disorder. During an interview, on 3/20/26 at 9:00 a.m., RN 4 indicated she was unaware of what Resident 13's PTSD triggers were, but she could look in the chart to find out. She indicated staff had online training, as well as in-services which addressed trauma care. Social service was a resource staff could use as well if they had questions. During an interview, on 3/20/26 at 10:05 a.m., the Director of Nursing (DON) indicated the trauma care plan was not added prior to the survey. The care plan should be added when a resident was admitted with or had a diagnosis of PTSD. A current facility policy, titled Trauma Informed Care, dated as revised 10/22 and received from the Executive Director (ED) on 3/20/26 at 9:59 a.m., indicated .It is the policy of this facility to ensure that residents who are trauma survivors receive culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for residents' experiences and preferences to eliminate or mitigate triggers that may cause re-traumatization of the resident .Each resident will be screened for a trauma during the Social Services Assessment upon admission to the facility. This screen includes a review of current diagnosis or reported history of PTSD, combat, abuse.behavioral health services will assist the resident and Interdisciplinary Team in developing a plan of care which will be added to the medical record. This plan of care will incorporate individual experiences, customary routines, and cultural preferences of the individual's needs .The plan of care will routinely be evaluated whether the interventions have been able to mitigate (or reduce) the impact of identified triggers on the resident that may cause re-traumatization. If interventions do not appear effective, behavioral health and the IDT will collaborate on revised approaches A current facility policy, titled IDT Comprehensive Care Plan Policy, dated as revised 10/2025 and received from the Executive Director (ED) on 3/20/26 at 9:59 a.m., indicated .It is the policy of this facility that each resident will have an interdisciplinary comprehensive person-centered care plan developed and implemented based on Resident Assessment Instrument (RAI) process. The care plan must include measurable goals and resident specific interventions based on resident needs and preferences to promote the resident's highest level of functioning including medical, nursing, mental, and psychosocial well-being .Create an organized, resident-centered review on a routine basis to improve communication with residents, resident families and/or representative regarding the resident goals, total health status, including functional status, nutritional status, rehabilitation and restorative potential, ability to participate in activities, cognitive status, psychosocial status, sensory and physical impairments, as well as care and services provided to maintain or restore health and well-being, improve functional level or relieve symptoms .Improve relationships between resident, families and/or representative, and facility caregivers through understanding of resident's social history, culture and preferences to enhance the resident's life .Care plan problems, goals, and interventions must be reviewed and revised by the interdisciplinary team periodically and following completion of each OBRA MDS assessment 410 IAC (Indiana Administrative Code) 16.2-3.1-35(a) 410 IAC (Indiana Administrative Code) 16.2-3.1-35(b)(1) 410 IAC (Indiana Administrative Code) 16.2-3.1-35(b)(2)

Based on interview and record review, the facility failed to ensure blood pressures were obtained and documented prior to administering a blood pressure medication with parameter orders and to ensure a physician's order was followed according to the medication parameters for 2 of 6 residents reviewed for quality of care. (Residents 95 and 69)Findings Include: 1. The clinical record for Resident 95 was reviewed on 3/17/26 at 10:43 a.m. The diagnoses included, but were not limited to, end stage renal disease, dependence on renal dialysis, type 2 diabetes mellitus, hypertension, and Parkinson's disease.A care plan, dated 5/29/24, indicated Resident 95 was at risk for ineffective tissue perfusion related to high blood pressure. Interventions included, but were not limited to, administer medications as ordered.A physician's order, dated 2/11/26, indicated to administer 60 milligrams (mg) of nifedipine (a medication used to treat high blood pressure) every morning and to hold the medication if the systolic blood pressure was less than 130.The Medication Administration Record (MAR), dated 2/1/26 through 3/16/26, indicated nifedipine was administered without obtaining a blood pressure reading to determine the systolic blood pressure.During an interview, on 3/17/26 at 2;40 p.m., the Assistant Director of Nursing (ADON) indicated a blood pressure was to be obtained and documented daily prior to the administration of nifedipine. The blood pressure result would determine if the medication would be administered or held. There was no documentation a blood pressure was obtained before the medication had been administered and there should have been.During an interview, on 3/17/26 at 3:54 p.m., the Clinical Support Nurse (CNS) indicated a blood pressure reading should have been obtained and documented prior to the administration of the medication.During an interview, on 3/18/26 at 10:31 a.m., Qualified Medication Aide (QMA) 3 indicated a blood pressure must be obtained prior to administering a blood pressure medication with parameter orders. After the blood pressure was obtained, it would be documented. The blood pressure medication would be administered or held depending on the blood pressure results and the parameter orders.During an interview, on 3/18/26 at 10:37 a.m., LPN 2 indicated a blood pressure must be obtained, prior to administering the blood pressure medication, if there were parameter orders. The blood pressure medication would be administered if the blood pressure results were not out of parameters.2. The clinical record for Resident 69 was reviewed on 3/16/26 at 4:03 p.m. The diagnoses included, but were not limited to, essential (primary) hypertension, vascular dementia, and anxiety disorder.A care plan, dated 9/13/24, indicated the resident was at risk for ineffective tissue perfusion related to hypertension. Interventions included, but were not limited to, administer medications as ordered.A physician's order, dated 11/17/25, indicated to administer propranolol (a blood pressure medication) 20 mg once a day and to hold the medication for a systolic blood pressure less than 120.The Medication Administration Record (MAR), dated 12/1/25 through 12/31/25, indicated propranolol was administered outside of the hold parameters on the following dates: On 12/1/25, with a systolic blood pressure of 118.On 12/8/25, with a systolic blood pressure of 118.On 12/21/25, with a systolic blood pressure of 119.On 12/29/25, with a systolic blood pressure of 115.The MAR, dated 1/1/26 through 1/31/26, indicated propranolol was administered outside of the hold parameters on the following dates: On 1/3/26, with a systolic blood pressure of 117.On 1/26/26, with a systolic blood pressure of 115.On 1/27/26, with a systolic blood pressure of 104.On 1/28/26, with a systolic blood pressure of 118.The MAR, dated 2/1/26 through 2/28/26, indicated propranolol was administered outside of the hold parameters on the following dates: On 2/8/26, with a systolic blood pressure of 112.On 2/23/26, with a systolic blood pressure of 117.During an interview, on 3/18/26 at 3:46 p.m., the MDS (Minimum Data Set) Coordinator indicated medications should not be given outside of the ordered parameters. On the MAR if a medication was held, the nurse's initials would have parenthesis around them and there would be a note below saying it was held.During an interview, on 3/20/26 at 4:03 p.m., the Executive Director indicated medications should not be given outside of the ordered parameters.A current facility skill competency, titled Medication Administration (Medication Pass Procedure), dated as revised 4/2025 and received by the Executive Director on 3/18/26 at 9:06 a.m., indicated .Procedure Steps: Standards for all medications.Vital signs obtained, if necessary. 410 IAC (Indiana Administrative Code) 16.2-3.1-37(a)

Based on observation, interview and record review, the facility failed to ensure narcotic medications were free from theft of an employee for 2 of 3 residents reviewed for misappropriation of property. (Resident B and C) The deficient practice was corrected on 7/29/25, prior to the start of the survey, and was therefore past noncompliance.Findings include:During an interview, on 12/16/25 at 11:34 a.m., the Director of Nursing (DON) indicated Resident B had requested a pain pill on 7/26/25. LPN 4 was unable to find her oxycodone (narcotic pain medication) or the medication count sheet. LPN 4 called the pharmacy and was informed Resident B should have the narcotics available at the facility. LPN 4 then reported the missing narcotics and an investigation was started. During the investigation, it was discovered Resident C also had narcotic medication and a medication count sheet missing. The facility determined LPN 2 had stolen the narcotics. LPN 2 was terminated from the facility.1. The clinical record for Resident B was reviewed on 12/16/25 at 1:30 p.m. The diagnoses included, but were not limited to, a pathological fracture of the left shoulder, malignant neoplasm of the left lung, malignant neoplasm of the bone, osteoarthritis, and generalized anxiety disorder.A physician's order, dated 7/22/25, indicated to administer oxycodone 10 milligrams (mg) every eight hours as needed for moderate pain. 2. The clinical record for Resident C was reviewed on 12/16/25 at 2:00 p.m. The diagnoses included, but were not limited to, acute pain due to trauma, periprosthetic fracture around the internal prosthetic right knee joint, fracture of the upper end of the right tibia, and fracture of the rib on the left side. A physician's order, dated 7/14/25, indicated to administer oxycodone-acetaminophen 7.5-325 mg every four hours as needed for moderate pain. In a typed facility statement, dated 10/7/25, Qualified Medication Aide (QMA) 6 indicated the evening nurse had conducted a medication count and handed the medication cart keys to LPN 2 at the beginning of LPN 2's shift. At 1:30 a.m., on 7/26/25, LPN 2 took the medication cart into the hallway. LPN 2 had disappeared for at least 30 minutes, without telling the QMA or the CNAs where she was twice during her shift. After she disappeared the second time and came back, LPN 2 indicated she was not feeling well and wanted to go home. Between 3:30 and 3:40 a.m., LPN 2 handed QMA 6 her keys to the medication cart and left without waiting for a nurse to arrive to relieve her. LPN 2 did not count the medication cart with QMA 6 or report on the residents prior to clocking out and leaving the facility.During an observation, on 12/16/25 at 1:45 p.m., the Executive Director (ED) showed a video on her computer of LPN 2 removing narcotics from the narcotic drawer of the medication cart, on 7/26/25 at 2:23 a.m. LPN 2 then placed a jacket on her medication cart and pushed the cart to a darkened spot halfway down the hallway. At 2:25 a.m., LPN 2 took a medication card from the narcotic box, placed it inside the black jacket she had picked up off the cart, and wrapped the narcotic card inside the jacket. LPN 2 then placed the jacket back on the cart and pushed the medication cart back to the nurses' station. At 2:26 a.m., she placed the jacket in a bag sitting at the nurse's station after another employee left the area. At 2:32 a.m., she took the narcotic count sheet book from the medication cart, sat down at the desk for a few seconds, then took the narcotic book to the locked medication room. At 2:34 a.m., she brought the narcotic book back to the medication cart and placed it on the cart. During an interview, on 12/16/25 at 2:10 p.m., the DON provided an untitled document, dated 7/25/25-7/26/25, and indicated the document was LPN 2's time sheet. The time sheet indicated LPN 2 clocked in on 7/25/25 at 10:14 p.m., and clocked out on 7/26/25 at 3:48 a.m. The DON indicated LPN 2 had texted the scheduler and indicated she was sick and needed to go home. LPN 2 did not wait for the nurse to replace her to get to the facility prior to leaving. During a telephone interview, on 12/16/25 at 4:00 p.m., LPN 4 indicated on 7/26/25 at 2:00 p.m., she went to administer Resident B a pain pill and there were no pain pills in the narcotic drawer for Resident B. She called the Nurse Practitioner (NP) and was told the resident had a script filled on 7/21/25 for 38 pills, and the resident should have approximately 25 pills left. LPN 4 notified the Nurse Practitioner no narcotic medications or medication count sheet was available. LPN 4 immediately called the DON and notified her of the missing narcotics. A current facility policy, titled Abuse Prohibition, Reporting and Investigation, dated February 2010 and provided by the Executive Director (ED) on 12/15/25 at 12:15 p.m., indicated .Misappropriation of Resident Funds or Property-Deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's property or money without the resident's consent A current facility policy, titled Controlled Substances: Storage, Documentation, Inventory and Destruction (Includes Fentanyl Patch Removal and Destruction), dated 11/24 and provided by the Executive Director (ED) on 12/15/25 at 12:15 p.m., indicated .To prevent diversion, improper use and accidents related to controlled substances.all controlled substances will be stored, recorded, accounted for, and destroyed by state regulations.Facility will utilize the Shift Change verification of Controlled Substances form to count all controlled substances for each medication cart in the facility.The incoming Nurse or QMA will count all controlled substances being stored at the facility while the outgoing nurse or QMA watches the process. Both staff members sign that the count sheets and verification have been completed with no discrepancies.The on-coming and off-going nurse will also count the narcotic cards, boxes, and bottles to ensure accurate reconciliation and document on the Inventory of Controlled Substance Count Sheet.The off-going nurse will document an explanation of the shift Change Verification of Controlled Substance form if there are any discrepancies or changes with the card, box, or bottle counts The deficient practice was corrected by 7/29/25, after the facility audited all the narcotic sheets, interviewed residents, LPN 2 was terminated, all nurses were re-educated, and the pharmacy completed a house wide audit of narcotic medications.This citation relates to Intake 2572626.3.1-28(a)

Based on observation, interview, and record review, the facility failed to ensure a portable oxygen tank was turned on to administer the correct flow rate for 1 of 1 resident reviewed for respiratory care. (Resident 4) Findings include: During an observation, on 3/2/25 at 10:25 a.m., Resident 4 was in the hallway in her wheelchair at the nurse's medication cart with QMA 2 receiving her medications. The resident had a nasal cannula in her nose with a portable oxygen tank hanging on the back of her wheelchair. The flow rate on the portable tank was set at zero (0) liters/minute. QMA 2 administered medications to Resident 4 and signed the medication administration record (MAR). QMA 2 did not look at the portable oxygen tank to verify the amount of oxygen the resident was receiving. During an observation, on 3/2/25 at 12:15 p.m., the resident wheeled herself past 2 nurses and a certified nursing assistant (CNA) and greeted them as she entered the dining room for lunch. The nasal cannula was in her nose, and the portable oxygen tank on the back of her wheelchair was still set at zero (0) liters/minute. The clinical record for Resident 4 was reviewed on 3/4/25 at 9:59 a.m. The diagnoses included, but were not limited to, chronic obstructive pulmonary disease, chronic respiratory failure with hypoxia, and asthma. A physician's order, dated 10/15/24, indicated to give continuous oxygen at 4 liters per nasal cannula. A Nurse Practitioner (NP) progress note, dated 2/27/25 at 9:51 a.m., indicated to continue administering supplemental oxygen for the resident's respiratory diagnosis. During an interview, on 3/2/25 at 12:26 p.m., LPN 6 indicated Resident 4 needed 4 liters of oxygen per the physician's order, but the portable oxygen tank was turned off. During an interview, on 3/5/25 at 10:46 a.m., LPN 7 indicated the resident did not transfer herself. A CNA would transfer the resident into her wheelchair and the nurse would turn the portable oxygen tank on to the correct liter flow based on the order. During an interview, on 3/6/25 at 10:09 a.m., LPN 8 indicated the nurse was supposed to make sure the portable oxygen tank was set on the correct liter flow. If the resident had gotten herself up, then the nurse would check the oxygen flow rate as they gave the resident her medications. A current facility policy, titled Oxygen Therapy, dated 4/23 and received from the Executive Director on 3/5/25 at 8:40 a.m., indicated .The nurse will coordinate the oxygen therapy services as ordered by the resident's physician 3.1-47(a)(6)

Based on interview and record review, the facility failed to ensure a medication for blood pressure was held according to the physician's ordered parameters for 1 of 1 resident reviewed for quality of care. (Resident 100) Findings include: The clinical record for Resident 100 was reviewed on 3/4/25 at 10:41 a.m. The diagnoses included, but were not limited to, paraplegia, neuromuscular dysfunction of the bladder, familial dysautonomia, and chronic systolic congestive heart failure. An Emergency Department After Visit Summary, dated 1/11/25, indicated the resident was seen for a headache and his blood pressure was higher than the normal range during the visit. A physician's order, dated 1/13/25, indicated to give midodrine (a medication used to increase blood pressure) 10 milligrams (mg) three times per day with special instructions to hold the medication if the systolic blood pressure was greater than 120. The Medication Administration Record (MAR), dated January 1 through 31, 2025, indicated a midodrine dose was not held: a. On 1/14/25 at 1:00 p.m., with a systolic blood pressure of 128 and 8:00 p.m., with a systolic blood pressure of 126. b. On 1/16/25 at 1:00 p.m., with a systolic blood pressure of 122. c. On 1/18/25 at 8:00 p.m., with a systolic blood pressure of 136. d. On 1/21/25 at 8:00 p.m., with a systolic blood pressure of 126. e. On 1/31/25 at 1:00 a.m., with a systolic blood pressure of 126. The MAR, dated February 1 through 28, 2025, indicated a midodrine dose was not held: a. On 2/4/25 at 1:00 a.m., with a systolic blood pressure of 126. b. On 2/6/25 at 8:00 p.m., with a systolic blood pressure of 125. c. On 2/8/25 at 1:00 a.m., with a systolic blood pressure of 128 and 1:00 p.m., with a systolic blood pressure of 122. d. On 2/10/25 at 1:00 p.m., with a systolic blood pressure of 127. e. On 2/12/25 at 8:00 p.m., with a systolic blood pressure of 125. f. On 2/14/25 at 8:00 p.m., with a systolic blood pressure of 129. g. On 2/16/25 at 1:00 a.m., with a systolic blood pressure of 122. h. On 2/18/25 at 1:00 a.m., with a systolic blood pressure of 122. i. On 2/19/25 at 1:00 a.m., with a systolic blood pressure of 126 and 1:00 p.m., with a systolic blood pressure of 122. j. On 2/20/25 at 1:00 p.m., with a systolic blood pressure of 132. k. On 2/21/25 at 8:00 p.m., with a systolic blood pressure of 139. l. On 2/22/25 at 1:00 a.m., with a systolic blood pressure of 126 and 1:00 p.m., with a systolic blood pressure of 132. m. On 2/24/25 at 8:00 p.m., with a systolic blood pressure of 124. n. On 2/25/25 at 8:00 p.m., with a systolic blood pressure of 129. o. On 2/26/25 at 8:00 p.m., with a systolic blood pressure of 127. p. On 2/27/25 at 1:00 p.m., with a systolic blood pressure of 126. The MAR, dated March 1 through 6, 2025, indicated a midodrine dose was not held: a. On 3/1/25 at 8:00 p.m., with a systolic blood pressure of 128. b. On 3/3/25 at 1:00 p.m., with a systolic blood pressure of 122 and 8:00 p.m., with a systolic blood pressure of 125. c. On 3/4/25 at 8:00 p.m., with a systolic blood pressure of 127. During an interview, on 3/6/25 at 10:05 a.m., LPN 8 indicated the vital signs, and the medication orders should be reviewed before giving medication. If the systolic blood pressure was above the hold parameter, then the medicine should not be given and charted it was not given. The staff initials would then be in parenthesis on the MAR and there would be a note to indicate why the medication was not given. A current facility policy, titled General Dose Preparation and Medication Administration, dated 11/15/24 and received from the Executive Director on 3/5/25 at 8:40 a.m., indicated . Prior to administration of medication .if necessary, obtain vital signs 3.1 -37(a)

Based on observation, interview and record review, the facility failed to ensure staff wore gloves when touching a resident's medication for 1 of 9 residents observed for medication administration. (Resident 3) Findings include: During an observation, on 3/2/25 at 10:12 a.m., QMA 2 removed the resident's medication from the medication cart. She placed the card of multivitamin 7.5 milligrams (mg) iron with 400 micrograms (mcg) of folic acid in her right hand. QMA 2 used her right hand and popped the pill from the card into her left bare hand. She took the pill with her fingers and placed the pill into the medication cup. During an interview, on 3/2/25 at 10:14 a.m., QMA 2 indicated she should have used gloves and not touched the pill with her bare hands. The clinical record for Resident 3 was reviewed on 3/2/25 at 10:12 a.m. The diagnoses included, but were not limited to, diabetes mellitus, atrial fibrillation, and anxiety disorder. A physician's order indicated to give a multivitamin 7.5 milligrams (mg) iron and 400 micrograms (mcg) folic acid tablet daily. A current facility policy, titled General Dose Preparation and Medication Administration, dated as revised 1/3/25 and received from the Director of Nursing on 3/2/25 at 12:07 p.m., indicated .Appropriate hand hygiene should be performed before and after direct resident contact. Medications should not come in contact with any surface except for the medication cup 3.1-18(b)

Based on observation, interview, and record review, the facility failed to ensure staff were documenting resident behaviors, implementing and documenting nonpharmacological interventions for behaviors, and failed to ensure potential side effects of an antipsychotic medication were documented and assessed for a resident with dementia for 1 of 5 residents reviewed for dementia care (Resident 75). Findings include: During an observation, on 3/12/24 at 10:31 a.m., the resident was sitting up in her wheelchair in the activity room. The resident was continuously rocking herself back and forth in the wheelchair. The resident was very fidgety and pulling at a blanket while continuously moving her hands. During an observation, on 3/12/24 at 10:57 a.m., the resident was still in the dining area and was fidgeting with a napkin on the table and the blanket on her lap and making constant movements with her body. During an observation, on 3/13/24 at 1:58 p.m., the resident was sitting up in her wheelchair in the common area at a table by herself. The resident was constantly touching a piece of paper and a plastic cup and rolling them back and forth across the tablecloth. During an observation, on 3/13/24 at 2:22 p.m., the resident was sitting up in her wheelchair in the dining area and was constantly rocking back and forth in her wheelchair. The clinical record for Resident 75 was reviewed on 3/13/24 at 4:19 p.m. The diagnoses included, but were not limited to, unspecified dementia, Alzheimer's disease, severe recurrent major depressive disorder with psychotic symptoms, anxiety disorder, delusional disorder, a cognitive communication deficit, and unspecified psychosis not due to a substance or known physiological condition. A care plan, dated 2/24/23, indicated the resident was at risk for adverse side effects related to the use of psychotropic medications and the resident was on an antipsychotic medication. The goal was for the resident to have no adverse side effects. The approaches included, but were not limited to, AIMS assessment two times a year, observe for tremors and for abnormal involuntary movements. A care plan, dated 4/27/23, indicated the resident had a history of becoming verbally and physically combative with care. The approaches included, but were not limited to, redirect the resident to sit on the recliner by the television for a quieter space, offer the resident a snack and drink, provide personal space, staff to offer care at a later time and/or with a different staff member. A physician's order, dated 9/1/23, indicated to give Risperdal (an antipsychotic medication) 0.5 milligram (mg) daily for anxiety disorder due to a known physiological condition. An annual Minimum Data Set (MDS) assessment, dated 11/1/23, indicated the resident's Brief Interview for Mental Status (BIMS) was a 3 which indicated severe cognitive impairment. A quarterly MDS assessment, dated 12/28/23, indicated the resident's BIMS was 2 which indicated severe cognitive impairment. A pharmacy Consultation Report, dated 1/14/24, indicated the resident had experienced more than one fall in the last 30 days and received the following psychotropic medications which could increase the risk of falls. The psychotropic medications included buspirone (an antianxiety medication), Cymbalta (an antidepressant) and Risperdal 1 mg at bedtime. The recommendation indicated to consider decreasing the Risperdal to 0.5 mg at bedtime. The Psychiatric Nurse Practitioner (NP) response, dated 2/7/24, indicated to accept the recommendations. A monthly behavioral report, dated 2/2/24, indicated the resident did not display any new or worsening behaviors. A physician's order, dated 2/7/24, indicated Risperdal 0.5 mg at bedtime for depression. The nursing progress notes, dated 2/8/24 through 2/20/24, indicated there were no changes in the resident's mood or behaviors, the resident was sleeping at night and there were no adverse drug reactions related to the decrease in the dose of Risperdal except for 2/15/24 at 5:10 a.m. A nursing progress note, dated 2/15/24 at 5;10 a.m., indicated there were no adverse effects noted from the decrease in Risperdal. The resident had slept well all night with no behaviors. During the last bed check, the resident scratched the Certified Nursing Assistant's (CNA) arm with care. The CNA stopped and then continued the care without problems. A nursing progress note, dated 2/21/24 at 9:08 p.m., indicated the resident had episodes of crying this evening and talking to unseen stimuli. The resident was getting upset because the unseen stimuli was not responding. The progress note did not include non-pharmacological interventions utilized for the behaviors. There were no more progress notes documented in the EHR and no documented behaviors between 2/21/24 at 9:08 p.m. and 2/22/24 at 8:31 a.m. An NP progress note, dated 2/22/24 at 8:31 a.m. and recorded as a late entry on 2/23/24 at 8:31 a.m., indicated the resident had a failed gradual dose reduction (GDR) for Risperdal. The resident was seen for follow up after a GDR of Risperdal. The resident was taking the medication for management of symptoms of a delusional disorder. The staff had reported the resident had been yelling out and had an increase of distressing hallucinations since the decrease of the Risperdal. The resident had been observed crying and talking to an unseen stimuli. The resident had an increase in aggression with care. The resident was asleep upon entering her room and did not engage in the NP visit when she awakened. The staff reported there were no changes in the resident's appetite or sleep since the last visit. The symptoms of aggression, agitation, delusions and hallucinations had increased since the GDR of the Risperdal. The Risperdal 1 mg at bedtime would be resumed due to the failed GDR. A physician's order, dated 2/22/24, indicated to give Risperdal 1 mg at bedtime for a delusional disorder. An Abnormal Involuntary Movement Scale (AIMS) assessment, dated 2/23/24 at 10:06 a.m., completed by the Dementia Unit Manager (UM), indicated a full examination was conducted and scored. The total score was a zero. The resident had no facial or oral movements, had no movements of the extremities and had no rocking, twisting, squirming or pelvic gyrations. During an interview, on 3/14/24 at 2:35 p.m., the Director of Nursing Services (DNS) indicated the staff would talk about the residents behaviors during the behavior meetings although they did not document all the behaviors reviewed during the meeting in the electronic health record (EHR). During an interview, on 3/14/24 at 3:13 p.m., Licensed Practical Nurse (LPN) 2 indicated she was working the evening of 2/21/24 on the dementia unit. The resident was crying and was upset because of the unseen stimuli was not responding to her. LPN 2 had the resident sit at the nurses desk with her, had her listen to music and had a snack. The resident accepted the snack. The resident would be crying and upset, then would be fine and would ask why he was not responding to her. LPN 2 indicated usually she would document the interventions in the EHR although she was busy and did not document them. During an interview, on 3/14/24 at 3:23 p.m., the Social Services Director (SSD) indicated she talked to the LPN 3 who had worked the night shift from 10:00 p.m. on 2/21/24 through 10:00 a.m. on 2/22/24 and LPN 3 indicated the resident did go to bed and did not have any further problems for the shift. During an interview, on 3/14/24 at 3:39 p.m., the Psychiatric NP indicated when she saw the resident on 2/22/24, the resident was asleep. The resident did not want to talk to the NP when she woke up. The staff told the NP the resident was more aggressive and had been yelling out. The NP saw one nursing progress note with the information the resident was tearful, had hallucinations and was distressed. The staff had verbally told the NP the resident was having more behaviors. The failed GDR was based on what the staff had told the NP. The NP went by what the staff had told her even though there was only one documented behavior in the EHR. During an observation, on 3/14/24 at 4:24 p.m., with the dementia unit manager (UM), the resident was in her room while the UM was completing an AIMS assessment. The resident was constantly moving in her wheelchair while the UM was attempting to complete the evaluation. The resident stood up in her chair and tried to ambulate on her own. The UM indicated she could not complete the AIMS assessment since the resident was too fidgety. The resident was not able to follow the directions of the UM. The UM indicated while completing an AIMS assessment she would ask the resident if she experienced abnormal movements and would ask to see the resident's tongue. The UM was not aware of the instructions on the AIMS assessment on how to complete the assessment or the modifications for a resident who could not cooperate with the assessment. She indicated she was trained to do the assessment by other staff including the previous UM. During an interview, on 3/14/24 at 4:52 p.m., the DNS indicated the staff should have documented the resident's behaviors from the previous week in the EHR to show if it was new or worsening behaviors. The EHR only had one note of behaviors documented on 2/21/24. The instructions for the AIMS were on the AIMS assessment form. The staff were not given training on how to complete an AIMS assessment. Resident 75 was not capable of having a full AIMS assessment. The staff should not have marked the full AIMS assessment was completed. There was a difference in a full AIMS assessment and the options to include the resident was uncooperative or non ambulatory. The DNS was not aware if the resident's constant movements were related to side effects of the psychotropic medication. The current Nursing Drug Handbook, indicated the adverse reactions of Risperdal included, but were not limited to, extrapyramidal movement dysfunction symptoms including akathisia (a combination of feelings of restlessness/agitation and a compelling need to move including uncontrollable rocking, pacing and shifting weight). The nursing considerations included, but were not limited to, watch for evidence of extrapyramidal effects. A current policy, titled, Behavior Management, revised on 8/22 and received from the DNS on 3/15/24 at 9:48 a.m., indicated, .It is the policy of American Senior Communities to provide behavior interventions for residents with problematic or distressing behaviors. Interventions provided are both individualized and non pharmacological and part of a supportive physical and psychosocial environment that is directed toward preventing, relieving and/or accommodating a resident's behavioral expressions .When a behavioral expression occurs, the staff communicates to the nurse what behavior occurred. The nurse records the behavior in Matrix[the electronic health record] .If the behavioral expression is new, worsening, or high risk, the nurse will record the behavior using the New/Worsening Behavior Event. New or worsening behaviors are reviewed by the IDT [interdisciplinary team] for assessment and preventative actions. New/Worsening Behaviors include .Behaviors that are new for the resident .Behaviors that are directed at another resident .Behaviors that are increasing in either frequency or severity .Behaviors that have potential for risk to others including sexual advances, intrusive wandering, exit seeking and chronic combativeness with care .The IDT review is a discussion with the team as to the behavioral expression, an evaluation of interventions, presentation of new interventions if applicable and an assessment of underlying causes of the behavior .The root cause and preventative interventions will be included in the resident's plan of care .If the behavioral expression is not new, worsening or high risk .the nurse will record the behavior in the progress notes using the Behavior Communication Note. The IDT will review progress notes the next business day to determine if immediate follow up action is required for the Behavior Communication. If the behavior requires an interdisciplinary response as described above, the IDT will complete the IDT Behavior Review. If not, the plan of care will be reviewed and updated if needed to include a description of the behavior and effective interventions A current policy, titled, Psychotropic Management, revised on 7/22 and received from the DNS on 3/15/24 at 12:30 p.m., indicated, .It is the policy of American Senior Communities to ensure that a resident's psychotropic medication regimen helps promote the resident's highest practicable mental, physical and psychosocial well-being with person centered intervention and assessment .Potential adverse side effects to psychotropic medications will be observed each shift by a licensed nurse. An AIMS assessment will be completed for residents who are taking antipsychotic medication as a tool to monitor for adverse side effects. The assessment should be completed within 72 hours of new order to initiate an antipsychotic, within 72 hours of an increase in antipsychotic medication and then every six months The instructions for the AIMS assessment included, but were not limited to, before or after completing the Examination Procedure, observe the resident unobtrusively at rest. The chair used in the examination should be a hard, firm one without arms, ask the resident if he/she notices any movements in the mouth, face, hands or feet. If yes, ask the resident to describe and to what extent the movements bother the resident or interferes with their activities. As the resident to sit with their hands hanging unsupported. Have the resident sit in the chair with their hands on their knees with their legs slightly apart and their feet flat on the floor. Ask the resident to open their mouth and observe their tongue at rest. Ask the resident to protrude their tongue and observe for abnormal mouth movements. Ask the resident to tap their thumb with each finger as rapidly as possible for 10-15 seconds with the right hand and then with the left hand while observing for facial and leg movements. Flex and extend the resident's left and right arms and note any rigidity. Have the resident walk a few paces, turn and walk back to the chair. 3.1-37(a)

Based on observation, interview, and record review, the facility failed to ensure medication carts were free of loose pills and opened medications were dated for 1 of 3 medication carts reviewed for medication storage (The Walnut Unit and a combined medication cart for the [NAME] and Magnolia Units). Findings include: During a medication storage observation with the Qualified Medical Assistant (QMA) 4 on 3/14/24 at 11:10 a.m., the Walnut unit cart was observed to have the following: a. The second left large drawer had 17 loose pills on the bottom. b. The third left large drawer had 33 loose pills and 13 half tablets on the bottom of the drawer c. The third right drawer had a bottle of opened Milk of Magnisium (MOM) for Resident 89 opened and not dated. The record for Resident 89 was reviewed on 03/14/23 at 11:40 a.m. A physician order, dated 12/28/23, indicated to give MOM 400 Milligram(mg)/5 Milliliter(ml) daily when needed. During an interview, on 3/14/23 at 11:23 a.m., QMA 4 indicated the pills should not be in the bottom of the cart. The pills should be destroyed in a jug in the medication room. During an interview, on 3/14/24 at 11:48 a.m., the Dementia Facilitator 5 indicated the loose pills probably should not be in the bottom of the drawers. During a medication cart observation with QMA 7 on 3/14/24 at 10:38 a.m., the [NAME] and Magnolia unit cart was observed to have the following: a. The first large drawer had 12 loose pills on the bottom of the drawer. b. The second large drawer had 11 loose pills on the bottom of the drawer. During an interview, on 3/14/24 at 10:30 a.m., QMA 7 indicated there were a lot of pills and the pills should not be on the bottom of the cart. The pills should be taken out and destroyed. During an interview, on 3/15/24 at 12:16 p.m., Unit Manager(UM) 9 indicated she did not know who was assigned to clean the medication carts. The nurses on any shift could clean the cart. During an interview, on 3/15/24 at 12:19 p.m., Licensed Practical Nurse (LPN) 6 indicated the nurse on night shift usually cleaned out the carts. There was a cleaning list in a binder on the Walnut unit and had a cleaning schedule. During an interview, on 3/15/24 at 2:09 p.m., UM 9 indicated they do have a cleaning list and the nurse on night shift was responsible to clean the carts. A current policy, titled, LTC [long term care] Facility's Pharmacy Services and Procedure Manual, revised on 8/07/2023 and received from the Director of Nursing (DON) on 3/14/24 at 4:47 p.m., indicated, .Facility should ensure that medications and biological's are stored in an orderly manner in cabinets, drawers, carts, refrigerators/freezers of sufficient size to prevent crowding .Facility staff may record the calculated expiration date based on date opened on the primary medication container .Facility personnel should inspect nursing station storage areas for proper storage compliance on a regularly scheduled basis 3.1-25(j) 3.1-25(0)

Based on observation, interview, and record review, the facility failed to store clean clothing or resident personal care items in a clean environment for 4 of 117 residents (Residents 2, 14, 52, and 76). Findings include: 1. During an observation on 03/11/24 at 01:15 p.m., clean clothes were hanging from one end of the shower curtain rod to the other over the bathtub in the bathroom of Residents 2 and 52. Blankets and a large black trash bag of items were in the bathtub. The toilet had armrests attached, no lid, and was positioned immediately beside the bathtub. Multiple items of clean hanging clothes were touching the armrest of the toilet. At least half of the hanging items were within the contamination splash zone of the flushing toilet of less than 3 feet. During an observation on 03/12/24 at 09:37 a.m., clean clothes continued to hang from one end of the shower curtain rod to the other over the bathtub, were touching the armrest of the toilet, and were within the splash zone of the flushing toilet. During an observation on 03/13/24 at 10:40 a.m., clean clothes continued to hang from one end of the shower curtain rod to the other over the bathtub, were touching the armrest of the toilet, and were within the splash zone of the flushing toilet. During an interview on 03/12/24 at 10:39 a.m., Resident 2 indicated she used the bathroom in the room. During an interview on 03/13/24 at 11:30 a.m., the Assistant Director of Nursing Services (ADNS) indicated she thought the hanging clothes were Resident 52's from the room move and she did not know why clean clothes were hanging in the bathroom on the shower curtain rod instead of in the closet. During an interview on 03/13/24 at 11:53 a.m., the Executive Director (ED) indicated clean clothing was not to be stored in bathrooms or bathtubs and she would have all clothing removed from the bathroom and placed in linen closets for Residents 2 and 52. During an interview on 03/13/24 at 2:06 p.m., the ED indicated the clothes were removed from the bathroom of Residents 2 and 52. The ED indicated the bag of clothes in the tub were from the previous resident who had discharged and should have been put in overflow and not left in the room. During an interview on 03/12/24 at 03:12 p.m., the Infection Preventionist (RN 10) indicated clean laundry and linens were covered while transported from laundry to the units and then stored in closets. The clinical record for Resident 52 was reviewed on 03/15/24 at 09:52 a.m. The diagnoses included, but were not limited to, cellulitis (skin infection), chronic ulcer of the skin, chronic pain, edema, rheumatoid arthritis, type 2 diabetes mellitus without complications, hypertensive heart disease with heart failure, chronic systolic (congestive) heart failure, contracture of muscle, stage 4 pressure ulcer of left buttock, and chronic obstructive pulmonary disease. The electronic medical record indicated Resident 52 was transferred to room [ROOM NUMBER]A on 12/22/2023 at 03:38 p.m. A Progress Note, dated 02/13/2024 at 07:22 a.m., stated, Patient has a wound on their bottom, with redness initially observed on the left side of their hip and pelvis. The redness has now spread to the right side of their pelvis and peri area. Patient started taking Keflex 500 milligrams over the weekend and began the medication today. Patient has a history of rheumatoid arthritis, congestive heart failure, COPD, and diabetes.and they have swelling in their right leg and foot. There is slight redness and warmth in their left foot, which is the side with the majority of the wound on their coccyx and buttocks. An IDT Weekly Wound Review Note, dated 02/15/2024 at 02:42 p.m., indicated an overall decline in the resident's condition with worsening of Resident 52's pressure ulcer and signs and symptoms of infection. Redness, swelling, and warmth were noted in the Resident's torso and thigh. A care plan, initiated on 02/19/24, stated Resident 52 had impaired skin integrity: pressure ulcer noted to left posterior thigh. A MDS (Minimum Date Set) assessment, dated 02/28/24, indicated Resident 52 was fully dependent on staff for toileting and was always incontinent of bowel and bladder. The clinical record for Resident 2 was reviewed on 03/15/24 at 03:15 p.m. The diagnoses included, but were not limited to, cerebral infarction (stroke), hemiplegia (paralysis of body parts on one side of the body) and hemiparesis (muscle weakness or partial paralysis of parts of the body on one side) following cerebral infarction affecting left non-dominant side, weakness, legal blindness, and type 2 diabetes mellitus without complications. An annual MDS (Minimum Data Set) assessment, dated 01/15/24, for Resident 2 indicated resident was continent of bowel and bladder and required partial to moderate assistance for toilet transfers. The electronic medical record contained the toileting record for Resident 2. It listed multiple urine outputs and bowel movements for Resident 2 on the survey dates of 03/11/24, 03/12/24, and 03/13/2024 when the clean clothing was observed hanging in the bathroom and touching the toilet arm. 2. During an observation on 03/11/24 at 02:02 p.m., the bathroom for Resident 14 and Resident 76 had a strong odor of urine and bowel movement. The sink handles were dirty and rusty. The bathtub had plywood over it and was being used for storage of the residents' clean personal care supplies. During an interview on 03/13/24 at 11:53 a.m., the ED indicated she was not sure why the plywood was over the tub in bathroom for Residents 14 and 76. The ED indicated she did not know why the bathtub was being used for clean storage. During an interview on 03/13/24 at 2:06 p.m., the ED indicated the plywood was removed from the bathtub and clean items were no longer stored in the bathtub. A current policy, titled, Laundry/Linen revised on 12/2021 and received from the DON on 03/15/24 at 02:30 p.m., indicated The laundry and nursing staff shall handle, store, .linen appropriately to prevent the spread of infection in resident-care areas.Clean linen must be protected from soiling or contamination. Splash Zone Information Sheet (April 20, 2023) was retrieved on 03/18/24 at 09:10 a.m. from the Health Quality Innovation Network at https://hqin.org/wp-content/uploads/2023/04/Splash-Zone-Infosheet.pdf. The Centers for Medicare & Medicaid Services (CMS) uses 3 feet as their guide for determining the splash zone because Studies have shown that splashing can occur up to 3 feet from the sink, (toilet) or drain.Evidence indicates sinks and other drains, such as toilets or hoppers, in healthcare facilities can become contaminated with multidrug-resistant organisms (MDROs). These microorganisms can stick to the pipes to form biofilms, which allow the organisms to persist in drains for long periods of time. In addition, microorganisms can multiply in moist conditions and are often difficult to impossible to fully remove. How are Patients/Residents Exposed? Splashes may occur when flowing water hits the drain or when a toilet or hopper is flushed. Splashes can lead to dissemination of MDRO-containing droplets, which in turn may contaminate the environment, equipment, and skin or clothing of healthcare personnel and patients/resident.Avoid storing supplies within 3 feet of splashing water. 3.1-18(b)(1)

Based on observation, interview, and record review, the facility failed to ensure a resident's oxygen was on the correct liter flow per the physician's orders for 1 of 1 residents reviewed for respiratory care (Resident 60). Findings include: During an observation, on 3/13/24 at 11:03 a.m., Resident 60's oxygen was at 1 liter flow. The clinical record was reviewed on 3/13/24 at 11:17 a.m. The diagnoses included, but were not limited to COPD, chronic respiratory failure with hypoxia, and influenza due to novel influenza A virus. A physician's order, with a start date of 2/21/24 and an end date of 3/13/24, indicated the resident was to wear oxygen at 2 liters per nasal canula continuously. A physician's order, started on 3/13/24 at 9:17 a.m., indicated the resident was to wear 2 liters of oxygen per nasal canula at bedtime. During an observation and interview, on 3/13/24 at 2:20 p.m., the DNS (director of nursing services) saw and indicated the resident's oxygen was on 1 liter. During an interview, on 3/13/24 at 2:21 p.m., the DNS indicated the resident had a continuous oxygen order at 2 liters to be worn at bedtime. The order was changed last night. A history of oxygen saturation results indicated the following: a. 3/10/24 at 10:06 p.m.- oxygen was on at 3 liters. b. 3/11/24 at 9:25 a.m.- oxygen was not used. c. 3/11/24 at 2:19 p.m.- oxygen was not used. d. 3/12/24 at 6:17 a.m.- oxygen was not on. During an interview, on 3/14/24 at 2:39 p.m., Resident 60 indicated she did not touch her oxygen concentrator. Resident 60's record lacked documentation she had ever adjusted her oxygen concentrator before. A policy, titled, Oxygen Concentrator, not dated and received from the DON on 3/15/24 at 3:40 p.m., indicated .1) Verify and understand the physician's orders. 2) know the flow rate and duration of use . 3.1-47(a)(6)

Based on interview and record review, the facility failed to correctly code an annual Minimum Data Set (MDS) assessment for 1 of 3 residents reviewed for Preadmission Screening and Record Review (PASARR) (Resident 9). Finding include: The clinical record for Resident 9 was reviewed on 3/13/24 at 9:20 a.m. The diagnoses included, but were not limited to, unspecified dementia with mood disturbance, insomnia, bipolar disorder, major depressive disorder, and psychotic disorder with delusions. A notice of PASARR level 2 outcome, with a notice date of 12/23/22, indicated the resident had a long-term approval without specialized services based on the diagnoses of bipolar disorder NOS (not otherwise specified), unspecified depressive disorder, dementia NOS, unspecified insomnia disorder, and for treatment history, current symptoms, and service needs. An annual MDS assessment, dated 1/10/23, indicated the resident was not currently considered by the state level 2 PASARR process to have a serious mental illness and/or intellectual disability or related condition. During an interview, on 3/14/24 at 11:01 a.m., the SSD (Social Services Director) indicated the MDS assessment was marked in error and should have been marked as a yes on the assessment. During an interview, on 3/15/24 at 3:40 p.m., the DNS (Director of Nursing Services) indicated the facility used the RAI (resident assessment instrument) manual for the facility policy for MDS assessments. A CMS (Centers for Medicare and Medicaid Services) document titled, Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.18.11 October 2023, indicated, .It is important to note here that information obtained should cover the same observation period as specified by the MDS items on the assessment, and should be validated for accuracy (what the resident's actual status was during that observation period) by the IDT completing the assessment. As such, nursing homes are responsible for ensuring that all participants in the assessment process have the requisite knowledge to complete an accurate assessment 3.1-31(d)

Based on interview and record review, the facility failed to notify the resident's representative of a psychotic disturbance and the start of an antipsychotic medication for 1 of 5 residents reviewed for unnecessary medications (Resident 89). Finding includes: The clinical record for Resident 89 was reviewed on 3/13/24 at 4:44 p.m. The diagnoses included, but were not limited to, nondisplaced fracture of the right femur, major depressive disorder, generalized anxiety disorder, cognitive communication deficit and dementia with psychotic disturbance. A physician's order, dated 1/4/24, indicated to give Risperdal (an antipsychotic medication) 0.25 milligram (mg) at bedtime for dementia with psychotic disturbance. A physician's order, dated 1/25/24, indicated to give Risperdal 0.5 mg at bedtime for dementia with a psychotic disturbance. A physician's order, dated 2/7/24, indicated to give Risperdal 1 mg twice a day. A Pharmacy Consultation Report, dated 1/14/24, indicated the resident received Risperdal 0.25 mg at bedtime for dementia with psychotic disturbance. Antipsychotics had a boxed warning for an increased risk of mortality in older adults with psychosis related to dementia. The recommendation was to consider discontinuing the Risperdal. The prescriber response, dated 1/25/24, indicated the recommendation was declined due to the resident had delusions. A Psychiatric Nurse Practitioner (NP) note, dated 1/4/24 and recorded as a late entry on 1/5/24 at 7:57 a.m., indicated the resident was seen by staff request for a medication review due to increased falls. The resident continued to agree to feelings of sadness and reported she cries frequently. The resident continued to display delusional thinking and symptoms of depression. She had been getting up at night because she was afraid. The resident's delusional thinking continued to be distressing and was difficult to redirect. Risperdal 0.25 mg at bedtime would be started for dementia with psychotic disturbance. The progress notes did not include notification to the resident's representative for the start of the antipsychotic medication. During an interview, on 3/15/24 at 12:45 p.m., the Director of Nursing Services (DNS), indicated there was no documentation of the resident's representative being notified of the start of the antipsychotic medication and no documentation to indicate the representative had been informed of the risks of the antipsychotic medications versus the benefits. A current policy titled, Resident Change of Condition Policy, revised on 11/2018 and received from the DNS on 3/15/24 at 3:41 p.m., indicated, .It is the policy of this facility that all changes in resident condition will be communicated to the physician and family/responsible party and appropriate, timely, and effective intervention takes place .Non-Urgent Medical Change .The nurse in charge is responsible for notification of physician and family/responsible party .Documentation will include time and family/physician response 3.1-5(a)(3)

Based on observation, interview and record review, the facility failed to ensure Resident B was free from staff-to-resident physical abuse for 1 of 3 residents reviewed for abuse. This deficient practice resulted in Resident B sustaining 14 severe first-degree burns (a first-degree burn affects the outer layer of skin. Burn sites were red, painful, and dry without blisters) on an ear, a lip, the neck, the upper back, the breasts, the abdomen, the bilateral thighs, the bilateral buttocks, and the perineal area. Finding includes: The immediate jeopardy began on January 6, 2024, when it was identified the resident had 14 burns that were caused from a hair dryer. Resident B sustained burns in 14 different locations across her body, which included, but were not limited to her breasts, pubic area, bottom, back of the neck, ear, and mouth area. The Executive Director (ED), Regional [NAME] President of Operations, Regional Director of Clinical Services, and Director of Nursing Services (DNS) were notified of the immediate jeopardy on 1/9/24 at 2:54 p.m. The immediate jeopardy was removed on 1/10/24, but noncompliance remained at the lower scope and severity level of isolated, no actual harm with potential for more than minimal harm that is not immediate jeopardy. An incident report to the Indiana Department of Health, dated 1/6/24, indicated the resident was found with 11 raised circular areas upon skin inspection. During investigation of the skin issues, from 1/6/23, the Nurse Practitioner (NP) determined the marks were burns. During an interview, on 1/9/24 at 8:45 a.m., the DNS and the ED were in attendance. The ED indicated she received a call from the DNS, on 1/6/24, indicating Resident B had 11 circular areas found on her body. A reportable was sent into Indiana Department of Health. They began their investigation. On 1/7/24, the DNS received a call from a staff member who indicated the circular areas on Resident B looked like they were made by a hair dryer. At that time, a white hair dryer was observed in the ED's office with a large circle and a smaller inner circle with eight lines connecting the large and smaller circles together. The DNS indicated the resident had been burned by the hair dryer on multiple areas of her body. The DNS showed a picture of one of the burned areas on the resident and it was observed to have a large circle with a smaller inner circle with eight lines connecting the large and smaller circles together just as the white hair dryer. The ED indicated once the resident's daughter was with the resident, the resident indicated she was hurt with a hair dryer, by a middle-aged white female who was a little heavy with blonde hair. A housekeeper, a nurse who matched the description, and the CNA who gave the resident her shower, on 1/6/24, were all suspended on 1/8/24. During an observation, on 1/9/24 at 9:54 a.m., the resident was sitting in her wheelchair. She was placed in bed by two CNAs. She had burn wounds to her chin, right ear, lower left jaw, right cheek, right and left breasts, lower left abdomen, right and left inner thigh areas, pubic area, right buttock and three on the back of her neck. Several of the burns were circular in nature with lines intersecting throughout the circle and were red in color. The resident was observed to have a flat affect and was grabbing for staff member's hands during the observation. When she was placed back into her wheelchair she had tears in her eyes, with a frown, was very soft spoken, and complained of a headache. The record for Resident B was reviewed on 1/9/24 at 2:20 p.m. Diagnoses included, but were not limited to, aphasia (a language disorder caused by damage in a specific area of brain which controls language expression and comprehension), anxiety disorder, cognitive communication deficit, unspecified dementia, and psychotic disorder with delusions due to known physiological condition. A care plan, dated as last reviewed 11/7/23, indicated the resident exhibited a cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of less than 13. Interventions included, but were not limited to, provide simple instructions, give resident choices throughout the day regarding decisions, provide resident with prompts and cues and encourage participation in daily activities particularly regarding orientation, socialization, and stimulation. A care plan, dated as last reviewed 11/7/23, indicated the resident may become combative with care and try to hit staff. Interventions included, but were not limited to, reapproach later, and try a different caregiver. A care plan, dated as last reviewed 11/7/23, indicated the resident had episodes of eating her feces, and taking it out of brief and throwing it. Interventions included, but were not limited to, offer gum or hard candy, keep physician and family informed, mental health services in place, offer snack and drink, offer re-directional activities, and assess for toileting, pain, hunger. A care plan, dated as last reviewed 11/7/23, indicated the resident's cognition varied throughout the day. The resident was slow to respond at times in conversation. Interventions included, but were not limited to, encourage social interaction, provide simple instructions, and repeat as needed, give the resident choices throughout the day regarding decisions as able, and encourage participation in daily activities particularly regarding orientation, socialization, and stimulation. A care plan, dated as last reviewed 11/7/23, indicated the resident required assistance with toileting incontinence care due to impaired mobility, impaired vision, medications, impaired cognition, and the resident was incontinent. Interventions included, but were not limited to, check at least every 2 hours for incontinence, assist with elimination, assist with toileting and incontinent care as needed, document any abnormal findings, and notify the physician, and assess and document skin condition weekly and as needed. A care plan, dated as last reviewed 11/7/23, indicated the resident required assistance with Activities of Daily Living (ADLs) including bed mobility, transfers, eating, and toileting related to impaired mobility, incontinence, impaired cognition, impaired vision, medications, impaired communication. Resident prefers to not shower at times. Resident has dementia and expressive language disorder. Interventions included, but were not limited to, prefers to get up before breakfast, shower 2 times a week in the p.m., and go to bed after 10 p.m., or when tired, assist with toileting and/or incontinent care as needed: incontinent, assist with bathing as needed per resident preference, and offer showers two times per week, partial bath in between. A Quarterly Minimum Data Set (MDS) assessment, dated 11/7/23, indicated the resident had a score of 11 which indicated she was moderately cognitively impaired. She exhibited no behaviors and required substantial/maximal assistance with showering/bathing. A nursing progress note, dated 1/6/2024 at 11:06 a.m., recorded as a late entry on 1/7/24 at 7:07 a.m., indicated a red facial rash was noted. There was no signs or symptoms of infection, drainage, pain, or itching. A new order for Hydrocortisone cream every shift to the area was ordered. The progress note was written by LPN 1. A nursing progress note, dated 1/6/24 at 10:34 p.m., indicated at approximately 8:45 p.m., the CNA came to the writer with concerns regarding rash type areas covering the resident's body. Upon assessment, the resident was found to have 13 circular raised rash areas to the following: right cheek, right nipple, left inner breast, right buttock, right inner thigh, left inner thigh, across the pubis, and the left posterior neck/shoulder, left lower lip, and right back of the neck. Some areas have blistering noted along the edges. Measurements were obtained. The resident denied knowing what/how the areas happened, pain or itching to the areas. The DNS and physician were notified. The progress note was written by RN 2. A social services progress note, dated 1/8/24 at 12:15 p.m., recorded as a late entry on 1/8/24 at 1:25 p.m., indicated Social Services (SS) met with the resident on this date. The resident presented with a flat affect per her usual demeanor. She did not display any signs or symptoms of psychosocial distress. No crying or tearfulness. A social services progress note, dated 1/8/24 at 3:15 p.m., recorded as a late entry on 1/8/24 at 4:01 p.m., indicated the mental health Nurse Practitioner (NP) was in the facility and completed a trauma screen, recommendations to follow. An Interdisciplinary Team (IDT) initial wound review note, dated 1/8/24 at 7:41 p.m., indicated the describe of the new wound/skin injury was a burn to the right cheek, the lower lip into the left cheek, right ear, left breast, right nipple, right buttock, right posterior neck, left posterior neck, left upper shoulder below the left posterior neck, right inner thigh time two (2), left inner thigh, and pubis. The root-cause determination was a burn. A nursing progress note, dated 1/9/24 at 3:32 a.m., indicated treatment was done to the areas as ordered and tolerated well. The areas to the lower lip and cheek were peeling and the resident was licking her chin. No tearfulness, or signs and symptoms of fear or anxiety was noted this shift. A nursing progress note, dated 1/9/24 at 4:08 a.m., indicated the resident was turned and repositioned. The resident started crying when turned and facial grimacing was noted. Pain meds to be given as ordered. A psychiatry note, dated 1/8/24, indicated the reason for the visit was a trauma assessment. It was reported the resident was found to have approximately 13 circular raised rash areas to the following: right cheek, right nipple, left inner breast, right buttock, right inner thigh, left inner thigh, across the pubis, and the left posterior neck and shoulder. Some areas have blistering noted along the edges. The resident denied knowing what/how the areas happened at the time of discovery. The resident displayed a flat affect per her usual demeanor. She was soft spoken and reached out for the writer's hand as if to seek comfort multiple times during the visit. When asked about the area to her skin, she first reported she did not know what happened. After further discussion and efforts to make the patient feel at ease, she reported the areas have been there since Saturday and someone hurt her with the hair dryer. She reported she was unsure who hurt her and indicated she never saw her before, and she had brown hair. She did report she was getting a shower at the time of the incident but could not recall specific details of what happened leading up to the incident. She had shared similar accounts of the event with minor variation. The variation was likely attributable both to mild cognitive impairment present and the impact of the trauma upon capacities for recalling specific/component aspects of event that transpired. The resident indicated she was not afraid of anyone; she was just a little bit sad. Sometimes it hurts. She was tired of all the questions and had a headache. The assessment and plan indicated it was recommended to avoid the use of a hair dryer in the future and to monitor for psychosocial distress related to bathing/showering and the use of the shower room and limit exposure to shower room if distress occurs. A nurse practitioners note, dated 1/8/24, indicated the resident had multiple wounds located on her mouth, right cheek, right ear, three spots on the top of her shoulders, right nipple, left breast, inside both thighs, across her pubis and a couple on her abdomen. The wounds were red, raised, and scabbed, all appearing to be the same stage. The resident had a flat affect, which was normal for her. She did appear tearful at the beginning of the encounter. The wounds were consistent with burns. A wound management detail report completed by the facility, dated 1/8/24, indicated the resident had the following wounds: 1. A burn to the right ear which measured 3 centimeters by 1 centimeter. 2. A burn to the back of the neck which measured 3.5 centimeters by 4 centimeters. 3. A burn to the left upper back which measured 1 centimeter by 3 centimeters. 4. A burn to the back of the neck which measured 4 centimeters by 4 centimeters. 5. A burn to the left thigh which measured 2.5 centimeters by 2 centimeters. 6. A burn to the right buttocks which measured 3.5 centimeters by 3.5 centimeter. 7. A burn to the right cheek which measured 4 centimeters by 3 centimeters. 8. A burn to the right breast which measured 4 centimeters by 4.5 centimeters. 9. A burn to the perineal area which measured 8 centimeters by 6 centimeters. 10. A burn to the right thigh which measured 2 centimeters by 2 centimeters. 11. A burn to the right thigh which measured 4 centimeters by 3.5 centimeter. 12. A burn to the left lower quadrant of the abdomen which measured 1.5 centimeters by 4 centimeters. 13. A burn to the left breast which measured 3 centimeters by 4 centimeters. 14. A burn to the lower lip which measured 4 centimeters by 10 centimeters. In a witness statement, dated 1/8/24, LPN 1 indicated she saw CNA 3 take Resident B for a shower Saturday morning. She saw a new area on the resident's chin which looked chapped. In a witness statement, dated 1/8/24, CNA 4 indicated on Friday night into Saturday morning there were no marks on the resident's skin. On Saturday, CNA 5 found the marks on the resident. In a witness statement, dated 1/8/24, CNA 3 indicated she gave Resident B a shower on Saturday morning. Her chin and lips looked like cracked skin. She provided her care after lunch (after 1), and she did not see any areas on her skin. The resident was in bed from 9 a.m., until 11:30 and then the resident was up for lunch and laid back down after lunch. In a witness statement, dated 1/8/24, CNA 5 indicated she cared for Resident B for the evening shift on Saturday. The resident was in bed from 2 p.m., until around 8:45 p.m., when she provided her care and found the markings on her skin. In a witness statement, dated 1/8/24, CNA 6 indicated she saw Resident B on Saturday after breakfast and her chin and ear were red. In a witness statement, dated 1/8/24, the Executive Director (ED) indicated Resident B indicated the injuries occurred in the shower room. When asked if someone did this to her, she indicated the girl got a little carried away. She indicated it was someone who worked here, and she was wearing scrubs. During a phone interview, on 1/9/24 at 3:46 p.m., LPN 1 indicated CNA 3 was the CNA who gave Resident B her shower Saturday morning. CNA 3 notified her the resident had a rash on her face after she got her out of the shower before breakfast. During a phone interview, on 1/10/24 at 8:56 a.m., the resident's medical physician indicated the burn wounds were all the same age, so they all happened at the same time. The burns were severe first-degree burns with a concern for a secondary Staph infection from the resident licking her chin. During an interview, on 1/10/24 at 10:20 a.m., CNA 3 indicated she gave Resident B a shower around 7:00 a.m., on Saturday 1/6/24. After her shower, she took the resident to breakfast. When she brought the resident back to her unit after breakfast, she noticed a rash on her chin. She did not notice any marks on the resident during her shower or throughout the rest of her shift besides her chin. During an interview, on 1/10/24 at 11:05 a.m., CNA 5 indicated she worked the evening shift, on Saturday 1/6/24. Her shift started at 2:00 p.m. When she started her shift, CNA 3 reported to her, she had just provided Resident B with peri-care. CNA 5 did not check or change the resident until around 8:45 p.m. The resident did not get up for dinner and received her meal in bed. Around 8:45 p.m., she went to get the resident ready for bed and provide peri-care. When she removed her gown, she saw red, circular marks on her breasts. She discovered more marks on her thighs and peri-area and immediately went and found a nurse. During a phone interview, on 1/10/24 at 10:30 a.m., CNA 7 indicated Resident B had dried feces on her at the start of the shift, Saturday 1/6/24, and she needed a shower. CNA 3 was the CNA responsible for caring for Resident B. She offered to help CNA 3 give Resident B a shower, but CNA 3 indicated she did not need help. So, CNA 7 went to help with breakfast. There were no marks noted on Resident B prior to her getting into the shower. CNA 7 went into Resident B's room, at approximately 8:30 a.m., when CNA 3 was buttoning up Resident B's clothes. CNA 7 observed a red mark on her chin and abdomen, but she thought the red mark was from where the feces were scrubbed off or the water may have been too warm. A current policy, titled Resident Rights: Know Your Rights under Federal Nursing Home Regulations, dated March 15, 2017 and provided by the DNS on 1/9/24 at 9:45 a.m., indicated Resident Rights: You have the right to a dignified existence, self-determination and communication with and access to the persons and services inside and outside the facility .Respect and Dignity: You have a right to be treated with respect and dignity, including: The right to be free from abuse A current policy, titled Abuse Prohibition, Reporting and Investigation, dated June 2023 and provided by the DNS on 1/9/24 at 9:45 a.m., indicated Purpose of Policy: Provide guidelines to prohibit and prevent abuse .of residents . Policy: It is the policy of America Senior Communities to provide each resident with an environment that is free from abuse .This includes but is not limited to .physical abuse .Definitions/Examples of Abuse: Willful, used in the definition of abuse, means the individual must have acted deliberately, not that the individual intended to inflict injury to harm. Abuse-Willful infliction of injury, unreasonable .intimidation, or punishment with resulting physical harm, pain, or mental anguish .Instances of abuse of all residents, irrespective of any mental or physical condition, cause of physical harm, pain, or mental anguish. Abuse includes .physical .Physical Abuse-A willful act against a resident by another resident, staff member or other individual(s). Examples may include but not be limited to hitting, slapping, punching, and choking .Identification: Abuse includes: 1. Staff to resident abuse of any type .Types of abuse .4. Physical abuse The National Library of Medicine website, dated 8/8/2023, indicated .First Degree Burns .Outcomes The prognosis for the majority of people with a first-degree burn is excellent. However, children and the elderly may require admission depending on the degree and location of the burn. Besides pain, hypothermia is a potential complication The Immediate Jeopardy that began on 1/6/24 was removed on 1/10/24, when the facility completed the following: Psychiatric services completed an assessment on the resident and screened Resident B for trauma. The resident was placed on 1:1 for comfort. All residents were interviewed for abuse and any residents who were not able to be interviewed had skin assessments completed. In-servicing on abuse and behavior management was completed to all staff members. The ED met with the Resident Council President to discuss reporting concerns of abuse immediately and the ED will attend the next resident council meeting with permission. All hair dryers were removed from the shower rooms. Nursing Management will make rounds daily to observe for any new resident behaviors or new skin areas. Home office consultants will review incidents and accidents upon routine visits reported to the Executive Director and Director of Nursing Services. Quality Assurance tools will be used weekly for four weeks, then monthly for five months and then quarterly thereafter. This Federal tag relates to Complaint IN00425631. 3.1-27(a)(1)

Based on observation, interview and record review, the facility failed to complete weekly weights as recommended by the Registered Dietician (RD) and to complete a weight for a resident with a known nutritional concern for 3 of 5 residents reviewed for nutrition. (Residents 14, 34 and 36) Findings include: 1. During an observation, on 12/12/22 at 4:25 p.m., Resident 14's sides of his face were sunk in. During an observation, on 12/14/22 at 3:15 p.m., the resident was lying in bed, his eyes were closed, and the sides of his face were sunk in. The record for Resident 14 was reviewed on 12/19/22 at 4:43 p.m. Diagnoses included, but were not limited to, dementia with mood disturbance, cognitive communication deficit, cerebral infarction, and dysphagia (difficulty swallowing). A care plan, dated 1/29/21, indicated the resident was at risk for altered nutrition related to the diagnosis of dementia. The goal was to remain within a normal BMI (body mass index) and weight gain was desired. The approaches included, but were not limited to, monitor weight as indicated. A nutrition note, dated 11/18/22 at 4:33 p.m., indicated the resident's weight was 132 pounds. The BMI was 17 which was underweight. The resident was to be added to the nutrition at risk (NAR) and have his weight monitored for 4 weeks. The following weights were recorded: 1. On 10/8/22, the weight was 138 pounds. 2. On 11/10/22, the weight was 132 pounds which was a 4.35% weight loss in one month. There was not a weight recorded for the month of December. During an interview, on 12/20/22 at 12:13 p.m., the Director of Nursing (DON) indicated the NAR did not get initiated and there was not a reason it was not completed. The resident did not get the weekly weights for 4 weeks. 2. The record for Resident 34 was reviewed on 12/19/22 at 5:02 p.m. Diagnoses included, but were not limited to, moderate protein-calorie malnutrition, dysphagia, and dementia. A care plan, dated 10/28/22, indicated the resident was at risk for an altered nutritional status due to the diagnoses of moderate protein-calorie malnutrition, dementia, dysphagia, and advanced age. The goal was for the resident to be free of significant weight changes and to have a gradual weight gain to reach her usual body weight of 130-136 pounds. The interventions included, but were not limited to, monitor intakes and weight changes. An admission nutrition note, dated 10/31/22 at 3:36 p.m., indicated the resident's weight was 125 pounds. The goal was to be free of chewing or swallowing difficulties and to maintain the weight. The following weights were recorded: 1. On 10/26/22, the weight was 125 pounds. 2. On 11/9/22, the weight was 124 pounds. There was no weight recorded for the month of December. When a weight for the month of December was requested, on 12/19/22 at 4:30 p.m., the following weights were provided: 1. On 12/19/22 at 6:43 p.m., the weight was 106 pounds which was a 14.53% significant weight loss in 39 days. 2. On 12/20/22 at 9:17 a.m., the weight was 103 pounds which was a 16.94% significant weight loss in 40 days. An IDT (interdisciplinary note), dated 12/20/22 at 8:59 a.m., indicated the resident's current weight was 106 pounds which was a 14.5% weight loss in 40 days. The root cause of the weight change was an overall decline in the resident's condition resulting in decreased food and fluid intake. The current nutritional goal was to have no significant weight changes, no chewing or swallowing difficulties, and to have a gradual weight gain to reach the usual body weight. During an interview, on 12/20/22 at 11:31 a.m., the DON indicated the person who did the weights did not get the resident's weights entered into the electronic health record. It would not be typical for a resident to go over a month without having a weight obtained. During an interview, on 12/20/22 at 12:22 p.m., the DON indicated the weights did not get completed for the resident until 12/19/22 when the surveyor had asked about the weight. She did not have a reason the weight was not completed prior to 12/19/22 or documented until 12/19/22. 3. The record for Resident 46 was reviewed on 12/19/22 at 5:13 p.m. Diagnoses included, but were not limited to, dementia with behavioral disturbance, dysphagia, pneumonitis due to inhalation of food and vomit, type 2 diabetes, and lymphedema. A care plan, dated 7/7/22, indicated the resident was at risk for an altered nutritional status due to the diagnoses of diabetes, heart failure, and hypertension. The goal was for the resident to be free of significant weight changes. The approaches included, but were not limited to, monitor intakes and weight changes. A nutrition note, dated 11/18/22 at 5:04 p.m., indicated the resident's weight was 223 pounds. The resident had a trending weight loss. The resident would continue on NAR and weights would be monitored weekly for 4 weeks. The following weights were documented: 1. On 9/7/22, the weight was 237 pounds. 2. On 10/3/22, the weight was 223 pounds which was a 5.91% significant weight loss in less than one month. 3. On 12/19/22, the weight was 215 pounds which was a 9.28% weight loss since 9/7/22 and a 3.59% weight loss since 10/3/22. There were no weekly weights documented after the RD nutrition note dated 11/18/22. During an interview, on 12/20/22 at 4:37 p.m., the DON indicated the weekly weights for 4 weeks as recommended by the RD were missed and were not documented. A current policy, titled IDT Weight Review, dated as revised on 4/2018 and received from the DON on 12/20/22 at 4:37 p.m., indicated .It is the policy of American Senior Communities to identify residents who are at nutritional risk or have had a significant weight change and be reviewed by the IDT to initiate appropriate interventions .Residents recommended for IDT Weight Review .New admissions and readmissions with nutritional concerns .Residents with continuous, gradual weight loss that has not triggered as significant .Resident with significant weight loss/gain .Residents with change of condition which has significantly affected appetite/intake or increases their risk for weight loss .IDT Documentation of Residents with Weight Loss or Nutritional Concerns to include .New interventions implemented .Intervention[s] will be communicated with direct care staff .Weight Review should be completed weekly A current policy, titled Resident Weight Monitoring, dated as revised on 1/2016 and received from the DON on 12/20/22 at 4:15 p.m., indicated .It is the policy of this facility to have resident weights reviewed routinely by the Registered Dietician and the Nursing Department. An interdisciplinary team will review any resident who has weight or nutritional concerns .The interdisciplinary team will place the following residents on weekly weights .New admission or readmission for a minimum of 4 weeks Residents who may be at risk for weight loss but have not experienced a significant weight loss .Residents who experienced a significant weight loss or gain of 5% in 30 days, 7.5% in 90 days or 10% in 180 days .The IDT will discuss any resident with significant weight gain to determine the need for weekly weights 3.1-46(a)(1)

Based on interview and record review, the facility failed to transfer a resident using the ordered mechanical lift and with the assist of two persons for 1 of 3 residents reviewed for accidents (Resident B). Resident B sustained a knee fracture and had to have surgery to repair the fracture. Finding includes: During an interview, on 1/25/2022 at 12:52 p.m., Resident B indicated a couple of weeks ago he was getting a shower and there was only one staff to help him. He slid down the bed and his legs went behind him. They probably should have had two staff since there was usually two staff assisting him. He injured his left knee from the fall and just had surgery on it a few days ago. The record for Resident B was reviewed on 1/25/2022 at 12:23 p.m. Diagnoses included, but were not limited to, secondary malignant neoplasm of bone, secondary malignant neoplasm of unspecified site-likely prostate primary, Colles' fracture of left radius (located close to the wrist), [CONDITION(S)], unsteadiness on feet and neoplasm related pain. A MDS (minimum data set) assessment, dated 11/30/2021, indicated the resident required two person physical assist for transfers. A physician's order, dated 9/2/2021 through 1/21/2022, indicated the resident could be up ad lib (as much and as often as desired) with assist, was NWB (non-weight bearing) to the LUE (left upper extremity) and was to be transferred with a mechanical lift and assistance of two staff. A care plan, dated 7/29/2021, indicated the resident required assistance with ADLs (activities of daily living) including bed mobility, transfers, eating and toileting related to malignant neoplasm of the bone metastatic cancer and impaired mobility. The approaches included, but were not limited to, up with mechanical lift x 2 staff assist in wheelchair and non-weight bearing to left upper extremity and left lower extremity. A care plan, dated 7/29/21, indicated the resident was at a risk for falls due to impaired mobility, age, history of falls, malignant neoplasm of the bone and receiving [CONDITION(S)]. A progress note, dated 1/5/2022 at 4:28 p.m., indicated the resident had a witnessed fall during a transfer from the bed to a shower chair. The resident complained of left knee pain and there was swelling noted above the knee and a small skin tear which measured 0.5 cm (centimeter) by 0.5 cm. The nurse practitioner was notified and a new order for an X-ray of the left knee was obtained. An IDT (interdisciplinary team) progress note, dated 1/6/2022 at 4:11 p.m., indicated the resident had a witnessed fall during a transfer. The resident had pain and swelling to his knee and they were awaiting X-rays. The root cause of the fall was identified as the residents legs became weak during the transfer. The intervention put in place for the fall was staff counseling for transfers. A progress note, dated 1/6/2022 at 8:45 p.m., indicated the radiology report showed the resident had a minimally displaced intra-articular fracture of the medial femoral condyle (the ball shape located at the end of the thigh bone-knee). The resident was referred to orthopedics. A progress note, dated 1/19/2022 at 10:40 a.m., indicated the resident was transferred by ambulance to the hospital for surgery. A hospital report, dated 1/19/21, indicated the resident suffered a fall at the nursing home and was noted to have a fracture. The preoperative diagnosis was a left distal femur fracture. The risks of surgery include infection, bleeding, anesthesia, damage to nerves or blood vessels, incomplete recovery, medical or anesthetic complications. The procedure performed was an open reduction and internal fixation (surgical process of repairing a bone) of the left distal femur. A progress note, dated 1/21/2022 at 12:30 p.m., indicated the resident returned to the facility. He had an immobilizer on his left knee. A written statement, dated 1/5/2022, from CNA 3 indicated she was trying to assist Resident B from his bed to the shower chair for his shower. She had the chair set against his bed with the wheels locked and lowered the bed to be level with the seat of the chair. She assisted the resident to sit on the edge of the bed. While standing in front of the resident with her hands under his armpits, she tried to stabilize the resident as he scooted into the shower chair. The resident started to slide and CNA 3 assisted the resident to the floor. During an interview, on 1/25/2022 at 3:30 p.m., the Director of Nursing (DON) indicated the resident had a fall when CNA 3 manually attempted to transfer the resident from his bed to the shower chair. CNA 3 stated she had not followed the plan of care and realized she was in error with the transfer. The CNA assignment sheet was correct for the use of the mechanical lift and two person assist the day the fall occurred. A current policy, titled Fall Management Program, dated as revised on 11/2017 and received from the DON on 1/25/2022 at 3:29 p.m., indicated .It is the policy of American Senior Communities to ensure residents residing within the facility receive adequate supervision and or assistance to prevent injury related to falls .A 'Fall' refers to unintentionally coming to rest on the ground, floor, or other lower level. An episode where a resident lost his/her balance and would have fallen, if not for another person or if he or she had not caught him/herself, is considered a fall. A fall without injury is still a fall. Unless there is evidence suggesting otherwise, when a resident is found on the floor, a fall is considered to have occurred .Facilities must implement comprehensive, resident-centered fall prevention plans for each resident at risk for falls or with a history of falls .Fall risk will be assessed upon admission or re-admission, quarterly and with significant change utilizing a formalized fall assessment tool .A care plan will be developed at time of admission with specific care plan interventions to address each resident's fall risk factors .Residents who are categorized as moderate to high risk should have fall interventions implemented based on resident specific risk factors .The resident specific care requirements will be communicated to the assigned caregiver utilizing resident profile or CNA assignment sheet This Federal Tag relates to Complaint IN 505 3.1-45(a)(1) 3.1-45(a)(2)

Based on observation, interview and record review, the facility failed to ensure call lights were in reach for 2 of 2 randomly observed residents reviewed for accommodation of needs. (Resident 62 and 13) Findings include: 1. During an observation, on 9/14/21 at 12:59 p.m., the call light for Resident 62 was found on the floor and she was unable to reach the call light. During an interview, on 9/14/21 at 1:05 p.m., CNA 4 indicated the resident's call light sometimes fell down. She attached the call light on the bed rail within reach of the resident. During an observation, on 09/20/21 at 9:40 a.m., Resident 62 was sitting in bed in an upright position, leaning to the left with her head off the pillow. The resident's breakfast tray was on the bedside table. The call light was hanging off the rail and out of the reach of the resident. LPN 6 assisted the resident with her call light. The record for Resident 62 was reviewed on 09/15/21 at 12:30 p.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . 2. During an observation, on 9/20/21 at 2:40 p.m., Resident 13 was lying in bed with the right side of the bed against the wall. The resident's call light was on the floor on the left side. During an interview, on 9/20/21 at 2:41 p.m., CNA 5 indicated the resident moved around in bed and probably dropped it on the floor. She stated the call lights should be where the residents could use them. The record for Resident 13 was reviewed on 09/15/21 at 12:30 p.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview, on 9/16/21 at 2:15 p.m., the Administrator indicated the facility did not have a policy on call lights. 3.1-3(v)(1)

Based on observation, interview and record review, the facility failed to ensure residents were monitored during medication administration and to ensure medications were not left unattended for 1 of 1 randomly observed resident. (Resident 43) Finding include: During an observation, on 09/16/21 at 10:15 a.m., Resident 43 was asleep, in her bed, with a cup of 4 pills on the nightstand. There were 1 green and 3 white pills. During an interview, on 09/16/21 at 10:17 a.m., LPN 5 indicated she had given the resident the medication, Vitamin D (supplement), Calcium (supplement), [MEDICATION(S)] (blood pressure) and [MEDICATION(S)] (antidepressant) and thought she would take them. She indicated she should have stayed with the resident to watch her take the pills and was not aware of the facility policy. The record for Resident 43 was reviewed on 09/16/21 at 12:30 p.m. Diagnoses included, but were not limited to, hypertension, depression and [CONDITION(S)]. There was no self-medication assessment and no physician's order for self-medication administration located in the record. A current facility policy, titled General Dose Preparation and Medication Administration, dated 12/1/07, indicated .This Policy 6.0 sets forth the procedures relating to general dose preparation and medication administration. Facility staff should also refer to Facility policy regarding medication administration and should comply with Applicable Law and the State Operations Manual when administering medications .3.9 Facility staff should not leave medications or chemicals unattended .5.9 Observe the resident's consumption of the medications (s) 3.1-45(a)(2)

Based on record review and interview, the facility failed to ensure the person centered care plan interventions were followed for 1 of 2 residents reviewed for behaviors (Resident B). Finding includes: The record for Resident B was reviewed on 9/17/21 at 1:47 p.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A behavior care plan, dated 4/9/2021, indicated the resident had episodes of anxiety and agitation. The resident would curse at staff, throw things and makes gestures. The approaches included, but were not limited to, give the resident her personal space immediately if she becomes agitated [as appropriate], assess for pain, toileting and hunger, continue mental health services and make a referral to Geri-psych as appropriate. A progress note, dated 9/1/2021 at 1:26 a.m., indicated the resident was awake and yelling at staff most of the shift. The resident hit Nurse 5 when she was trying to provide G-tube care and scratched and hit QMA 6 while she was trying to provide care. Nurse 5 and QMA 6 were continuing to provide care while the resident was hitting and scratching them. A progress note, dated 9/5/21 at 1:31 a.m., indicated Resident B became aggressive toward RN 5 when RN 5 was changing the tubing to the G-tube. The resident grabbed RN 5's hand. When QMA 6 attempted to assist RN 5 with care, the resident began to hit and scratch QMA 6. QMA 6 held hands with the resident while RN 5 continued to provide care. After the care was completed the resident threw a glass of ice water at QMA 6. The care planned intervention of giving the resident her personal space was not followed. During an interview, on 9/20/21 at 1:16 p.m., RN 5 indicated when she was changing the G-tube tubing Resident B swatted at her. RN 5 instructed QMA 6 to hold the resident thumb to thumb to prevent the resident from hitting RN 5 while she continued to provide care. During an interview, on 9/20/21 at 2:02 p.m., QMA 6 indicated Resident B was combative when RN 5 tried to provide care. QMA 6 held Resident B's hand to prevent her from ripping out her G-tube. QMA 6 indicated she returned to the room later in the shift to assist CNA 7 with resident care and Resident B was combative again with care. During an interview, on 9/20/21 at 2:06 p.m., CNA 7 indicated Resident B became combative when CNA 7 and QMA 6 were providing incontinence care. A current policy, titled Behavior Management Policy, with a revision date of 5/19 and received from Administrator on 9/21/21 at 3:30 p.m., indicated .Care plans should be initiated for any behavioral issue that affects, or has the potential to affect, the resident or other residents .discussion with the team as to the behavior event, an evaluation of interventions, presentation of new interventions .and an assessment of any underlying causes of the distressed behavior This Federal tag relates to Complaint IN 912. 3.1-43(a)(1)

Based on observation and interview, the facility failed to dispose of a compromised controlled substance and to store medication in the proper area for 1 of 3 medication carts and 1 of 2 medication rooms reviewed for medication storage. (Maple Lane cart and the second floor medication room) Findings include: 1. During a medication storage observation with LPN 4, on [DATE] at 11:48 a.m., the medication cart on Maple Lane had a card of [MEDICATION(S)] (a controlled pain medication ) ,d+[DATE] mg (milligrams) for Resident 73. The covering on slot 30 of the card was torn and tape was applied over the slot. During an interview, on [DATE] at 11:48 a.m., the Unit Manager indicated the pill should not be taped back in. During an interview, on [DATE] at 11:50 a.m., LPN 4 indicated she did not see the tape over the medication card during the controlled medication count. 2. During an observation, on [DATE] at 12:00 p.m., the medication room on the 2nd floor had a clear bag dated [DATE] with 10 vials of [MEDICATION(S)] (antibiotic) reconstitute solution for Resident 25 stored in a cabinet with wound dressings and oxygen supplies. During an interview, on [DATE] at 12:00 p.m., the Unit Manager indicated she did not know why the bag of antibiotics were in the cabinet and she would give them to the nurse for storage. A current policy, titled Disposal/Destruction of Expired or Discontinued Medication, dated [DATE] and received from the Unit Manager on [DATE] at 12:09 p.m., indicated .Facility staff should destroy and dispose of medication in accordance with Facility policy and Applicable Law, and applicable environmental regulations .controlled substances may not be returned to Pharmacy, unless sent to the Facility in error .Wasted medications are defined as medication contaminated or refused that require disposal. Facility should not place wasted medication back in their original containers .wasted controlled medication should be destroyed by two licensed nurses employed by Facility, and the disposal should be documented on the accountability record on the line representing that dose A current policy, titled Storage and Expiration Dating of Medications, Biological's, Syringes and Needles, dated [DATE] and received by the Administrator on [DATE] at 10:00 a.m., indicated .facility should ensure that medication and biological's that: (1) have an expired date on the label .facility should store all medication and biological requiring special containers for stability in accordance with manufacturer/supplier specifications 3.,d+[DATE](o)

Based on observation, interview and record review, the facility failed to ensure staff followed the facility recipe for pureed breaded chicken patties for 10 of 10 residents who received pureed diets. (Cook 2) Finding includes: During an observation, on 9/16/21 at 11:46 a.m., Cook 2 added 9 breaded chicken patties, chicken base, water and thickener to the robot coupe food processor. After mixing the ingredients, Cook 2 added an extra amount of hot water to the mixture in the robot coupe machine. During an interview, on 9/16/21 at 11:46 a.m., Cook 2 indicated they did not use the pureed bread and biscuit mix because the breaded chicken patties have breading on them. A recipe, titled Pureed Breaded Chicken Sandwich, provided by Cook 3 on 9/16/21 at 1:30 p.m., indicated .10 serving .Chicken Patty 3.53z .10 Patties .1. Combine first amount of Pureed Bread and Biscuit Mix and Hot water .6. Combine second amount of Pureed Bread and Biscuit Mix and Hot water 3.1-21(a)(3)

Based on interview and record review, the facility failed to ensure facility staff transferred a resident appropriately while following the resident's care plan and physician's orders [REDACTED]. This resulted in harm when Resident E experienced left leg pain and experienced a left distal femoral fracture. Finding includes: An Indiana State Department of Health Survey Report, dated 12/16/2020, provided by the Executive Director (ED) on 1/28/2021 at 12:15 p.m., indicated the incident involving Resident E occurred on 12/11/2020 at 7:04 p.m. The incident was reported to the ISDH (Indiana State Department of Health) portal on 12/12/2020 which indicated Resident E heard a pop on 12/11/2020, during a transfer. She also reported left knee pain on this date. An X-ray of her left knee was obtained, which revealed a distal femoral fracture and osteopenia. The record review for Resident E was completed on 1/29/2021 at 1:15 p.m. [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. A Significant Change Minimum Data Set (MDS) assessment, dated 10/23/2020, indicated the resident was cognitively intact and required an extensive assist of two staff members for transfers. The resident had a care plan, dated 1/10/2019, which addressed the problem she required assistance with ADL's (Activities of Daily Living) including transfers. The approaches included, but were not limited to, 1/10/2019, assist with transfers: Stand up lift times two staff into wheelchair. Progress notes documented from 12/9/2020 to 12/14/2020 indicated: On 12/11/2020, an aide reported to the nurse the resident complained of left knee pain. The nurse assessed the resident's left knee, which was observed to be swollen, no redness or warmth and tender to touch. The resident reported while being transferred on Wednesday she felt her knee twist wrong and indicated the pain had increased. The NP (Nurse Practitioner) was notified and gave an order for [REDACTED]. On 12/11/2020 at 7:45 p.m., the resident was given an order for [REDACTED]. On 12/11/2020 at 8:53 p.m., an X-ray to the left knee was completed. On 12/11/2020 at 11:12 p.m., the X-ray results were called to the NP, which showed moderate [MEDICAL CONDITION] changes, osteopenia and a distal femoral fracture. The bedrest order was to continue and no weight bearing to the left leg. The resident was to be evaluated by the family Nurse Practitioner on Monday and an orthopedic visit to be scheduled if needed. On 12/12/2020 at 2:39 p.m., the nurse assessed Resident E's left knee pain and the resident indicated she heard a pop on Wednesday during a transfer. The resident was informed at this time of the risk of injury related to the distal femur fracture. The NP was updated and recommended to send the resident to the ER for further evaluation. On 12/12/2020 at 9:11 p.m., the resident returned from the hospital with an immobilizer in place to the left leg and an order to follow up with an orthopedic doctor. A Radiology Report for Resident E, dated 12/11/2020 at 9:47 p.m., indicated the reason for the exam was pain in her left knee. The conclusion to the X-ray results indicated she had an acute (new) distal femoral shaft/supracondylar fracture (The thigh bone or femur bone was broken at the knee. The distal femur was the area right above the knee.) A small suprapatellar joint effusion (knee swelling caused by excessive fluid accumulating on or around the knee joint which can be the result of a traumatic injury to the knee.) Osteopenia was also noted with moderate [MEDICAL CONDITION] changes. The DNS (Director of Nursing Services) began an investigation into how Resident E's left distal femur was fractured. The following were accounts from the DNS's timeline of the events from 12/9/2020 to 12/14/2020: On 12/9/2020, Resident E was transferred with the stand-up lift by RN 1 and CNA 2 on the evening shift. When the lift was being lowered, the resident reported her left leg extended backward. On 12/11/2020 at 7:04 p.m., Resident E complained of pain, she had swelling of her left knee and an X-ray of her left leg was ordered. On 12/11/2020 at 8:53 p.m., the left knee X-ray was completed. On 12/11/2020 at 11:12 p.m., Resident E was evaluated at the emergency room and returned with an immobilizer, an order for [REDACTED]. A typed statement, provided by the ED on 1/28/2021 at 12:15 p.m., indicated RN 1 signed the typed statement and dated it as 12/14/2020. She indicated in the statement, on 12/9/2020, she had CNA 2 and CNA 7 assist her to lay Resident E down in her bed, so she could change her wound dressing. The stand up lift was taken into the resident's room. RN 1 was informed by CNA 2 and Resident E, she no longer used a stand up lift to transfer, she was now a two person transfer. RN 1 and CNA 2 assisted Resident E into bed, then back out of bed and into her wheelchair, after the dressing change. Once the resident was back into her wheelchair, she indicated her knee twisted. RN 1 assessed Resident E's bilateral knees and did not observe any abnormalities or complaints of pain. A handwritten statement, provided by the ED on 1/28/2021 at 12:15 p.m., indicated the Social Services Director (SSD) handwrote, signed and dated the statement on 12/14/2020. She indicated, in the statement, she spoke to Resident E on 12/14/2020, who indicated she was on the lift and as she was being put into her wheelchair she felt her leg go back. Resident E indicated she was crying and the CNA rubbed her leg. A Witness Statement-Confidential, documented as a phone interview with CNA 3, on 12/14/2020 at 3:25 p.m., completed by the DNS and the ADNS (Assistant Director of Nursing Services) indicated around 12/9/2020, CNA 3 and QMA (Qualified Medication Aide) 4 transferred Resident E without using the lift. Resident E complained of pain to her leg during the transfer and indicated she had hurt her leg earlier while in her wheelchair. A Witness Statement-Confidential, documented as a phone interview with QMA 4, on 12/14/2020 at 3:30 p.m., completed by the DNS and the ADNS, indicated around 12/9/2020, QMA 4 and CNA 3 completed a two person transfer with Resident E. Resident E told both QMA 4 and CNA 3 to be careful while transferring her because her knee hurt. QMA 4 indicated the resident told both of them she was sitting in her wheelchair and her knee popped, but she was not sure if it happened the day before or earlier on 12/9/2020. A Witness Statement-Confidential, documented as a phone interview with CNA 10, on 12/14/2020, completed by the DNS and the ADNS, indicated around 12/9/2020, CNA 10 was informed by CNA 3 and QMA 4 Resident E's leg hurt during a transfer. Review of Employee Communication Forms, dated between 12/14/2020 and 12/16/2020, for CNA 3, QMA 4 and CNA 2 indicated they were given verbal warnings for transferring Resident E manually with two people rather than using a stand up lift with two people. The forms indicated Resident E had a fracture to the left distal femur and stated her knee was hurt during a transfer. An Employee Coaching & Counseling form, dated and signed by RN 1 and the DNS on 12/16/2020, indicated RN 1 on 12/11/2020 transferred Resident E with a two person assist manually when she had an order for [REDACTED]. During an interview, on 1/28/2021 at 4:25 p.m., Resident E indicated she was being transferred from her bed to her wheelchair by two aides from out of town (upon clarification, the resident was referring to agency aides) (she did not know the aides' names) with the stand up lift and as one of them were lowering her down into her wheelchair seat her left leg bent underneath the wheelchair, while her right leg stayed in a straight standing position. She yelled out when her left leg popped as it went underneath the wheelchair seat and her nurse came running into her room. The nurse was mad because the out of town aides did that to her knee. The nurse assessed her left knee, which did not hurt that bad once the aides brought her back up with the lift, so they could get her leg out from under the wheelchair seat. She believed it was a day or two when an X-ray was taken due to she was having severe pain in her left knee. She was told the next day she had a fractured leg. She was then sent to the emergency room (ER). She indicated the agency aides did not have the strap around her legs as the usual facility staff typically did when they used the stand up lift to transfer her. Her leg popped and was bent under her wheelchair. She did not remember what date it was, she just knew it was a couple of days prior to her going to the ER (Resident E's medical record indicated she went to theER on [DATE]). During an interview, on 1/29/2021 at 10:51 a.m., Resident E indicated she was transferred with the stand up lift from her bed to the chair without a strap on the stand up lift by two aides from out of town (upon clarification, the resident was referring to agency aides). When specifically asked if there was a nurse and an aide from the facility who transferred her when her knee popped and was injured, Resident E indicated no there was no regular staff in the room until the nurse came running in to see what happened to her when she screamed out in pain. During an interview, on 1/29/2021 at 11:45 a.m., the DNS indicated according to her investigation and the interviews she did with the staff, RN 1 and CNA 2 were the staff members in the room who did the transfer when the resident indicated her knee was injured. She had documented the names of CNA 11 and CNA 12, who were agency staff, on the timeline incorrectly before she finished her investigation. She changed the names to the correct staff who transferred her. During the investigation, Resident E indicated it was CNA 11 and CNA 12 who transferred her. The investigation indicated it was RN 1 and CNA 2, who transferred her and they did not use the stand up lift. CNA 2 indicated they did a two person lift because the staff was no longer using the stand up lift on the resident. During an interview, on 1/29/2021 at 12:14 p.m., CNA 3 indicated Resident E did not like to use the Stand up lift because it hurt her knees when she was transferred on it. She would rather do a two person transfer, but she did not refuse to use the stand up lift. CNA 3 gave her the option whether she wanted to use the stand up lift or not because Resident E indicated to CNA 3 and QMA 4 her left knee was hurt and to be careful when they transferred her. CNA 3 indicated she could tell the resident was in pain and she was not going to injure her leg anymore by using the stand up lift and pushing her knees up against the bars. She gave the resident the option and she chose to do the two person transfer. CNA 3 indicated they should have transferred her with the stand up lift, but she could not see making Resident E hurt anymore than she already was. She indicated she got in trouble because she did not use the stand up lift when she transferred Resident E. CNA 3 indicated she was sure she received a verbal warning for not using the stand up lift to transfer Resident E. During an interview, on 1/29/2021 at 1:51 p.m., the DNS indicated after reviewing Resident E's care plans and physician orders, the staff should have been using a stand up lift to transfer her, instead of doing a two person lift. She indicated CNA 2 worked PRN (as needed) at the facility and she had not returned the facility's calls nor had she returned to work since the incident with the fracture of Resident E's leg. She was not able to contact her other than to leave her a message. This Federal tag relates to Complaint IN 361. 3.1-45(a)(2)

Based on interview and record review, the facility failed to ensure a proper resident transfer which resulted in a fall and death for 1 of 4 residents reviewed for falls and or accidents (Resident C). The Immediate Jeopardy began on [DATE] when the facility failed to execute a proper transfer for Resident C, he fell hit his head and was sent to the hospital for evaluation and treatment and died . Resident C fell during a transfer from his bed to a wheel chair. CNA 13 was positioned behind the residents w/c, utilizing a gait belt. The resident stood up and did a 360 degree turn and fell between the w/c and his bed. The resident was assessed to be bleeding from his nose but was alert and confused. The Nurse Practitioner (NP ) was notified and orders were received to transport the resident to the hospital for evaluation and treatment. The resident died during the evaluation at the hospital. The Executive Director was notified of the Immediate Jeopardy on [DATE] at 4:20 p.m. The IJ was removed, and the deficient practice corrected on [DATE] prior to the start of the survey and was therefore Past Noncompliance. Findings include: The clinical record of Resident C was reviewed on [DATE] at 12:43 p.m. [DIAGNOSES REDACTED]. Resident C's resident care sheet, dated [DATE], indicated the resident was a one person assist for transfers. A Physical Therapy (PT) Plan of Care, dated [DATE], indicated resident was a moderate assist (30%) for transfers from bed to chair, sit to stand and stand to sit. A nursing progress note, dated [DATE] at 8:15 a.m., indicated the resident was transferring from his bed to the w/c with the CNA to go to breakfast meal. Resident C fell and CNA 13 called for help. Nursing assessment indicated the resident was on his stomach on the floor between his bed and the w/c. The resident was assessed to be moderately bleeding from his nose. His nose was assessed to be swollen. The resident indicated he was OK and wanted to roll over onto his back. CNA 13 and LPN 14 attempted to reposition resident with little success. Resident denied any pain at the time of the fall. The resident's vital signs included blood pressure (BP) ,[DATE], respirations (R) 16, pulse (P) 55 and oxygen saturation was 87% on 2 liters of oxygen. The resident was assessed to have an altered mental status and slight confusion. A nursing progress note, dated [DATE] at 8:45 a.m., indicated the resident was sent to hospital via ambulance. Report called to hospital charge nurse and NP was aware of the resident condition. The family was notified of the fall and the hospital transport. A Nurse Practitioner (NP) note, dated [DATE], indicated nursing staff verbalized the resident had sustained a fall during the transfer from bed to wheelchair. The resident fell forward face first and hit his face against the floor and wall. The nursing staff observed the residents level of consciousness had changed and may have fractured (fx) his nose. The resident was non-ambulatory and used w/c for mobility. Resident did not lose consciousness. .Ears/ Nose/ Mouth/Throat : Bleeding from bilateral nares with reported pain An incident report, sent to the Indiana Department of Health on [DATE] indicated the resident was being transferred out of bed to w/c had gait belt around waist, shoes on, CNA had hold of gait belt and w/c brakes in locked position. Resident transferred per plan of care and therapy instruction. Resident was moderate assist of one for transfers. Resident stood up after sitting on side of bed , turned completely around prior to attempting to sit in w/c in which he lost balance and fell forward between w/c and bed. CNA unable to break fall due to resident weight. Resident left in place until paramedics arrived . Resident rolled himself to his side. When resident left facility resident was talking. Type of injury nose bleed. During interview, on [DATE], with CNA 13 and the Director of Nursing (DON), CNA 13 indicated she assisted the resident to the side of bed, she positioned herself to the back of the w/c to hold the w/c while the resident grabbed hold of the w/c arms. She indicated the resident completed a 360 degree turn when he was trying to get into his w/c. The resident then pushed against the w/c and fell between the bed and the w/c and he fell face first onto the floor. During interview, on [DATE] at 1:00 p.m., with CNA 13, she indicated she was not at the resident's side during the transfer on [DATE] and she was positioned behind the resident's w/c to stabilize the w/c because the resident was a large man. A gait belt was on the resident and w/c brakes were locked. CNA 13 indicated she should have been at the resident's side during the transfer. During an interview, on [DATE] at 2:15 p.m., with the DON, she indicated CNA 13 did receive coaching and counseling regarding the transfer of Resident C on [DATE], resulting in the resident's fall and transport to hospital. CNA 13 stood behind the w/c to assist the resident instead of standing beside the resident. She was coached to always stand beside the resident with gait belt in use for assist transfers. An Employee Coaching and Counseling report, dated [DATE], indicated CNA 13 was coached and counseled on the facility policy and procedure for transfers to a w/c. During an interview, on [DATE] at 2:33 p.m., with the Regional Clinical Support, she indicated CNA 13 did not follow the facility policy and procedure for a resident transfer to a w/c. Hospital emergency report, dated [DATE] at 8:52 a.m., indicated the resident fell from the w/c , and fell face first onto the floor and complained of (c/o) nose and right shoulder pain. The resident was confused, event oriented, person oriented and place oriented. The resident's skin was cold, cyanotic, diaphoresis, hot and jaundice, lividly, mottled and pale. The resident had no back pain but the resident c/o neck pain when he was rolled. X-ray's, dated [DATE] at 9:37 a.m., indicated the resident had a complex fx of the C3 vertebra. There was 100% posterior displacement of C2 relative to C3 with resultant severe narrowing of the AP canal diameter. There was an oblique fx involving the posterior superior aspect of C3 vertebral body. The fracture lines appear to extend into the right pedicle of C3. There was a fx at the left posterior arch of C3. There was posterior subluxation at the right C3-C4 facet joint. The hospital emergency report dated [DATE] at 11:23 a.m., indicated the resident died . A current policy and procedure titled TRANSFER TO WHEELCHAIR dated ,[DATE], provided by the Director of Nursing on [DATE] at 12:30 p.m., indicated, .10. Stand in front of resident, with feet about 12 inches apart and knees slightly bent. 11. Place gait belt around resident's waist. 12. Grasp belt securely on both sides 13. With legs on the outside of the resident's legs, brace resident's lower legs to prevent slipping . The past noncompliance immediate jeopardy that began on [DATE]. The immediate jeopardy was removed and the deficient practice corrected on [DATE] after the facility implemented a systemic plan that included the following actions: corrective action for CNA involved in transfer, in-servicing education to staff related to providing proper transfer of a resident with an assist, a skills checklist on transfers and the observations of staff participating in transfers, with ongoing monitoring. This Federal tag relates to Complaint IN 045. 3XXX,[DATE](a)(1) 3XXX,[DATE](a)(2)

Based on observation, interview, and record review, the facility failed to provide adequate supervision of a dependent resident resulting in the resident being stuck in an elevator for three hours for 1 of 3 residents reviewed for accidents (Resident B). The immediate jeopardy began on 7/8/2018 when the facility failed to supervise Resident B, when he was placed in the elevator for dinner at approximately 6:00 p.m. without staff supervision. Resident B was discovered missing during 7:30 p.m. rounds by the Director of Nursing. Resident B was released from the elevator at 9:10 p.m. The Administrator was notified of the immediate jeopardy on 7/9/2018 at 5:00 p.m. The immediate jeopardy was removed on (MONTH) 11, (YEAR), but the noncompliance remained at the lower scope and severity level of no actual harm with the potential for more than minimal harm that is not immediate jeopardy. Findings include: The clinical record of Resident B was reviewed on 7/9/2018 at 2:15 p.m. [DIAGNOSES REDACTED]. Resident B's care plan, dated 6/20/2018, indicated staff must anticipate Resident B's needs, and Resident B was unable to communicate most of the time. Nursing progress note, dated 6/29/2018 at 12:33 a.m., indicated the resident was alert to self, and the staff anticipated the resident's needs. Resident B was a total assist with activities daily living (ADLs), toileting and transfers, and the resident was propelled by staff in a wheelchair. Nursing progress note, dated 6/30/2018 at 1:57 p.m., indicated the resident was alert to self, staff anticipated his needs. Resident B was a total assist with ADLs, toileting and transfers, and he was propelled by staff in wheelchair. Nursing progress note, dated 7/8/2018 at 9:20 p.m., indicated Resident B was found, unattended in the elevator that was not working properly. The fire department was called and immediately got the elevator door open. Resident B was alert and oriented x 3 and vital signs were oxygen 88% on room air, 96% on 2 liters of oxygen per Emergency Medical Technicians (EMTs), blood pressure 88/56, pulse 76, and respirations 16. Resident B's temperature was 99.1 degrees. Resident B was given a drink of water immediately and conversed with family and staff. The Medical Doctor (MD) was notified and the resident was sent to hospital for a precautionary assessment. Hospital emergency report, dated 7/8/2018 at 9:42 p.m., indicated Resident B's recent medical evaluation history was reported as the patient was in an elevator for 3 hours. EMTs reported oxygen stats were 66% with systolic blood pressure in the 80's. Resident had Alzheimer's/dementia, and was normally only alert to self and normally nonverbal. Hospital emergency report, dated 7/8/2018 at 9:42 p.m., indicated Resident B's oxygen level was 88% upon arrival to the emergency room . Resident was nonverbal. Vital signs were temperature 98.8 degrees, heart rate 78, respirations 18, and blood pressure 125/71. The physical exam indicated the resident appeared well-developed and well-nourished. No distress noted. Resident B could not follow commands. Skin was warm and dry. Clinical impression indicated, 1. Mild dehydration, 2. Feared condition not demonstrated. Hospital emergency report, dated 7/9/2018 at 12:09 a.m., indicated the resident was discharged to home/self, and resident's discharge condition was stable. During an interview on 7/9/2018 at 11:10 a. m., with the Director of Nursing, she indicated Resident B was missing during rounds check at 7:30 p.m. and the elopement protocol was initiated. Resident B was not found. Family was notified at 8:30 p.m. to see if the resident had been on family leave without being signed out by the family. The family indicated resident was not at home. Staff indicated one elevator had been not working since 7:00 p.m. after dinner and a search indicated Resident B was in elevator. Facility elevator keys would not release the elevator door and the fire department was called. Resident B was released from the elevator. Resident B was OK and sent to hospital for assessment. The family was at facility and MD had been notified. During an observation on 9/7/2018 at 2:00 p.m., Resident B was not able to propel himself in the wheel chair and the resident was alert to only self. Resident B did remember he was in elevator on 7/8/2018, but no other details. During an interview on 7/9/2018 at 2:10 p.m., with Certified Nursing Assistant (CNA) 4, she indicated Resident B could not propel himself into an elevator. During an interview on 7/11/2018 at 1:48 p.m., with Dietary Manager 21 she indicated she was not sure Resident B was at evening meal on 7/8/2018. She indicated if a resident was not at the meal his floor nurse would have been contacted and a search for the resident should have occurred. During an interview on 7/11/2018 at 1:52 p.m., with Dietary Manager 22, she indicated she was not sure Resident B was at evening meal on 7/8/2018. She indicated if a resident was not at the meal his floor nurse would have been contacted and a search for the resident should have occurred. During an interview on 7/13/2018 at 2:02 p.m., with the Dietician, she indicated if a resident was not present at the evening meal his floor was contacted to find out why he was missing and what type of meal he preferred. If the resident could not be found the missing resident protocol would be started to locate the resident. A dietary consumption record was reviewed for Resident B on 7/12/2018. The record indicated the resident did not consume any food for the evening meal on 7/8/2018. During an interview on 7/11/2018 at 1:30 p.m., with the DON, she indicated the last time any one saw Resident B was in the hallway on the second floor at 6:00 p.m., near the elevator waiting for assistance to enter for the trip to the first floor for the evening meal. She indicated it was unknown whether the resident had eaten his evening meal. She indicated the resident was found on the first floor when the elevator door was opened by the fire department. She indicated if the resident had not received his evening meal the kitchen staff should have called the floor nurse to advise what to do regarding the resident's meal and if he could not be found a search for the resident should have occurred. During an interview with the Administrator on 7/10/18 at 12:10 p.m., he indicated there was no policy related to transporting residents in the elevator. He indicated staff continued to be unsuccessful in their attempts to contact the CNA believed to have assisted Resident B into the elevator on 7/8/18. A current policy and procedure titled, Elopement Prevention and Response Program, dated 10/2017, provided by the Director of Nursing on 7/12/2018 at 12:30 p.m., indicated, .e. each charge nurse coordinates a search of their assigned area including resident rooms, restrooms, closets, shower rooms, hallways, offices, service areas like kitchen, laundry,etc . The immediate jeopardy that began on 7/8/18 was removed on 7/11/18 when the facility provided the following: in-servicing education to staff related to providing supervision of residents to prevent accidents including on elevators, an elevator repair company serviced the elevator and ensured the elevator was working, and staff were inserviced to call maintenance and/or the ED immediately if the elevator was not working. The noncompliance remained at the lower scope and severity level of no actual harm with the potential for more than minimal harm that is not immediate jeopardy because of the facility's need for continued monitoring. This Federal tag relates to Complaints IN 783 and IN 549. 3.1-45(a)(2)

Based on interviews and record review, the facility failed to investigate the alleged injury of unknown origin for 1 of 1 residents reviewed for injury of unknown origin. Resident F was observed to have a large bruise located on her chest and the investigation into the resident's injury was not started immediately after the allegation was made by staff to the supervising nurse. (Resident F) Findings include: During record review, on 7/10/2018 at 3:00 p.m., Resident F's [DIAGNOSES REDACTED]. A nursing note, on 6/21/2018 at 6:06 p.m., indicated the resident had complained of right knee pain after the evening. Routine pain medication for the resident was given for pain. A physician's orders [REDACTED]. A nursing note, on 6/22/2018 at 7:09 a.m., indicated the resident's x-ray noted a fracture and an order was obtained to send the resident to the hospital. The family was notified. A hospital note, on 6/22/2018 at 7:35 a.m., indicated the resident had a fracture to the distal femur and she had some bruises on her body of unknown origin, including a bruise on her chest. An investigation note, dated 6/25/2018, from Certified Nursing Aide (CNA) 26, indicated she observed on 6/19/2018, the resident had a bruise located on her chest. She reported the observation to Qualified Medication Aide (QMA) 24. An investigation note, dated 6/22/2018, from QMA 24 indicated she observed on 6/19/2018, the resident had a bruise located on her chest. She indicated she reported her observation to Licensed Practical Nurse (LPN) 20. An investigation note, dated 6/22/2018, from LPN 19, indicated she observed on 6/21/2018, the resident had a bruise located on her chest. She indicated she was given report from LPN 20 who indicated the resident had a bruise on her chest, pain in her right knee and an x-ray had been ordered for the resident. During an interview, on 7/12/2018 at 1:25 p.m., CNA 26 indicated she had observed on 6/19/218 the resident had a bruise on her chest and she reported the bruise to QMA 24. Together she and QMA 24 reported the bruising to LPN 20. During an interview on 7/12/2018 at 2:10 p.m., QMA 24 indicated she had observed on 6/19/218 the resident had a bruise on her chest and she reported the bruise with CNA 26 to the nurse in charge, LPN 20. During an interview on 7/12/2018 at 3:25 p.m., LPN 19 indicated she had observed on 6/21/2018 the resident had a bruise on her chest. She indicated she was given report from LPN 20 who indicated the resident had a bruise on her chest, pain in her right knee and an x-ray had been ordered for the resident. During an interview on 7/12/2018 at 3:25 p.m., LPN 20 indicated she was not aware of any bruising for the resident. She indicated she was not told by CNA 26 or QMA 24 that the resident had a bruise on her chest. She indicated she did not remember reporting to LPN 19 the bruise on Resident F's chest on 6/21/2018. She did remember reporting the resident was scheduled for an x-ray and she had right knee pain. During an interview on 7/9/2018 at 2:50 p.m., LPN 9, she indicated an incident report was completed for the resident for injury of unknown origin on 6/22/2018. The hospital had reported the resident had a fractured right knee and bruising. The resident had not had a recent fall or bruise noted in the nursing notes. She indicated she was not aware of the bruise until the hospital called the facility with the report. She indicated a report should have been started immediately if the resident had an injury of unknown origin, and the investigation was started on 6/22/2018. The progress notes for Resident F were reviewed and no bruise or fall was noted in the notes from 6/11/2018 through 6/21/2018. The resident shower sheets for 6/14, 6/18, and 6/21/2018 were reviewed and did not indicate any bruises on the resident. A skin assessment summary, dated 6/17/2018, was reviewed and indicated Resident F did not have any bruising. During an interview on 7/9/2018 at 3:30 p.m., with the Director of Nursing, she indicated she was not aware Resident F had any bruising until the hospital report was reviewed. She indicated the Coroner had requested a copy of the nursing notes for Resident F. An investigation had been conducted 6/22/2018 by the administration into the injury of unknown origin for Resident F and no staff member knew about a fall or how the resident obtained any bruising. During an interview on 7/11/2018 at 3:32 p.m., with the Coroner, he indicated he was investigating the death of Resident F in the hospital. He indicated the resident had a fracture to her right knee and chest bruising. He indicated the orthopedic surgeon at the hospital was concerned the resident's fracture was from a fall or a [MEDICATION NAME] force trauma and the facility indicated they were not aware of a fall or any trauma involving the resident. The facility was not aware of any resident bruising and the resident had a large bruise located on her chest. He indicated he had asked the facility for resident records. The current facility policy titled, ABUSE, PROHIBITION, REPORTING, AND INVESTIGATION, revised 11/2016, received from the Executive Director on 7/13/2018 at 2:35 p.m., indicated, .Injuries of unknown source . 2. marks or bruising .PR[NAME]EDURE reporting within 24 hours of occurrence .1. an incident must be reported within 24 hours after discovery of the incident This Federal tag relates to Complaint IN 355 3.1-28(c)

Based on interview and record review, the facility failed to implement physician orders [REDACTED]. The resident had a weight gain of 17 pounds in 20 days with no notification to the physician and developed difficulty breathing due to fluid volume overload. Findings include: The record for Resident 110 was reviewed on 6/6/18 at 3:35 p.m. [DIAGNOSES REDACTED]. The resident was hospitalized from [DATE] through 3/5/18 with [DIAGNOSES REDACTED]. A Hospital History and Physical report, dated 3/3/18, indicated Resident 110 had an 18 pound weight gain in a 13 day time span according to intermittent weights provided by the facility and should have been on a daily weight protocol due to her [DIAGNOSES REDACTED]. A hospital discharge report, dated 3/5/18, indicated .Additional Discharge Instructions: [MEDICAL CONDITION] .Weigh every day using the same scale at the same time, if weight changes suddenly, Call your Health Care Provider The facility provided weights for Resident 110 for the following dates: a. On 3/5/18, the resident's weight was 113 pounds. b. On 3/14/18, the resident's weight was 95 pounds. c. On 3/19/18, the resident's weight was 102 pounds. d. On 3/28/18 , the resident's weight was 110 pounds. e. On 4/3/18, the resident's weight was 112 pounds. f. On 4/10/18, the resident's weight was 112 pounds. The resident had a 7 pound weight gain between 3/14/18 and 3/19/18. The resident had a 15 pound weight gain between 3/14/18 and 3/28/18. The resident had a 17 pound weight gain between 3/14/18 and 4/3/18. A quarterly Registered Dietician (RD) note, dated 4/12/18 at 4:49 p.m., indicated the resident had a significant weight gain and had fluctuating [MEDICAL CONDITION]. The facility did not provide documentation of the physician being notified of the weight gains which occurred on 3/19/18, 3/28/18 and 4/3/18. A progress note, dated 4/15/18 at 1:10 a.m., indicated the resident was having trouble breathing and said she couldn't catch her breath. A progress note, dated 4/15/18 at 1:30 a.m., indicated the ambulance was called to transport the resident to the emergency room . The resident was hospitalized from [DATE] through 4/24/18 with [DIAGNOSES REDACTED]. During an interview, on 6/11/18 at 11:19 a.m., the Unit Manager indicated if there was a hospital discharge order for daily weights then the resident should have had weights completed daily. During an interview, on 6/11/18 at 11:45 a.m., the DON indicated the facility had an admission nurse to look at the hospital discharge instructions and process the orders and then the Medical Records staff should do a double check of the discharge orders. A current facility policy titled Resident Change of Condition revised on 1/2015 and received from the DON on 6/12/18 at 11:50 a.m., indicated . It is the policy of this facility that all changes in resident condition will be communicated to the physician and family/responsible party, and that appropriate, timely, and effective intervention takes place .All symptoms and unusual signs will be documented in the medical record and communicated to the attending physician promptly A current policy titled Nursing Admission/Return Admission Procedure reviewed on 11/17 and received from the DON on 6/12/18 at 11:32 a.m., indicated .Transcribe the admission orders [REDACTED].Transcribe treatment orders to include the specific areas to be treated, frequency, dosage, and reason needed 3.1-37(a)

Based on interview and record review, the facility failed to ensure a resident's Physician was notified of a critical [MEDICATION NAME] (a medication used to heart conditions) level in a timely manner to prevent further doses from being administered for 1 of 2 residents being reviewed for significant medication errors (Resident G). This deficient practice resulted in Resident G being administered her same continued doses of [MEDICATION NAME] when she had a critical [MEDICATION NAME] level, resulting in her being admitted to the hospital with [REDACTED]. The toxicity was a type of poisoning that occurred when a person took too much of the medication [MEDICATION NAME]). Findings Include: 1. An Intake Information sheet was opened on 3/8/18 at 9:47 a.m., the report indicated an anonymous person sent a concern to the ISDH (Indiana State Department of Health) office, which indicated Resident G was sent to the ER in (MONTH) (YEAR), for [MEDICATION NAME] toxicity ([MEDICATION NAME] was a medication used to treat heart failure or an irregular heart beat known as [MEDICAL CONDITION]. The toxicity was a type of poisoning that occurred when a person took too much of the medication [MEDICATION NAME]). The report indicated Resident G was given the same ordered doses of [MEDICATION NAME] even though her [MEDICATION NAME] laboratory report indicated she had a critical level. QMA 1 administered a [MEDICATION NAME] dose to Resident G even though her pulse rate indicated it should have been held. The record review for Resident G was completed on 3/23/18 at 3:40 p.m. [DIAGNOSES REDACTED]. The resident's Electronic Medication Administration Record [REDACTED] 7/8/18--[MEDICATION NAME] 250 mcg (micrograms) orally twice a day. Hold for heart rate less than 60 or SBP (Systolic Blood Pressure) less than 100. (Order was discontinued on 7/14/17). 7/11/18--BMP, CBC, [MEDICATION NAME], Lipid Profile once 7/14/18--[MEDICATION NAME] 125 mcg daily on Monday, Wednesday and Friday (Name of Laboratory) result for Resident G's [MEDICATION NAME] level dated 7/11/17 at 11:22 a.m., indicated the result was 2.6 ng/ml (nanograms per millilitre) (Critically high) Normal--0.9 to 2.0 ng/ml. ***Critical Result Called to Nurse was circled with a pen and handwritten inside another circle was (Initials of QMA 1 11:23 am 7/11 Towards the bottom of the page was a handwritten note with the words faxed 7/13. Resident G's EMAR dated (MONTH) (YEAR), indicated the following: On 7/10/17 at 7:00 a.m. to 11:00 a.m., LPN 2 administered the resident's [MEDICATION NAME] 250 mcg with a SBP ( Systolic Blood Pressure) of 98/58 and a Pulse rate of 64 when it should have been held for a SBP of <100. On 7/13/17 at 7:00 a.m. to 11:00 a.m., QMA 1 administered the resident's [MEDICATION NAME] with a pulse rate of 55 and SBP of 90/60, when it should have been held for a pulse rate under 60 and a SBP less than 100. The resident continued to receive 250 mcg of [MEDICATION NAME] twice a day on these dates and times with a [MEDICATION NAME] level of 2.6 ng/ml: 7/11/17 at 4:00 p.m. to 9:00 p.m. 7/12/17 at 7:00 a.m. to 11:00 p.m. 7/13/17 at 7:00 a.m. to 11:00 a.m. 7/13/17 at 4:00 a.m. to 9:00 p.m. 7/14/17 at 7:00 a.m. to 11:00 a.m. The resident's 250 mcg was not discontinued on 7/14/17 as ordered and the 125 mcg was not started on 7/14/17 as ordered. Resident G's record lacked documentation to indicate the Physician had been called in regards to the elevated [MEDICATION NAME] level or that he had made medication adjustments as a new order timely. A progress note dated 7/14/17 at 3:11 p.m., indicated PCAT (Personal Care Ambulance Transport) contacted writer on way back from [MEDICAL TREATMENT] and stated that they were transferring resident to ER (emergency room ) for eval. They said BP was 85/48 pulse was 35 and had res on 4 L (liters) of O2 (oxygen) A progress note dated 7/14/17 at 7:51 p.m., indicated Res (resident) is being admitted to hosp (hospital) .Dx: (diagnosis) [MEDICATION NAME] toxicity. An ER Physician Exam from (Name of Hospital) dated 7/14/17, indicated the resident was admitted to the hospital for [MEDICATION NAME] toxicity (Poisoning by cardiac-stimulant glycosides and drugs of similar action, accidental (unintentional), initial encounter, Onset Date: (MONTH) 14, (YEAR). The ER Diagnosis: [REDACTED]. History and Physical from (Name of Hospital) dated 7/14/17, she was admitted to the hospital from [MEDICAL TREATMENT] that day after being found drowsy and bradycardic in the 30's with a low BP. She was admitted to the ICU (Intensive Care Unit) and received digibind (a medication used to treat [MEDICATION NAME] toxicity). Discharge Summary from (Name of Hospital) dated 7/21/17, indicated discharge [DIAGNOSES REDACTED]. She had a [MEDICATION NAME] level greater than 4.0 ng/ml (0.8-2.0 ng/ml was normal). She required 10 vials of Digibind and she had been on [MEDICAL TREATMENT], but there was a very slo (sic) removal with that. Her [MEDICATION NAME] level came back at 0.6 ng/ml after treatment. She was in a controlled heart rate for five days. A written statement signed by LPN 3 dated 3/26/18, indicated On (MONTH) 11th and 12th I was out sick from work. On (MONTH) 13th noted fax in MDS (Minimum Data Set) file folder and faxed to office verbally spoke with MD (Name of Physician 6) on 14th of July. Lab was contacted to determine who received notification of lab which was (Name of QMA 4). (Name of QMA 4) stated she notified nurse (Name of LPN 5) of lab on phone. (Name of LPN 5)stated by the time she got to call lab had hung up and she did not call back. Upon speaking with (Name of Physician 6) verbal order obtained to cut [MEDICATION NAME] dose in half. (Name of Physician 6) stated dig ([MEDICATION NAME]) would be pulled off in [MEDICAL TREATMENT]. A written statement signed by LPN 5 undated, indicated On (MONTH) 11th AM the lab called Willow nursing station, (Name of QMA 4) answered. I heard (Name of QMA 4) say I can't talk to you, I'll get a nurse. She asked me to take the call. When I picked up the phone, they were gone. I was busy, so I did not call back. I did not receive any lab work off the fax machine. A written statement signed by (Name of QMA 4) dated 7/18/17, indicated on Tues. the 11th of (MONTH) Lab called I explain to them that I can not take the call because I am not qualified, would they please hold. The nurse was at the desk and she was going to take call (Name of LPN 5) when she went to pick up phone it was disconnected . She was waiting for the call to return call back. I don't' know if they did or not I went to lunch or downstairs, I know I did leave from desk at that time. An Employee Coaching & Counseling form dated 7/19/17, indicated LPN 3 on 7/13/17, violated the critical lab policy. When a critical lab is faxed to facility from lab you must call it to MD. Unacceptable to fax it. An Employee Coaching & Counseling form dated 7/19/17, indicated LPN 5 violated the critical lab policy. When lab calls you and they hang up before you answer, the phone, call them back to see what they were calling to report. An Employee Coaching & Counseling form dated 7/19/17, indicated QMA 4 violated the critical lab policy. When lab calls et (and) you are working the hall, please find out the reason they are calling and tell the nurse. If nurse had been notified of a critical lab she could have called lab back et could have been expecting paper copy so MD could be called with result. A current policy titled Resident Change of Condition dated 8/1998 with a most recent revision date 1/2015, provided by the DNS on 3/23/18 at 12:18 p.m., contained the following, Policy: It is the policy of this facility that all changes in resident condition will be communicated to the physician and family/responsible party, and that appropriate, timely and effective interventions takes place. Procedure: 2. Acute Medical Change: a. Any sudden or serious change in a resident's condition manifested by a marked change in physical or mental behavior will be communicated to the physician. b. If unable to contact the attending physician or alternate physician in a timely manner, notify the Medical Director for medical intervention. c. The responsible party will be notified that there has been a change in the resident's condition and what steps are being taken. d. All nursing actions/interventions will be documented in the medical record as soon as possible after resident needs have been met. This Federal tag relates to Complaint IN 147. 3.1-25(b)(9)

Based on interview and record review, the facility failed to implement weight loss interventions for significant weight loss for 2 of 4 residents being reviewed for significant weight loss (Residents L and O). Resident L lost 32 pounds or 13.1% weight loss in 90 days and Resident O lost 63 pounds or 20.9 % of his weight loss in 90 days, which was a significant weight loss (Resident L and O). Findings include: 1. During an interview on 3/22/18 at 12:49 p.m., the Registered Dietician (RD), indicated Resident L was recently in the hospital. He was more of a nursing issue as far as his weight loss went because he had a back device placed and had a general decline after the device was placed and they would know more about that than she would. She indicated there did not appear to have been interventions in place now or during the time when he was losing the significant amount of weight. He was on Nutrition at Risk (NAR) until he was admitted to the hospital. NAR is every week and she attended the NAR meetings. The RD indicated fortified foods could have been prescribed if the NAR team felt it was warranted. He lost 32 pounds or 13.9% of his weight in 90 days. The RD indicated she could have also offered ensure, whole milk every meal, ice cream, yogurt or cottage cheese at every meal to increase his weight if it was warranted. They try to do a food first approach by talking to the resident and offering that food more often to them. Resident L's weight fluctuated quite a bit, so the team were watching his weights, but did not feel he needed an intervention. The RD indicated he started out at 248 pounds on 12/19/17 and weighed 199 pounds on 3/14/18. She liberalized his diet in (MONTH) 4, (YEAR). He was on a 2 gram NA (sodium) diet and she changed him to a regular no added salt diet because that diet had more choices and possibly because he did not want the sodium restricted diet since it was prior to the weight loss. The record review was completed for Resident L on 3/23/18 at 3:00 p.m. [DIAGNOSES REDACTED]. The resident's weights were as follows: 12/27/17-238 1/3/18-236 1/9/18-238 1/16/18-231 1/23/18-229 1/29/18-201 2/21/18-215 3/9/18-212 3/14/18-199 The resident's food consumptions were between 50-100%. There were no weight loss interventions implemented. On 3/23/18 at 7:50 p.m., the resident refused his tray. He requested ice cream to eat. 2. During an interview on 3/22/18 at 1:24 p.m., the RD indicated Resident O had a 63 pound or 20.9 % weight loss in 90 days. She indicated the resident was followed in NAR. She indicated on 12/19/17 he weighed 302 pounds and on 3/5/18 he weight 239.0 pounds. He was on diuretic therapy, but any questions regarding his weight loss because of the diuretics would need to be addressed with the nursing department. She met with him on 2/23/18, and he refused all interventions. She liberalized his diet on that date from a carb consistent and 2 gram sodium and changed to a regular with no added salt diet, which added more calories and he would have more choices. On 2/28/16, he weighed 239.0 and had lost 63 pounds or 20.9% weight loss. She indicated this was the peak of his weight loss and short of going through all the NAR notes she did not know what interventions if any were tried before the 2/28/18. The record review for Resident O was reviewed on 3/23/18 at 3:25 p.m. [DIAGNOSES REDACTED]. The resident's weights were as follows: 12/5/17-302 12/12/17-304 12/19/17-302 12/26/17-302 1/2/18-303 1/9/18-231 1/11/18-270 1/18/18-251 1/23/18-238 1/29/18-221 1/31/18-229 2/16/18-235 2/27/18-230 2/28/18-239 3/5/18-239 3/13/18-235 The resident's food consumption's were 50-100%. There was no known weight loss interventions implemented On 3/23/18 at 7:55 p.m., the resident had eaten all his dinner off his tray and he was getting a snack. This Federal tag relates to Complaint IN 570. 3.1-46(a)(1)

Based on interview and record review, the facility failed to ensure a resident's Physician was notified of a critical [MEDICATION NAME] level result in a timely manner and failed to ensure a family member was notified the resident was sent to the ER (emergency room ) after a change of condition for 2 of 3 residents reviewed for notification of change (Resident G and C). Resident G was admitted to the hospital, as a result of the critical [MEDICATION NAME] level not being called to the resident's Physician in a timely manner in order to receive treatment to decrease the [MEDICATION NAME] level and prevent [MEDICATION NAME] toxicity Findings include: 1. An Intake Information sheet was opened on 3/8/18 at 9:47 a.m., the report indicated an anonymous person sent a concern to the ISDH (Indiana State Department of Health) office, which indicated Resident G was sent to the ER in (MONTH) (YEAR), for [MEDICATION NAME] toxicity ([MEDICATION NAME] was a medication used to treat heart failure or an irregular heart beat known as [MEDICAL CONDITION]. The toxicity was a type of poisoning that occurred when a person took too much of the medication [MEDICATION NAME]). The record review for Resident G was completed on 3/23/18 at 3:40 p.m. [DIAGNOSES REDACTED]. The resident's Electronic Medication Administration Record [REDACTED] 7/8/18--[MEDICATION NAME] 250 mcg (micrograms) orally twice a day. Hold for heart rate less than 60 or SBP (Systolic Blood Pressure) less than 100. (Order was discontinued on 7/14/17). 7/11/18--BMP, CBC, [MEDICATION NAME], Lipid Profile once (Name of Laboratory) result for Resident G's [MEDICATION NAME] dated 7/11/17 at 11:22 a.m., indicated the result was 2.6 ng/ml (nanograms per milliliter) (Critically high) Normal--0.9 to 2.0 ng/ml. ***Critical Result Called to Nurse was circled with a pen and handwritten inside another circle with a handwritten note (QMA 4's initials) 11:23 am 7/11 Towards the bottom of the page was a handwritten note with the words faxed 7/13. Resident G's record lacked documentation to indicate the Physician had been notified in regards to the elevated [MEDICATION NAME] level in a timely manner. A progress note dated 7/14/17 at 3:11 p.m., indicated PCAT (Personal Care Ambulance Transport) contacted writer on way back from [MEDICAL TREATMENT] and stated that they were transferring resident to ER (emergency room ) for eval. They said BP (blood pressure) was 85/48 pulse was 35 and had res on 4 L (liters) of O2 (oxygen) A progress note dated 7/14/17 at 7:51 p.m., indicated Res (resident) is being admitted to hosp .Dx: (diagnosis) [MEDICATION NAME] toxicity. An ER Physician Exam from (Name of Hospital) dated 7/14/17, indicated the resident was admitted to the hospital for [MEDICATION NAME] toxicity (Poisoning by cardiac-stimulant glycosides and drugs of similar action, accidental (unintentional), initial encounter, Onset Date: (MONTH) 14, (YEAR). The ER Diagnosis: [REDACTED]. History and Physical from (Name of Hospital) dated 7/14/17, indicated on her last admission she was loaded with 250 mcg [MEDICATION NAME] for 4 doses, one time only during the last hospital course, then later she was discharged on the [MEDICATION NAME] dose 250 mcg twice a day, which she had been taking since 7/2/17. She presented to theER on [DATE], with weakness and a fall, which resulted in a hematoma on the left side of her face and head. The CT (Computed Tomography) scan to her head was negative. She was admitted to the hospital from [MEDICAL TREATMENT] that day after being found drowsy and bradycardic in 30's with a low BP. She was admitted to the ICU (Intensive Care Unit) and received digibind (a medication used to treat [MEDICATION NAME] toxicity). Discharge Summary from (Name of Hospital) dated 7/21/17, indicated the discharge [DIAGNOSES REDACTED]. She had a [MEDICATION NAME] level greater than 4.0 ng/ml (0.8-2.0 ng/ml was normal) upon admission to the hospital. She required 10 vials of Digibind and she had been on [MEDICAL TREATMENT], but there was a very slo (sic) removal with that. Her [MEDICATION NAME] level came back at 0.6 ng/ml after treatment. She was in a controlled heart rate for five days. A written statement signed by LPN 3 dated 3/26/18, indicated On (MONTH) 11th and 12th I was out sick from work. On (MONTH) 13th noted fax in MDS (Minimum Data Set) file folder and faxed to office verbally spoke with MD (Name of Physician 6) on 14th of July. Lab was contacted to determine who received notification of lab which was (Name of QMA 4). (Name of QMA 4) stated she notified nurse (Name of LPN 5) of lab on phone. (Name of LPN 5)stated by the time she got to call lab had hung up and she did not call back. Upon speaking with (Name of Physician 6) verbal order obtained to cut [MEDICATION NAME] dose in half. (Name of Physician 6) stated dig ([MEDICATION NAME]) would be pulled off in [MEDICAL TREATMENT]. A written statement signed by LPN 5 undated, indicated On (MONTH) 11th AM the lab called Willow nursing station, (Name of QMA 4) answered. I heard (Name of QMA 4) say 'I can't talk to you, I'll get a nurse.' She asked me to take the call. When I picked up the phone, they were gone. I was busy, so I did not call back. I did not receive any lab work off the fax machine. A written statement signed by (Name of QMA 4) dated 7/18/17, indicated on Tues. the 11th of (MONTH) Lab called I explain to them that I can not take the call because I am not qualified, would they please hold. The nurse was at the desk and she was going to take call (Name of LPN 5) when she went to pick up phone it was disconnected . She was waiting for the call to return call back. I don't know if they did or not I went to lunch or downstairs, I know I did leave from desk at that time. An Employee Coaching & Counseling form dated 7/19/17, indicated LPN 3 on 7/13/17, violated the critical lab policy. When a critical lab is faxed to facility from lab you must call it to MD. Unacceptable to fax it. An Employee Coaching & Counseling form dated 7/19/17, indicated LPN 5 violated the critical lab policy. When lat calls you and they hang up before you answer, the phone, call them back to see what they were calling to report. An Employee Coaching & Counseling form dated 7/19/17, indicated QMA 4 violated the critical lab policy. When lab calls et (and) you are working the hall, please find out the reason they are calling and tell the nurse. If nurse had been notified of a critical lab she could have called lab back et could have been expecting paper copy so MD could be called with result. 2. The record review for Resident C was completed on 3/23/18 at 3:13 p.m. [DIAGNOSES REDACTED]. A progress note dated 1/11/18 at 7:39 a.m., indicated Writer received report on resident stated resident increased confusion, [MEDICAL CONDITION] in bilat (bilateral) hands +4 [MEDICAL CONDITION] in left hand, lung sounds; rales/diminished throughout. Pt (patient) has hx (history) of [MEDICAL CONDITIONS]. Writer received in report that MD on call/(Name of Physician 6) called at approx (approximately) 0430 (4:30 a.m.) .at time of report MD had not responded. MD responded at approx 0645 (6:45 a.m.) with order to send to ER for eval and treat. Daughter called and notified/stated on her way to meet at (Name of Hospital) requested . 911 called and transported to (Name of Hospital). Resident C's record lacked documentation indicating Physician 6 was called again or the Medical Director was called in regards to the resident's change of condition and in an attempt to get her sent to ER sooner. During an interview on 3/23/18 at 5:03 p.m., the Director of Nursing Services indicated if the Physician could not be reached, than the nurse should have sent the resident to the hospital by 911 and got the order when the Physician called the facility or called the Medical Director and obtained the order to send the resident to the ER. A current policy titled Resident Change of Condition dated 8/1998 with a most recent revision date 1/2015, provided by the DNS on 3/23/18 at 12:18 p.m., contained the following, Policy: It is the policy of this facility that all changes in resident condition will be communicated to the physician and family/responsible party, and that appropriate, timely and effective interventions takes place. Procedure: 2. Acute Medical Change: a. Any sudden or serious change in a resident's condition manifested by a marked change in physical or mental behavior will be communicated to the physician. b. If unable to contact the attending physician or alternate physician in a timely manner, notify the Medical Director for medical intervention. c. The responsible party will be notified that there has been a change in the resident's condition and what steps are being taken. d. All nursing actions/interventions will be documented in the medical record as soon as possible after resident needs have been met. This Federal tag relates to Complaint IN 035. This Federal tag relates to Complaint IN 147. 3.1-5(a)(2) 3.1-5(a)(3)

Based on observation, record review and interview, the facility failed ensure residents were manually transferred safely by using a gait belt for 2 of 4 residents reviewed for accidents. (Resident K and Resident D) Resident K was transferred without the use of a gait belt and fell resulting in a fracture to her femur. Findings include: During record review on 1/5/2017 at 10:35 p.m., Resident K's [DIAGNOSES REDACTED]. A fall report, dated 12/3/16, indicated resident had a fall in her bathroom. The resident was being toileted by CNA# 12 and the resident fell to floor. The resident was assisted back to her chair per staff and she complained of knee pain. An incident report on 12/7/2016, reported to the State indicated the resident had a fall on 12/2/2016 which resulted in a fracture to her femur. An employee coaching and counseling report on 12/2/2016 indicated CNA#12 did not use a gait belt when transferring the resident when she fell and broke her femur. A care plan dated 11/18/2010 and updated on 10/5/2012, indicated resident was a one person assist with transfers, bathing, dressing and toileting. A care plan dated 11/18/2010 for risk of falling indicated, assist with transfers. 2. During an observation on 1/4/2017 at 2:31 p.m., CNA# 12 was observed to assist Resident D in her room and to transfer her to her bed without using a gait belt. During record review on 1/4/2017 at 3:00 p.m., Resident D's [DIAGNOSES REDACTED]. A Plan of care dated 11/21/16 indicated a problem of At risk for falls related to history of falls . with approaches that indicated assist resident with ambulation and locomotion as needed. Fall events indicated the resident had fallen on 11/19/16 (rolled out of bed) and 1/3/17 (found on the floor). During an interview on 1/4/2017 at 2:40 p.m., with CNA# 12, she indicated she had not used a gait belt because she could not find one and she did not know the residents on the floor needed a gait belt for ambulation and transfers. During an interview on 1/4/2017 at 2:51 p.m., with LPN# 13, she indicated all staff should use a gait belt when transferring any resident. During an interview on 1/4/2017 at 2:51 p.m., with LPN# 14, she indicated all staff should use a gait belt when transferring or ambulating any resident. During an interview on 1/4/2017 at 3:20 p.m., with CNA# 21, she indicated all staff should use a gait belt when transferring any resident. During an interview on 1/4/2017 at 3:22 p.m., with CNA# 22, she indicated all staff should use a gait belt when transferring any resident. During an interview on 1/5/2017 at 1:30 p.m., with CNA# 23, she indicated all staff should use a gait belt when transferring any resident. The current facility policy, AMBULATION WITH CANE, WALKER OR CRUTCHES, dated 4/2012, received from the Director of Nursing on 1/5/2017 at 11:00 a.m., indicated .8. Grasp the gait belt while assisting the resident to stand The current facility policy, TRANSFER TO WHEELCHAIR, dated 4/2012, received from the Director of Nursing on 1/5/2017 at 11:00 a.m., indicated .11. Place gait belt around resident's waist This Federal tag relates to Complaint IN 962 3.1-45(a)(2)

Based on observation, interview and record review, the facility failed to place wound interventions in a timely manner to prevent a resident from getting a new Deep Tissue Injury (DTI) for 1 of 2 residents reviewed for pressure ulcers. (Resident #E) The facility also failed to use proper infection control technique while changing a resident's wound dressing for 1 of 1 residents observed for wound dressing change. (Resident #49) Finding includes: 1. The record review for Resident #49 was completed on 2/17/16 at 1:05 p.m. [DIAGNOSES REDACTED]. The progress notes indicated: *9/08/15 at 5:22 p.m.: The resident returned to the facility via ambulance from the hospital with two Emergency Medical Technician's and his wife at 4:47 p.m. Orientation and initial examination completed. The resident was alert and oriented X 3 with some forgetfulness. The resident had a Foley catheter in place for retention. He was on a low sodium diet and took his medications crushed in applesauce due to them not being absorbed properly. *9/10/15 at 4:53 p.m.: The resident was admitted to the facility with a reddened buttocks and noted to be deep tissue injury (DTI, Purple or maroon localized area of discoloration intct skin or blood filled blister due to damage of underlying soft tissue from pressure and shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as complared to adjacent tissues.) today to his buttock and his coccyx. There was small amount of bleeding from the center which was open. He had a DTI to his coccyx. The resident had history of [MEDICAL CONDITION] and recent [MEDICAL CONDITION] with surgical repair and surgical incision in the last stage of healing. He was on a facility pressure reducing mattress and would be changed to alternating air. He was sluggish to respond. The resident was on 2 gm Na+ (2 gram sodium) with vitamin daily. He was currently being treated for [REDACTED]. New treatment orders were noted. The resident events documentation indicated: New Skin Event *9/8/15- indicated the wound area was present on admission. Bilateral buttocks wound measurements indicated reddenedand indicated treatment was Veraseptine(a skin protection ointment ). Nurse Practitioner was notified and treatment was ordered. This was documented as completed by the Admissions Nurse. The Wound Nurse documented the rest of the pressure skin events: *9/10/16 at 5:08 p.m., indicated, .found on 9/10/16 suspected deep tissue injury to left buttock measuring 6.0 centimeters (cm) x 3.5 cm x 0.1 cm, was unstagable, purple in color and there was a scant amount of bleeding observed. The treatment order was current orders . *9/10/15 at 5:09 p.m., indicated, . found on 9/10/15, suspected deep tissue injury to the coccyx area. The area was unstagable and measured 2.0 cm x 2.5 cm x 0.1 cm . *9/15/15 indicated, . found on 9/10/16, a suspected deep tissue injury to coccyx area and was an unstagable area. The area measured 2.0 cm x 2.3 cm x 0.1 cm . *9/16/15 indicated, . right buttock, found on 9/16/15 as deep tissue injury and the area measured 6.5 cm x 1.5 cm x 0.1 cm . *9/22/15 indicated, . the coccyx wound measured 0.7cm x 0.3 cm x 0.1 cm and was red with pink surrounding edges . *9/22/15 the left buttock was a DTI and measured 4.5 cm x 3.0 cm x 0.1 cm and the wound was described as yellow in color with a scant amount of serosanginous serous fluid with blood) drainage . *9/29/15 indicated, . coccyx area that was a suspected DTI was now closed x 1. The left buttock was a suspected DTI and measured 3.0 cm x 1.7 cm x 0.1 cm and was yellow in color and a small amount of serosanginous drainage. The origin of the wound was 9/16/15. The right buttock wound that was a suspected DTI, was now closed x 1 . *10/6/15 indicated, . The left buttock area was a Stage III with yellow slough and measured 2.2 cm x 1.0 cm x 0.1cm, was yellow in color and had scant amount of serosanginous drainage and surrounding tissue was pink in color The Care Plan for skin dated, 9/11/15, indicated: Turn and Reposition every 2 hours, Treatment as ordered, Pressure reducing cushion or Low Air Loss mattress, Pressure reduction cushion in wheelchair, Incontinent care as needed, Moisture Barrier at bedside as needed, Encourage resident eat at least 75% (percent) of meal, Assess and document skin condition weekly and as needed. Notify MD of abnormal findings The Care Plan for skin indicated, on 9/28/15, a roho cushion was added to the interventions. During an interview on 2/18/16 at 10:04 a.m., the Wound Nurse indicated the resident assessment upon admission was incorrect and that LPN #7 had assessed incompletely and incorrectly. She indicated that it was more deep tissue injury. She indicated the Veraseptine, standard pressure reducing cushion for wheelchair and bed were in place. She indicated the Low Air Loss Mattress (LAL) had been in place on 9/10/15. She indicated the turning and repositioning was done for everyone and was documented in the progress notes. The wound nurse indicated the resident was a heavy gentlemen and that he was dead weight and did not move a lot when he first got here. She confirmed that the resident had new DTI wound on left buttock on 9/16/15. The progress notes were reviewed from 9/10/16 through 9/16/16 and the documentation indicated the resident was turned every two hours on the following dates: 9/10/15 at 1:16 p.m. 9/16/16 at 3:16 p.m. 2. The record review for Resident #E was completed on 2/18/16 at 3:30 p.m., [DIAGNOSES REDACTED]. On 2/18/16 at 2:45 p.m., the Wound Nurse and CNA (Certified Nursing Assistant) #7 were present for a wound dressing change. The Wound Nurse indicated at that time that the resident had received the Stage III (Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed Slough may be present but does not obscure the depth of tissue loss.) from her TED hose ([MEDICAL CONDITION] - deterrent hose) and her Circaid compression hose ([MEDICAL CONDITION] hose) as the resident had severe [MEDICAL CONDITION] concerns over the last year. She also indicated the resident had a long history of lower extremity circulation concerns and had even had surgery to improve circulation in her lower legs. CNA #7 took off the resident's right Circaid compression hose and took off the resident's TED hose. CNA #7 then removed resident's dirty dressing. The resident's stasis wound appeared as a small oval shape, resembling a small peach pit. The inner wound bed had a pink beefy appearance with scant serous drainage on the dirty dressing. At that time the Wound Nurse went to wash her hands. CNA #7 had set the residents leg with open wound near the pillowcase surface/circaid hose that had been on the resident's leg. On 2/18/16 at 2:50 p.m., the Wound Nurse indicated CNA#7 should not have set the resident's leg down without the protective chuck pad underneath. The wound nurse indicated she had forgotten to put down the cotton chuck pad. At that time, CNA #7 raised the resident's leg and the wound nurse placed the cotton chuck pad underneath of the resident's right lower leg. CNA #7 placed the Circaid back onto the resident's lower right leg. The Wound Nurse at that time told CNA #7 she had to reposition the Circaid as it was not on correctly. CNA #7 at that time indicated she could not find the middle velcro strap when she put it on. The Wound Nurse and CNA #7 repositioned the Circaid device and restrapped the velcro enclosures for the resident's lower right extremity. On 2/18/16 at 2:57 p.m., during the dressing change of the right lower leg wound the resident was attempting to pull up her right leg as well as moaning on occasion. The resident was observed to have furrowed brows. The Wound Nurse indicated the resident had just recently, within the last few days, started displaying a furrowed brow and having pain with the wound dressing changes. At that time, the Wound Nurse was asked what she would do if a resident was displaying pain during a dressing change. She indicated she would stop and let them rest a bit, and then resume the dressing change. On 2/18/16 at 3:00 p.m., the Wound Nurse had started to remove the old dressing for the lower left leg pressure wound. The wound was the size of a quarter and was light pink in color. The Wound Nurse began rinsing the dressings that were stuck to the wound with Normal Saline, and pulled them away from the wound and the resident started moaning and her brows became more furrowed. The Wound Nurse and CNA#7 both asked the resident if she was hurting and she mumbled. CNA #7 indicated maybe she just needed to be talked to during the dressing change and that might help. The old dressing was completely removed, but at that time the resident was moaning more often. The Wound Nurse indicated at that time she was going to stop and get ahold of the physician and see about pain medication as the pain medication the resident had received earlier wasn't working. During an interview on 2/18/16 at 3:50 p.m., the Assistant Director of Nursing indicated she would have expected the nurse to have stopped right away if the resident was displaying signs of pain. The Skin Management Policy, dated 2/2015, was provided by the Director of Nursing Services, on 2/18/16 at 5:02 p.m., and indicated this was the policy currently used by the facility. The policy indicated .PROCEDURE: head to toe assessment will be completed by a licensed nurse upon admission/re-admission and weekly .The wound nurse (licensed nurse assigned responsibility for wounds the building or assigned unit) will be notified of alterations in skin integrity .will complete further evaluation of the wounds identified and complete the appropriate skin evaluation on the next business day This Federal tag relates to Complaint IN 129. 3.1-40(a)(1) 3.1-40(a)(2)

Based on record review, observation and interview, the facility failed to implement care planned transfer mode for 1 of 1 resident (Resident #196) resulting in a hospital transfer with a femur fracture, failed to revise current fall prevention interventions for 1 of 1 resident (Resident # 222) with a subsequent fall and hospital transfer with a hip fracture, and failed to perform a mechanical lift transfer in a safe manner to prevent the possibility of injury for 1 of 3 residents (Resident # 255) reviewed for accidents. Findings Include: 1. The record review for Resident #196 was completed on 2/18/15 at 1:30 p.m. Current [DIAGNOSES REDACTED]. Physician orders [REDACTED]." A plan of care dated 10/23/14 indicated the resident had a self care deficit, with approaches that included, but were not limited to, Hoyer lift and assist of two staff for transfers. A "Resident Profile" for Resident # 196 indicated the resident was a Hoyer transfer with 2 assist. Nursing progress notes indicated the following: 10/23/14: requires 2 person or Hoyer for transfer 10/25/14: total assist with transfers per Hoyer lift 11/2/14: Hoyer lift to transfer to wheelchair 11/11/14: Hoyer lift 11/19/14: extensive assist with transfers with Hoyer lift 12/1/14: Hoyer lift for all transfers 2/10 /15: total assist with transfers per Hoyer 2/11/15: Resident was sent out to the hospital due to a fall in the resident's room. Right lower extremity was bent at a 90 degree angle and she was in pain. An "Observation" form dated 2/11/15 indicated the resident was sent to the emergency room due to a fall with a Right lower extremity deformity. The form indicated the resident's usual mental status was "alert, disoriented, but cannot follow simple instructions," was non-ambulatory. A "Name of Hospital" emergency room report indicated the resident was dropped at the extended care facility while transferring from a wheelchair. Resident was having pain in right knee and lower thigh. A "Name of Hospital" X-ray report indicated the resident had a "...comminuted fracture of the distal femur...." On 02/20/2015 at 9:40 a.m., during interview, the DON indicated she was called at home the night of 2/11/15 regarding Resident # 196's accident with injury. She indicated a newly hired CNA who had completed her orientation was assigned to this resident. She indicated earlier in the shift the CNA had gotten the Resident up with the Hoyer. The DON provided a written statement dated 2/11/15 and signed by CNA # 20 that indicated the CNA was trying to get the resident to bed and the other 2 CNA's on the unit were busy and she could not find the Hoyer lift. The CNA indicated she lifted the resident to try to put her to bed and the resident fell to the floor. The DON indicated the CNA was instructed to clock out and go home and was subsequently terminated. An "Employee Communication Form" dated 2/13/15 indicated the CNA was terminated for transferring Resident # 196 manually by herself when the resident was a Hoyer transfer and the CNA dropped the resident resulting in a fracture of the right lower extremity. On 02/20/2015 at 11:00 a.m., during interview, CNA # 21 indicated her first day of training was with the Staff Development Coordinator (SDC). She indicated the SDC went through all the policies including transfers. She indicated the SDC showed her the lifts and how they were used. She also indicated she was trained on the computer system so she could retrieve the resident profiles that told how to take care of each resident. She indicated when she was oriented with the floor staff, she was shown more intensively how to use the lifts, gait belts and care for the residents. She indicated she had a good orientation. She also indicated CNA # 20 was in her orientation. During an interview with CNA # 23, she indicated the computer had resident profiles that indicated how each resident transferred. She also indicated there was a Activities of Daily Living book at the nursing station that could also be reviewed for care. 2. The record for Resident #222 was reviewed on 02/19/2015 at 10:56 a.m. Current [DIAGNOSES REDACTED]. The Hospital "History and Physical" form dated 9/18/14 indicated the resident had a right superior and inferior pubic rami fracture. 9/29/14 plan of care: Resident required frequent toileting program due to frequently incontinent of bladder and needed assist with transfers, toileting, was cooperative with care, and was on a toileting program that consisted of toilet upon rising, before and after meals, at bed time and check and change through the night as needed. 9/22/14 plan of care: At risk for fall due to fall with fracture, impaired balances, uses walker and wheelchair. Approaches included, but were not limited to, 9/22/14 bed alarm, 9/22/14 assist with transfers, 10/14/14 chair alarm check function, 10/14/14 moved closer to the nursing station, call light in reach, non-skid footwear and therapy. Progress notes indicated: 9/24/14: extensive assist with transfers and able to make needs known. 10/4/14: limited assist with transfers, makes needs known. 10/9/14: found on the floor in front of the television area in her room. She was bleeding from the top of her head, she indicated she wanted to put her clothes away the family had brought. She could not recall what she hit her head on. She was sent to the emergency room and received 19 sutures. 10/10/14 bed and chair alarms applied, resident compliant IDT (Interdisciplinary Team) educated to call for assistance when needed. She had turned off her bed pad alarm at times. 10/13/14 late entry for 10:04 a.m., heard alarm going off, resident had transferred self from the wheelchair to the chair, alarm was sounding and call light was not on. She was reminded by CNA to use call light for assistance and not to transfer self without help present. 10/14/14 son approved room move to 120 closer to nurses station and this was completed. 10/14/14 at 2:03 p.m., responded to the alarm and found the resident transferring self to the toilet. She had not turned her call light on. She was educated to use her call light to ask for help and not to transfer herself. The resident stated she "doesn't need help." "Res (Resident) does not seem open to education." 10/14/14 at 10:24 p.m., the resident turned off bed alarm two times and was educated on safety of alarms, stated she understood but did not like it. 10/17/14 at 7:20 a.m., alarm was sounding and found resident on the toilet, educated on using the call light for help for safety. 10/17/14 at 10:09 a.m., the alarm was sounding, found the resident on the floor on her buttocks and her back up against the wall. The call light was not on. The resident complained of right hip pain and the right hip was rotated outward and noted to be shorter. 911 was called and the resident went to the hospital. 10/17/14 admitted to the hospital with [REDACTED]. On 02/20/2015 at 9:30 a.m., during an interview with the Director Nursing, she indicated the resident was being treated for [REDACTED]. She also indicated the resident was on a toileting plan as indicated in her plan or care. She indicated the resident was again treated for [REDACTED]. The resident was in Physical and Occupational Therapy. She also indicated bed alarm and chair alarms were applied and the resident was educated on use of call light and safe transfers. The DON also indicated the resident's bed had transfer rails to assist the resident to transfer and there were grab bar was on toilets and that would help if a resident was noncompliant to call for help. The DON indicated she was aware the resident had removed her alarms, had indicated she did not like them, had been resistive to education and had continued to transfer herself. She indicated no other intervention had been attempted to assist with monitoring the resident was unsafe transfers or that she was moving about in her room. A Policy titled "Fall Risk Interventions (not all inclusive-use as a reference tool)" was provided by the DON on 2/20/15 at 10 a.m., and deemed as current. The policy indicated: "....Equipment interventions....", that included, but were not limited to, wedge cushions, drop seats, hipsters, motion sensor, self-release belt, and pommel cushion. 3. The record for Resident # 255 was reviewed on 02/20/2015 at 9:04:05 a.m. [DIAGNOSES REDACTED]. A Physician order [REDACTED]. A Plan of care dated 2/17/14 indicated the resident was a Hoyer transfer with two person assist. On 02/19/2015 at 1:28 p.m., a Hoyer transfer of Resident # 255 was observed. As CNA # 22 attempted to position the mechanical lift to transfer the resident from the wheelchair to the bed, the CNA was watching the base of the lift and bumped the resident in the head with the upper lift mechanism. At that time the CNA indicated she was sorry and had been watching the positioning of the base of the lift. 3.1-45(a)(2)

Based on record review and interview, the facility failed to ensure 2 or more staff transferred the resident to prevent a laceration to a resident's lower left leg, during at transfer, resulting in a visit to the emergency room where sutures were placed in a jagged laceration for 1 of 3 residents with falls in a sample of 5 (Resident C). Findings included: 1. During the facility tour with the Unit Manager on 2/29/12 at 8:30 A.M., Resident C was identified was having a hematoma on her leg that had opened which required sutures. Resident C's clinical record was reviewed on 2/29/12 at 9:50 A.M. Resident C's [DIAGNOSES REDACTED]. Resident C's Admission MDS (minimum data set) assessment completed on 2/18/12 indicated Resident C's cognitive status was assessed with [REDACTED]. Her functional status was assessed as extensive assistance of two+ persons for transfers from the wheelchair to the bed. She was assessed as not steady with transfers. The occupational therapy notes dated 2/15/12 indicated the resident needed "Max assist x's 2 to sit to stand in bar (parallel type bars)." The physical therapy notes dated 2/15/12 indicated the resident "...needed assist x 3 to sit down in wc (wheelchair) behind her." The Care Plan dated 2/11/12 for the problem of "Fall risk related to: recieves (sic) cardiac and psychotropic medications, needs extensive assist for transfer and toileting." The approaches included but were not limited to, ".... Provide assistance as needed...." The progress notes dated 2/18/12 at 7:17 P.M., indicated "Writer was called into residents (sic) room by son stating "my mom is bleeding, please come help us." writer (sic) went into room to find a huge "L" shaped jagged edge of her LLE (left lower extremity) cut open and bleeding. approx (sic) area to be measured 33 cm (centimeters). resident (sic) had approx +2 pitting edema on BLE. area (sic) cleaned with water. areas (sic) was seaping (sic) with blood. no (sic) c/o (complaints of) SOB (short of breath) noted. resident (sic) has mild c/o pain at L leg. aid (sic) was helping get resident to bed with a nice gentle transfer, and noticed bleeding. area (sic) around wound has purple bruising noted. family (sic) in room...." Resident C was transferred to the emergency roiagnom on [DATE] at 8:03 P.M. The emergency room notes indicated the resident was a "high fall risk," had dementia, swelling to her left lower leg, and had a laceration to the left lower leg that was a jagged and measured 9 centimeters. The emergency room physician sutured the laceration closed. Review of the emergency room report dated 2/18/2012 at 8:05 P.M., indicated Resident C had a 9 centimeter laceration to her left lower leg with a small amount of bleeding noted. The left leg laceration was stitched per the physician and steri strips were applied with an ACE bandage applied to the left lower leg. Resident C was discharged back to the facility. The progress notes dated 2/18/12 at 9:25 P.M., indicated "res returned from ER via (name of ambulance service) has a running suture to LLE skin tear with steri strips and ace wrap...." During an interview with the ADON (Assistant Director of Nurses) on 2/29/12 at 1:40 P.M., she indicated the DON had told her the skin tear had occurred during the resident transfer. During a follow-up interview with the ADON on 2/29/12 at 1:50 P.M., she indicated the supervisor in the building that night had talked with the CNA and told her she needed to have assistance with another CNA helping her to transfer the resident. Review of an undated written statement made by CNA #4, provided by the DON on 3/1/12 at 8:30 A.M., indicated "I was educated after incident occurred c (with) hematoma to residents (L) (left) lower leg to always have two people during transfers @ all times." Review of the undated Resident Care Sheet provided on 2/29/12 at 1:45 P.M., indicated Resident C was dependent for transfers and needed the assistance of 2 staff members to transfer her. This form had geri-gloves and geri-sleeves were to be placed on the resident to help prevent skin tears. Review of an undated guideline provided by the ADON on 3/1/12 at 12:49 P.M., for "Accidents" indicated "Implement interventions to reduce hazard(s) and risk(s), including adequate supervision (observation and timely intervention by the facility and its staff to prevent or reduce likelihood of a accident), consistent with the resident's needs, goals, plan of care, and recognized standards of practice...." This Federal tag relates to complaint # IN 351. 3.1-45(a)(2)