Every finding on record at Oak Village

Based on observation, interview, and record review, the facility failed to develop and implement resident's plan of care based on current status for 1 of 1 resident reviewed for pressure ulcers, 3 of 5 residents reviewed for accidents, and 1 of 5 residents reviewed for unnecessary medications. A resident lacked a care plan for a current stage 3 pressure ulcer, lacked a care plan for behavior of cannabis smoking, lacked a care plan for antiplatelet medication, and not following fall interventions. (Resident 28, Resident 9, Resident 1, Resident 30, Resident 5)Findings include:1. During an observation on 12/18/25 at 10:48 A.M., Resident 5 was observed in the common area by the nurses' station in his wheelchair. The facility failed to have any activities available to the resident while seated in the wheelchair. During an observation on 12/18/25 at 11:36 A.M., Activities Assistant 4 pushed Resident 5 to the dining room to eat. Multiple residents entered the dining room after Resident 5. On 12/16/25 at 1:29 P.M., Resident 5's clinical record was reviewed. Diagnoses included, but were not limited to, diabetes mellitus, hypertension, and anxiety disorder. During an observation of care on 12/22/25 at 10:03 A.M., Certified Nurse Aide (CNA) 2 and CNA 3 transferred Resident 5 from his bed to the wheelchair with a lift. At that time, CNA 2 indicated there was not a non-stick layer between the cushion and the wheelchair, and she was unsure if there should have been. The most recent quarterly Minimum Data Set (MDS) assessment, dated 11/10/25, indicated severe cognitive impairment and was dependent on staff with toileting, bathing, bed mobility, and transfers. Resident 5's current care plan included, but was not limited to, The resident is at risk for falls with and without injury. Current interventions on the falls care plan included, but were not limited to, the following - Staff will transfer the resident to the dining room last for meals, start date 11/27/25 - While in a wheelchair, a rolling table with resident-focused activities in close proximity, start date, 12/9/25. - Dycem (non-skid layer) to wheelchair, start date 12/5/25 During an interview on 12/19/25 at 2:18 P.M., the Director of Nursing (DON) indicated all care plan interventions should be followed. d 2. On 12/21/25 at 9:12 P.M., Resident 1's clinical record was reviewed. Diagnoses included diabetes mellitus type II, anxiety, and peripheral vascular disease. The most recent quarterly Minimum Data Set (MDS) assessment, dated 11/24/25, indicated Resident 1 was cognitively intact and taking an antiplatelet medication. Physician's Orders included, but were not limited to, the following: Aspirin 81 milligram (mg) tablet, give one tablet by mouth once daily for peripheral vascular disease, ordered 3/16/25 The clinical record lacked a current antiplatelet care plan. 3. On 12/16/25 at 10:47 A.M., Resident 30 was observed sitting in the common area at the nurse's station in a pedal Broda chair wearing regular grey socks. On 12/21/25 at 9:47 P.M., Resident 30's clinical record was reviewed. Diagnoses included, but were not limited to, dementia, stroke, and anxiety. The most recent significant change MDS assessment, dated 11/13/25, indicated Resident 30's cognition was severely impaired, substantial to maximum assist of staff (staff performs over half the effort) to put footwear on and off, and dependent on staff for transfers. Resident 30 had two falls without injury since the prior assessment. A current Falls Care Plan, last revised 11/18/25, included an intervention to ensure that the resident was wearing appropriate footwear, such as non-skid socks, when ambulating or mobilizing in w/c, initiated 7/1/25 4. On 12/21/25 at 10:28 A.M., Resident 9's clinical record was reviewed. Diagnoses included, but were not limited to, Multiple Sclerosis, pain in bilateral legs, and tobacco dependence. The most recent quarterly mds assessment indicated Resident 9 was cognitively intact and dependent on staff for toileting, showers, and transfers. Progress notes included, but were not limited to, the following: On 10/26/25 at 2:46 P.M., Nursing Note: it was reported to this nurse that this resident and another resident (male) were at the back door of the facility smoking marijuanavape pen, this nurse and a coworker nurse approached residents, a heavy marijuana smell was noted, asked this resident, and was handed a vape pen by the resident, the administrator was notified by staff. On 12/10/25 at 10:40 A.M., Nursing Note: was reported to this nurse by another staff member that a resident and a male resident were at the back door of the facility smoking. This nurse went to assess and noted a strong smell of pot. The nurse questioned the residents, and the male denied having one. The female resident surrendered a vape pen. This was reported to the Director of Nursing (DON). The clinical record lacked a plan of care for the behavior of cannabis smoking. During an interview on 12/22/25 at 9:20 A.M., the Social Services Director (SSD) indicated the resident should be care planned for smoking cannabis behavior; it must have been missed. During an interview on 12/22/25 at 10:46 A.M., Licensed Practical Nurse (LPN) 10 indicated that nursing staff should develop care plans on admission, and then the MDS Coordinator should be reviewing after that. She indicated residents should have a care plan for medications they are on, staff should follow the interventions on the care plans, and behaviors should be included in care plans as well. 5. On 12/16/25 at 1:41 P.M., Resident 28's clinical record was reviewed. Diagnoses included, but were not limited to, diabetes mellitus and dementia. The most recent quarterly Minimum Data Set (MDS) assessment, dated 12/4/25, indicated no cognitive impairment and dependent on staff with toileting, bathing, bed mobility, and transfers. Resident 28 currently had three stage 3 pressure ulcers. Physician orders included, but were not limited to: Coccyx: Wound cleanser and triad paste, leave open to air twice a day and every 2 hours as needed, dated 12/15/25. Resident 28 returned from a hospital stay on 11/28/25 with a stage 3 pressure ulcer to the right buttock that was first identified and assessed on 12/1/25. The most recent evaluation, dated 12/15/25, indicated right buttock stage 3 pressure ulcer measuring 2.7x2.3x0.1 (centimeters) with treatment orders for wound cleanser, triad paste, and open to air. Resident 28's clinical record lacked a specific care plan for the right buttock stage 3 pressure ulcer. On 12/18/25 at 9:00 A.M., Registered Nurse (RN) 5 indicated resident care plans should be specific and reflect current status. She indicated residents should have in place a different care plan for each pressure area. On 12/20/25 at 8:14 A.M., the Administrator provided a current Care Plan policy, last revised 9/2022, that indicated A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs is developed and implemented for each resident. 3.1-35(a)

Based on observation, interview, and record review, the facility failed to ensure a safe, sanitary, and comfortable environment for all residents for 3 of 3 random observations. The resident's oxygen tubing was dragging on the ground, the urinary catheter bag and tubing were dragging on the floor, and clean linens were carried against a staff member's uniform shirt. (Resident 4, Laundry 9, Resident 23)Findings include: 1. On 12/11/25 at 11:57 A.M., Resident 23 was observed propelling himself in his wheelchair down the hallway with a urinary catheter tube dragging under the resident's black shoe and hitting the floor at times. On 12/17/25 at 11:15 A.M., Resident 23 was observed in the common area by the nurse's station in a wheelchair with a urinary catheter bag dragging the floor under the wheelchair. Two nursing staff members walked past the resident, and then the Activity Director wheeled him to the front activity room, continuing to drag the catheter bag on the floor. The resident continued sitting in the activity room with his catheter bag resting on the floor. On 12/18/25 at 11:26 A.M., Resident 23 was observed propelling self in his wheelchair down the hallway to the dining room with his urinary catheter bag dragging the floor and the bottom of his black shoes hitting the tubing. On 12/17/25 at 2:34 P.M., Resident 23's clinical record was reviewed. Diagnoses included, but were not limited to, retention of urine and hemiplegia and hemiparesis affecting the left non-dominant side following a stroke. The most recent quarterly Minimum Data Set (MDS) assessment, dated 10/24/25, indicated Resident 23 was cognitively intact, had an indwelling catheter, and was totally dependent on staff for transfers and toileting. During an interview on 12/19/25 at 1:15 P.M., the Director of Nursing (DON) and Regional Clinical Support indicated a urinary catheter bag should be hung on the back of the wheelchair so off the floor, and staff should notify the nurse if they observed the bag or tubing dragging the floor so she could fix it. 2. On 12/17/25 at 10:01 A.M., Laundry 9 was observed taking clean linen from the linen cart and placing it into the linen closet. Laundry 9 gathered the clean linen from the cart, stood up placing the linen against her uniform top, then placed the linen into the linen closet. 3. On 12/17/25 at 11:17 A.M., Resident 4 was observed sitting at the end of the hallway with oxygen on. The oxygen tubing was resting on the floor. Certified Nurse Aide (CNA) 7 was observed to wheel Resident 7 from the end of the hallway into the front activity room. Resident 4 was then observed sitting in a wheelchair in the activity room with oxygen tubing still resting on the floor and lying against the inside right wheel of the wheelchair. On 12/19/25 at 1:15 P.M., the Director of Nursing (DON) indicated that if oxygen tubing is observed dragging or resting on the floor, staff would be expected to pick it up and change it out. At that time, she indicated staff were also expected to carry clean linen away from the body so it did not rub against staff uniform tops. On 12/22/25 at 10:22 A.M., Registered Nurse (RN) 17 indicated residents were supposed to have their oxygen tubing coiled and stored in the bag that was hanging on the handle of the wheelchair so it did not drag on the ground. On 12/20/25 at 8:14 A.M., the Administrator provided a current Respiratory Therapy policy, last revised 11/2011, that indicated to follow infection control practices with oxygen tubing. On 12/20/25 at 8:14 A.M., the Administrator provided a current Linen policy, last revised 1/2014, that indicated . provide a process for the safe and aseptic handling, washing, and storage of linen . Separate soiled and clean linen at all times . Clean linen will remain hygienically clean (free of pathogens in sufficient numbers to cause human illness) through measures designed to protect it from environmental contamination . On 12/22/25 at 10:07 A.M., a current Urinary Catheter Care Policy, last revised August 2022, indicated . use aseptic technique when handling or manipulating the drainage system. Be sure the catheter tubing and drainage bag are kept off the floor . 3.1-18 (b)(1) 3.1-19(g)

Based on interview and record review, the facility failed to ensure resident care plans were revised to reflect current status for 1 of 1 residents reviewed for pressure ulcers and 3 of 5 residents reviewed for unnecessary medications. A resident's pressure ulcer care plan had not been discontinued when the area healed, resident's care plans reflected current use of a discontinued medications, a fall care plan was not revised to include current interventions, and a current diagnosis of shingles and pneumonia that were no longer active (Resident 28, Resident 4, Resident 30, Resident 1)Findings include:1. On 12/21/25 at 9:12 P.M., Resident 1's clinical record was reviewed. Diagnoses included, but were not limited to, diabetes mellitus type II, anxiety, and peripheral vascular disease. The most recent quarterly Minimum Data Set (MDS) assessment, dated 11/24/25, indicated Resident 1 was cognitively intact, on an antibiotic, and not taking an anticoagulant. Physician Orders included, but were not limited to, the following: Eliquis 2.5 milligram (mg) tablet (anticoagulant), give one tablet by mouth two times a day, discontinued 3/16/25Augmentin 875-125 mg tablet (antibiotic), give one tablet by mouth two times a day for pneumonia for 5 Days, ordered 11/20/25 and discontinued 11/25/25 Current care plans included, but were not limited to, the following: An Anticoagulant Care Plan for Eliquis was last revised 2/13/25. A care plan for shortness of breath related to pneumonia, initiated and last revised 11/21/25, included, but was not limited to, an intervention to administer Augmentin as prescribed for pneumonia. 2. On 12/21/25 at 9:47 P.M., Resident 30's clinical record was reviewed. Diagnoses included, but were not limited to, dementia, stroke, and anxiety. The most recent significant change MDS assessment, dated 11/13/25, indicated Resident 30's cognition was severely impaired, substantial to maximum assist of staff (staff performs over half the effort) to put footwear on and off, and dependent on staff for transfers. Resident 30 had two falls without injury since the prior assessment, and Resident 30 was not taking an anticonvulsant. Physician's Orders included, but were not limited to, the following: Depakote 125 mg tablet (anticonvulsant), give one tablet by mouth two times a day, discontinued 8/19/25 Current care plans included one for anticonvulsant use was initiated and last reviewed on 8/20/25. A current Falls Care Plan, last revised 11/18/25, included, but was not limited to, the following interventions: antiroll backs on w/c, initiated 10/22/25 The resident needs to be evaluated for, and supplied (Specify: appropriate adaptive equipment or devices as needed). Re-evaluate (FREQ) and as needed for continued appropriateness and to ensure the least restrictive device or restraint, initiated 11/21/25 Progress notes included, but were not limited to, the following: On 11/26/25 at 1:51 P.M., Interdisciplinary Team (IDT) Note: met to discuss the resident's fall on 11/20/2025. RCA is dementia, impulsivity, and end-of-life care. The resident was immediately assessed and placed by nurse's station to increase monitoring. Intervention per team: providing the resident with a Peddle Broda chair per therapy. The resident is tolerating well with no additional falls. Will continue to monitor for changes in condition. During an interview on 12/22/25 at 10:46 A.M., Licensed Practical Nurse (LPN) 10 indicated care plans should be updated quarterly and as needed by the MDS Coordinator. Resident 1 should not have a care plan for Eliquis, and Resident 30 should not have one for Depakote because they were not currently taking the medications. Resident 30 was moved to a peddle Broda chair, and looking over the current falls care plan, the interventions were not revised to reflect the peddle Broda chair because the resident was no longer in a wheelchair. 3. On 12/16/25 at 1:27 P.M., Resident 4's clinical record was reviewed. Diagnoses included, but were not limited to, dementia, anxiety, and depression. The most recent significant change Minimum Data Set (MDS) assessment, dated 11/18/25, indicated a severe cognitive impairment and dependent on staff with toileting, bathing, bed mobility and transfers. Physician orders included, but were not limited to: Famciclovir (antiviral) oral tablet 500mg (milligrams) three times a day for herpes zoster (shingles) for 7 days, dated 11/18/25 through 11/25/25. Keep areas on lower back (herpes zoster) covered with a dry dressing and change daily, dated 11/18/25 through 11/24/25. Lovenox (anticoagulant) infection 40mg/0.4ml (milliliters), inject one time a day for 28 administrations, dated 11/12/25 through 12/6/25. Resident 4's clinical record included, but was not limited to, a current care plan for anticoagulant use (Lovenox), initiated and last revised 11/12/25. Resident 4's clinical record included, but was not limited to, a current care plan for an active shingles diagnosis, initiated and last revised 11/19/25. Resident 4's December medication administration record (MAR) indicated the last dose of Lovenox was administered on 12/6/25. Resident 4's clinical record did not indicate a current diagnosis of shingles. The most recent progress note that indicated shingles was a skilled nursing note, dated 11/25/25. On 12/22/25 at 11:08 A.M., Licensed Practical Nurse (LPN) 10 indicated Resident 4 did not currently have an active diagnosis of shingles. 4. On 12/16/25 at 1:41 P.M., Resident 28's clinical record was reviewed. Diagnoses included, but were not limited to, diabetes mellitus and dementia. The most recent quarterly Minimum Data Set (MDS) assessment, dated 12/4/25, indicated no cognitive impairment and dependent on staff with toileting, bathing, bed mobility, and transfers. Resident 28 currently had three stage 3 pressure ulcers. Current care plans indicated, but were not limited to, a bilateral buttock unstageable pressure ulcer initiated and last revised 10/13/25. Resident 28's wound evaluations indicated a bilateral buttock unstageable pressure ulcer identified 10/9/25 and healed 11/6/25. On 12/28/25 at 9:00 A.M., Registered Nurse (RN) 5 indicated resident care plans should be specific and reflect current status. On 12/20/25 at 8:14 A.M., the Administrator provided a current Care Plan policy, last revised 9/2022, that indicated Assessments of residents are ongoing, and care plans are revised as information about the residents and the residents' conditions change. 3.1-35(a) 3.1-35(d)(2)(B)

Based on observation, interview, and record review, the facility failed to ensure behavior monitoring for 1 of 1 residents reviewed for behavior concerns. A resident's behaviors were not monitored, tracked, or treated leading to an escalation of behaviors. (Resident 2)Finding includes:On 12/17/25 at 11:28 A.M., Resident 2 was observed sitting in a wheelchair in the front activity room participating in an activity. On 12/16/25 at 1:32 P.M., Resident 2's clinical record was reviewed. Diagnoses included, but were not limited to, dementia, depression, and bipolar disorder. The most recent quarterly Minimum Data Set (MDS) assessment, dated 11/18/25, indicated no cognitive impairment and no behaviors. Resident 2's clinical record lacked a physician's order to monitor behaviors. A behavior monitoring care plan, initiated 6/23/23 and last revised 7/17/25, indicated behaviors related to medication changes in 2/2023 as well as a roommate change in 6/2023. A behavior care plan, initiated and last revised 3/26/24, indicated behaviors related to threats of self-harm and suicide. Behavior progress notes included, but were not limited to, the following:4/8/25 at 6:08 P.M. Resident was involved in a verbal altercation with another resident. The resident remained upset after separated from the other resident. The charge nurse was notified. The clinical record lacked documentation of notification to the physician or psychiatric provider. 8/3/25 at 1:40 P.M. Resident was involved in a verbal altercation with another resident. The resident yelled, cursed, and threatened to hit the other resident, then threatened to hit the nurse. The resident was removed from the area. The clinical record lacked documentation of notification to the physician or psychiatric provider. 12/13/25 at 9:45 A.M. Resident was involved in a verbal altercation with another resident. Residents are cursing at each other. The resident swung a fist but did not make contact with the other resident. Resident placed on 15-minute checks. Notification was made to the Administrator and Director of Nursing (DON). The clinical record lacked documentation of notification to the physician or psychiatric provider. The clinical record lacked Interdisciplinary (IDT) notes related to behaviors for the last 12 months. A care plan conference dated 6/12/25 indicated no behaviors noted. A care plan conference dated 9/11/25 indicated no concerns with behaviors. A care plan conference dated 11/24/25 indicated no noted behaviors and no behavior concerns. A psychiatric visit note, dated 4/16/25, indicated no behaviors reported by facility staff. On 12/22/25 at 9:04 A.M., the Social Services Director (SSD) indicated she was made aware of resident behaviors by reviewing the treatment administration record (TAR) when there is an order to monitor behaviors, or reviewing the behavior log binder that was located at the nurses' station. She indicated all behaviors were discussed in the morning meeting within 48 hours of the behavior, and any new interventions would be added to the plan of care at that time. She indicated that behaviors were also discussed at care plan conferences. She indicated she had just read about a behavior of several loud outbursts from Resident 2 that occurred over the weekend (12/20/25) and would be discussed later that day. She indicated she was unaware of any other behaviors from Resident 2, as she has not had any behaviors in a while. On 12/22/25 at 9:24 A.M., the SSD indicated Resident 2 was in need of a behavior monitoring care plan. On 12/22/25 at 10:53 A.M., Certified Nurse Aide (CNA) 7 indicated that when a resident displayed a behavior, the aides would notify the nurse, and the nurse would then document it. She indicated she was unaware of any current behaviors from Resident 2. She indicated Resident 2 had a history of name-calling, but behaviors had never been physical. On 12/22/25 at 10:56 A.M., Licensed Practical Nurse (LPN) 10 indicated behaviors were documented as a behavior note. She indicated some residents had behavior monitoring in the TAR from a physician's order, and nurses could document behaviors there as well. She indicated the physician, DON, Administrator, and SSD should be contacted with the resident's behaviors as well as the psychiatric provider. She indicated Resident 2 yelled and cursed a lot, attempted to smack her roommate, and threatened other residents constantly. On 12/20/25 at 8:14 A.M., the Administrator provided a current Behavior Monitoring policy, last revised 2/2025, that indicated Circumstances that warrant a behavioral assessment of a resident include . new or worsening change in status or condition . New onset or changes in behavior are evaluated and documented, regardless of the degree of risk to the resident or others . The IDT thoroughly evaluates new or changing behavioral symptoms to identify underlying causes and address any modifiable factors that may have contributed to the resident's change in condition . The IDT evaluates behavioral symptoms in residents to determine the degree of severity, distress, and potential safety risk to the resident, and develops a plan of care accordingly 3.1-37(a)3.1-43(a)(1)

Based on observation, interview, and record review, the facility failed to ensure transportation was provided for a resident to get to her neurologist appointments for 1 of 2 residents reviewed for transportation. A resident receiving Botox injections for her Multiple Sclerosis (MS) missed two appointments due to not having transportation. (Resident 9)Finding includes:During an interview on 12/15/25 at 10:44 A.M., Resident 9 indicated her legs hurt bad. Her last neurologist appointment was cancelled by the facility because of transportation issues and now she had to wait until February to get her Botox injection for her MS. On 12/21/25 at 10:28 A.M., Resident 9's clinical record was reviewed. Diagnoses included, but were not limited to, MS, diabetes mellitus type II, and pain in bilateral lower legs. The most recent quarterly Minimum Data Set (MDS) assessment, dated 10/15/25, indicated Resident 9 was cognitively intact and dependent on staff for toileting, showering, and transfers. Current Physician's Orders included, but were not limited to, neurologist appointment with: (provider name), (Provider Address) 2/2/26 at 11:00 A.M. A current Impaired neurological function related to MS care plan, last revised 8/13/25, included an intervention to assist with transfer to follow up neurology appointments. Progress notes included, but were not limited to, the following notes:On 11/21/25 at 2:39 P.M., Nursing Note: contacted [provider name] concerning reschedule appointment for Botox. Left message to return call. On 11/22/25 at 8:10 A.M., Medication Administration Note: resident complains of leg pain due to not getting her Botox injection. On 11/24/25 at 10:15 P.M., Nursing Note: left a voicemail for [provider name] office to return my call. Resident needs an appointment for Botox injection. During the resident council meeting on 12/17/25 at 10:00 A.M., residents indicated the facility used to have their own bus for transportation but they don't anymore and sometimes getting to appointments was a challenge. During an interview on 12/22/25 at 10:46 A.M., Licensed Practical Nurse (LPN) 10 indicated Resident 9 gets her Botox injections every 3-4 months. The nursing staff was responsible for scheduling resident appointments and there was a Scheduler who was in charge of coordinating transportation from the facility to the appointment and going with the resident's, if needed. She was on vacation during the survey period. LPN 10 indicated she had to reschedule the resident's appointment because transportation was not set up.During an interview on 12/22/25 at 1:50 P.M., Resident 9's neurologist's office indicated her last appointment was 8/21/25, and she had a Botox injection at that time. Her November appointment was rescheduled by the facility due to lack of transportation from facility to the appointment. She indicated Resident 9 should have Botox injection every 3 months. February was the first available appointment to get the resident back in for an injection.On 12/22/25 at 1:00 P.M., a current policy for transporting residents was requested and was not provided during the survey period.3.1-3(a)3.1-37(b)

Based on the interview and record review, the facility failed to ensure its smoking policy was implemented for 2 of 2 residents reviewed for smoking. Resident's smoking evaluations were not completed quarterly. (Resident 9, Resident 1)Findings include:1. On 12/21/25 at 9:12 P.M., Resident 1's clinical record was reviewed. Diagnoses included, but were not limited to, diabetes mellitus type II, tobacco use, and peripheral vascular disease. The most recent quarterly Minimum Data Set (MDS) assessment, dated 11/24/25, indicated Resident 1 was cognitively intact and dependent on staff for transfers and toileting.Resident 1's current care plans included a Smoking Care Plan, last revised 6/19/23.The last smoking evaluation on Resident 1 was completed on 3/25/25.2. On 12/21/25 at 10:28 A.M., Resident 9's clinical record was reviewed. Diagnoses included, but were not limited to, Multiple Sclerosis, pain in bilateral legs, and tobacco dependence.The most recent quarterly MDS assessment indicated Resident 9 was cognitively intact and dependent on staff for toileting, showers, and transfers.Resident 9's current care plans included a Smoking Care Plan, last revised 2/15/23.The last smoking evaluation on Resident 9 was completed on 2/21/25.During an interview on 12/22/25 at 10:46 A.M., Licensed Practical Nurse (LPN) 10 indicated that Resident 1 and Resident 9 both currently smoked at the facility. Smoking evaluations should be completed quarterly and as needed. If they were not done quarterly, they must have been missed.On 12/11/25 at 11:03 A.M., a current Smoking Policy, revised 2/13/23, was provided by the Administrator and indicated, . 7. An assessment will be completed to determine which Residents are safe and unsafe smokers and what restrictions, if any, will need to be placed on the Resident's smoking privileges. All Residents who smoke will be supervised to further ensure safety. Any smoking-related privileges, restrictions, and concerns shall be noted on the care plan, and all personnel caring for the Resident shall be alerted to these issues. 9. The facility may impose smoking restrictions on the Residents at any time if it determined that the resident cannot smoke safely with the available levels of support and supervision. Smoking aprons will be provided if determined to be necessary. 10. The staff will review the status of a Resident's smoking privileges quarterly and with significant changes .

Based on interview and record review, the facility failed to ensure pharmaceutical services were provided to meet the needs of residents for 1 of 5 residents reviewed for unnecessary medications and 1 of 2 closed records reviewed. Medications were not available to be administered as prescribed. (Resident 4, Resident 18)Findings include:1.On 12/16/25 at 1:27 P.M., Resident 4's clinical record was reviewed. Diagnoses included, but were not limited to, status post hip surgery, dementia, anxiety, and depression. The most recent significant change Minimum Data Set (MDS) assessment, dated 11/18/25, indicated a severe cognitive impairment. Physician orders included, but were not limited to:Aspirin 81mg (milligrams), 1 capsule every 3 days, dated 11/14/25. Breo Ellipta inhalation aerosol powder 100-25mcg (micrograms)/act (actuation/puff) 1 inhalation one time a day, dated 11/12/25. Lovenox injection 40mg/0.4ml (milliliters) inject 1 dose one time a day for 28 administrations, dated 11/12/25. Resident 4's medication administration record (MAR) indicated aspirin was not administered on 11/14/25 due to family would be picking up from the pharmacy. The next administration of aspirin was on 11/17/25. Resident 4's MAR indicated Breo Ellipta was not administered on the following dates:11/12/25 not available, waiting for delivery 11/13/25 continue to wait for delivery, son is to pick up medication from the pharmacy 11/14/25 family to pick up medication from pharmacy 11/16/25 medication not delivered from the pharmacy 11/17/25 waiting on delivery from son 11/18/25 continue to wait for son to deliver 11/19/25 medication yet to be picked up at the pharmacy per family 11/22/25 not available Resident 4's MAR indicated that Lovenox was not administered on the following dates:11/14325 no supply available 11/14/25 medication not available in the facility 11/15/25 no medication in the cart or refrigerator 11/16/25 medication unavailable 11/17/25 medication unavailable, uses outside pharmacy, and family has not delivered medication Resident 4's clinical record lacked documentation of notification to the pharmacy for the request of aspirin, Breo Ellipta, or Lovenox. Resident 4's clinical record lacked notification of the lack of medications to the pharmacy, physician, Director of Nursing (DON), Administrator, or social services. On 12/22/25 at 11:08 A.M., Licensed Practical Nurse (LPN) 10 indicated there had been delays obtaining medications from the pharmacy. She indicated medications had to be ordered prior to 5 P.M. on weekdays to receive them that night. Otherwise, it would be the next day. She indicated if a medication came in late and it was to be given once a day, it may be given later and the reason documented. She indicated the physician and pharmacy should be contacted if a medication was not available in the medication cart or Emergency Drug Kit (EDK). 2. During medication administration for Resident 18 on 12/18/25 at 8:45 A.M., Registered Nurse (RN) 5 indicated the resident had been out of Vitamin D3 for a while. She indicated the provider was aware. At that time, Resident 18's medication administration record was reviewed and indicated Vitamin D3 had not been administered 12/14/25, 12/15/25, or 12/16/25 due to an order from the pharmacy. On 12/22/25 at 10:00 A.M., the Director of Nursing (DON) indicated if a medication is on hold from the pharmacy or not available for some other reason, the nurse should check the EDK to see if the medication is there. If not, either the Social Services Director (SSD) or the Human Resources (HR) person could go and pick up the medication. She indicated this could be done immediately. On 12/20/25 at 8:14 A.M., the Administrator provided a current Medication Administration policy that indicated Medications are administered in a safe and timely manner, and as prescribed . Medications are administered in accordance with prescriber orders, including any required time frame. 3.1-25(a)

Based on observation, interview, and record review, the facility failed to ensure food was stored and distributed in accordance with professional standards for food service safety during 1 of 1 kitchen observations and failed to complete hand hygiene during meal service. Food was stored in a reach in freezer in the kitchen open to air, undated, and unlabeled. The kitchen equipment and spaces contained dust and debris, and the staff failed to complete hand hygiene after coming in contact with residents while assisting in the dining room. (Resident D, Resident F, Resident G) Findings include: 1. During a kitchen observation on 5/8/25 at 10:55 A.M., a standing reach in freezer contained a box of peas that were open to air, a box of broccoli open to air, a box of cookie dough open to air, an undated bag of pancakes open to air, an unlabeled and undated bag of meat patties, and an unlabeled and undated bag of frozen (what appeared to be) hashbrowns. The kitchen floor under the stove and around the base of the walls had a build up of dust an debris, the ceiling vents and panels contained a build up of dust above food prep areas, and the top of the dishwasher had a build up of dust, debris, and what appeared to be food crumbs. During an interview on 5/8/25 at 1:35 P.M., the Dietary Manager (DM) indicated stored frozen food should bed labeled and dated, and should be sealed properly in the freezer. During an interview on 5/8/25 at 2:05 P.M., RN 3 indicated kitchen staff had recently completed a deep clean of the kitchen, but did not document routine cleaning in a cleaning log. 2. During meal service in the main dining room on 5/8/25 at 12:05 P.M., [NAME] 4 was talking with resident D and touched the resident's hair with her right right hand, then touched Resident F's right shoulder with her right hand. [NAME] 4 then attempted to assist Resident G and placed her right hand on the top of Resident G's cup. No hand hygiene was completed between coming in contact with Resident D, Resident F, and Resident G's cup. During an interview on 5/8/25 at 1:45 P.M., CNA 7 indicated while assisting during meal service, staff should perform hand hygiene after delivering each tray of food and complete a hand wash after every third tray. Staff should perform hand hygiene after coming in contact with a resident. On 12/31/24 at 2:10 P.M., RN 3 supplied a facility policy titled, Storage Areas, dated, 11/2024. The policy indicated, .13. Leftover food is stored in covered containers or wrapped carefully and securely. Each item is clearly labeled and dated . All foods should be covered, labeled, and dated . A facility policy titled, Cleaning and Sanitation of Food Services Areas, dated 07/2023, included, The food service staff will maintain the sanitation of the dining and food service areas through compliance with a written, comprehensive cleaning schedule . 1. The food service manager will record all cleaning and sanitation tasks needed for the department . A facility policy titled, Hand Washing, dated 07/2023, included, Staff will wash hands as frequently as needed through out the day . 1. When to wash hands: After touching bare human body parts . 2. After engaging in other activities that contaminate the hands . This citation relates to complaint IN00458070. 3.1-21(i)(2) 3.1-21(i)(3)

Based on interview and record review, the facility failed to ensure accurate and appropriate medication administration practices were in place for 1 of 3 residents reviewed for pharmaceutical services. A resident received another resident's medications after the administering nurse preset residents' medications prior to the medication pass. (Resident C) Finding includes: On 4/1/25 at 10:45 A.M., an Indiana Department of Health (IDOH) Facility Reportable Incident (FRI) form, dated 3/23/25 at 1:01 P.M., indicated Resident C was given incorrect medications in error. The follow-up FRI, dated 3/28/25, indicated a RN 4 had set up medications prior to administering them and Resident C received the wrong medications. During record review on 4/1/25 at 11:00 A.M., Resident C's diagnoses included but was not limited to, paraplegia, anemia, depression, and seizures. Resident C's care plan included, but was not limited to, resident had an alteration in gastro-intestinal status (initiated 3/19/25) with an intervention that included, administer medications as ordered. Resident had an alteration in neurological status (initiated 3/19/25) with an intervention that included, administer medications as ordered. Resident C's nurse's progress notes included, but were not limited to: 3/23/25 at 8:00 A.M. - Incident Note - RN 4 accidentally gave resident the incorrect medication. Resident received the following medications: amiodarone 200 (milligrams) mg (antiarrhythmic), amlodipine 5 mg (can treat high blood pressure), aspirin 81 mg, clonidine 0.3 mg (can treat high blood pressure), docusate sodium 100 mg (stool softener), Eliquis 5 mg (anticoagulant), ferrous sulfate 324 mg (iron supplement), furosemide 40 mg (diuretic), isosorbide 30 mg (nitrate, can treat chest pain related to heart disease), metoprolol 25 mg (can treat high blood pressure), potassium 20 milliequivalent (mEq) (supplement), topiramate 25 mg (anticonvulsant), vitamin B 12 50 micrograms (Mcg) (supplement), vitamin C 250 mg (supplement), vitamin D 3 25 Mcg (supplement). Orders were obtained to start fluids and two attempts were made to start intravenous (IV) access without success. Resident was sent to hospital to start IV access site to receive fluids and for further observation. During an interview on 4/1/25 at 11:35 A.M., the Director of Nursing (DON) indicated Resident C had received another resident's medications the morning of 3/23/25 after RN 4 had preset medications prior to the medication pass. After administering medications to Resident C, RN 4 returned to the medication cart and realized that another resident's medications had just been given to Resident C and Resident C's medications were still in the medication cart. The DON indicated nursing staff should not preset medications and should always ensure the correct medications are administered to the correct resident. Resident C's hospital ED (Emergency Department) physician notes, dated 3/23/25 at 9:23 A.M., indicated the resident presented to the ED after she had received incorrect medications. The resident stated that she felt weird and she was hypotensive with a blood pressure of 93/52. Resident received IV fluids and her blood pressure improved. All other labs were within normal limits (WNL). On 4/1/25 at 11:45 A.M., the DON supplied a facility policy titled, Administering Medications, dated 12/2012. The policy included, Medications shall be administered in a safe and timely manner, and as prescribed . 6. The individual administering the medication must verify the right resident, right medications, right dosage, right time, and right method (route) of administration before giving the medication . The deficient practice was corrected on 3/27/2025 after the facility implemented a systemic plan that included the following actions: Ad HOC QAPI meeting was held on 3/24/25, an action plan included inservice review of policy for medication administration with staff, observations of medication pass, assessment of all residents and the on going monitoring of the medication passes. This citation relates to complaint IN00456371. 3.1-25(b)(5) 3.1-25(b)(7)

Based on observation, interview, and record review, the facility failed to provide appetizing and palatable meals for 1 of 1 lunch trays sampled on 1 of 2 halls. Residents complained of cold food temperatures and unappetizing food during meals. (100 hall, Resident J, Resident M, Resident P) Finding includes: During an interview on 12/30/24 at 10:40 A.M., Resident J indicated that she disliked the food at the facility. During an interview on 12/30/24 at 10:55 A.M., Resident M indicated at 1:00 P.M., Resident M indicated that the hot food was often served cold. During a review of facility Resident Council minutes on 12/30/24 at 11:10 A.M., a concern was reported to the facility, dated 12/27/24, that the hot food was cold and colder than last month. Resident Council minutes from 11/29/24 indicated, cold bacon every day, hot food has been cold when it comes to the hall rooms, tired of having the same food . chicken strips and French fries three times in 7 days . During an observation on 12/30/24 at 11:45 A.M., a lunch cart arrived on the 100 hall. At 11:45 A.M., the cart door was opened to retrieve a meal tray and left open until 11:50 A.M. At 11:53 A.M., a tray was pulled from the hall cart that contained chicken strips, French fries, slaw, and applesauce. The following temperatures were recorded from the tray: Chicken strips - 80 degrees Fahrenheit (F) French Fries - 90 degrees F Slaw - 70 degrees F Applesauce - 55 degrees F At 11:57 A.M., the same hall tray was sampled for palatability. The chicken strips were palatable but were not hot, the French fries were not hot and many of the fries were very hard and difficult to bite through. The slaw was unappetizing at the serving temperature of 70 degrees F. The applesauce was palatable. During an interview on 12/30/24 at 12:00 P.M., Resident P indicated that the French fries were terrible and were cold and hard. On 12/31/24 at 12:35 P.M. the Facility Administrator supplied a facility policy titled, Temperatures, dated 07/2023. The policy indicated, All hot food items must be cooked to appropriate internal temperatures, held and served at a temperature of at least 135 [degrees] F . All cold food items must be maintained and served at a temperature of 41 [degrees] F or below . This citation relates to complaint IN00447927. 3.1-21(a)(2)

Based on observation, interview, and record review, the facility failed to ensure food was stored and distributed in accordance with professional standards for food service safety during 1 of 1 kitchen observations. Food was stored in a reach in freezer in the kitchen open to air, and refrigerated and frozen foods were not labeled and dated. Findings include: 1. During a kitchen observation on 12/30/24 at 1:35 P.M., a standing reach in freezer contained a box of frozen vegetables that was not sealed and contained a bag that was open to air of frozen vegetables, a bag of what appeared to be frozen fish fillets were not labeled, and a bag of what appeared to be meatballs were unlabeled. A standing reach in refrigerator contained a an unmarked container of what appeared to be pasta salad. During an interview on 12/30/24 at 1:45 P.M., dietary aide 11 indicated that all food items should be labeled and dated and that unlabeled/undated food must be thrown out. dietary aide 11 proceeded to throw out the unlabeled pasta salad. On 12/31/24 at 12:35 P.M., the Facility Administrator supplied a facility policy titled, Storage Areas, dated, 11/2024. The policy indicated, .13. Leftover food is stored in covered containers or wrapped carefully and securely. Each item is clearly labeled and dated . All foods should be covered, labeled, and dated . This citation relates to complaint IN00447927. 3.1-21(i)(2) 3.1-21(i)(3)

Based on interview and record review, the facility failed to ensure accurate controlled drug records were maintained regarding the dispensing and administration of controlled drugs for 1 of 3 residents reviewed for pharmaceutical services. Controlled substance count sheets did not match the documented administration of controlled drugs during a 30 day review period. (Resident B) Finding includes: During record review on 12/30/24 at 2:15 P.M., Resident B's diagnoses included but were not limited to cerebral infarction, aphasia, fracture of left arm humurus, Resident B's most recent significant change Minimum Data Set (MDS) dated [DATE] indicated the resident had severe cognitive impairment and received opiod medications. Resident B's physician records included, but were not limited to, Norco Oral Tablet 5-325 milligrams (mg) (hydrocodone 5 mg / acetaminophen 325 mg) 1 tablet by mouth two times a day for 7 days (started 12/6/24) and Norco Oral Tablet 5-325 mg 1 tablet by mouth every 4 hours as needed for pain (started 9/29/24). Resident B's Medication Administration Record (MAR) for the month December, 2024 for physician orders Norco Oral Tablet 5-325 mg 1 tablet by mouth two times a day for 7 days and Norco Oral Tablet 5-325 mg 1 tablet by mouth every 4 hours as needed for pain, did not match Resident B's controlled substance count log on the following dates and times: On 12/5/24 at 7:30 P.M. Norco 5-325 mg was documented as administered in Resident B's MAR. The controlled substance sheet was not signed out for that administration. On 12/8/24 at 12:00 A.M. and 4:00 A.M., Resident B's controlled substance count log was signed out for both times. Resident B's MAR included no administration of Norco 5-325 mg at 12:00 A.M. or 4:00 A.M. on 12/8/24. On 12/13/24 at 4:00 A.M., Resident B's controlled substance count log was signed out with no administration of Norco 5-325 mg at that time. During an interview on 12/31/24 at 11:35 A.M., the Director of Nursing (DON) indicated being unaware of any controlled substance counts being off and that staff count controlled substances at the beginning and end of their shifts. The DON could not supply explanation for the inconsistencies between Resident B's MAR and Resident B's controlled substance count sheet. During an interview on 12/31/24 at 11:40 A.M., LPN 4 indicated that Resident B's Norco 5-325 mg orders were counted off using one controlled substance count sheet for both the as needed (PRN) and routine orders. During an interview on 12/31/24 at 12:00 P.M., LPN 8 indicated that when administering a controlled or narcotic medication, the nurse should document in the record that it was administered and also sign the medication out on a controlled substance count sheet, including the date, time, and signature of the nurse. The MAR and controlled substance count sheet should match. On 12/31/24 at 12:35 P.M., the Facility Administrator supplied a facility policy, titled Charting and Documentation, dated 07/2017. The policy indicated, All services provided to the resident . shall be documented in the resident's medical record . The following information is to be documented in the resident medical record: .b. Medications administered . This citation relates to complaints IN00445197 and IN00445195. 3.1-25(b)(3) 3.1-25(e)(3)

Based on interview, observation, and record review, the facility failed to provide activities when the Activity Director was out of the building for 6 of 7 residents reviewed for activities (Residents 2, 10, 25, 13, 3, and 12). Findings include: 1. During an interview on 9/16/26 at 11:22 a.m., Resident 2 indicated she liked to play bingo, but nobody was there to do activities and the staff do not work. On 9/17/24 at 1:36 p.m., observed a posted activities calendar in the hallway for the month of September 2024. The posted activities calendar indicated the facility would have the following activities for 9/16/24 at 9:00 a.m. Manic Monday, 10:00 a.m. EZ does it, 11:00 a.m. Devotion, and 2:00 p.m. Fancy Nails. None of the activities were observed to have taken place for 9/16/24. A record review was conducted for Resident 2's on 9/18/24 at 11:16 a.m. The profile indicated the resident diagnoses included, but were not limited to, dementia with unspecified severity, without behavioral disturbance, psychotic (when you perceive or interpret reality in a very different way from people around you) disturbance, mood disturbance (a category of mental illnesses that affect a person's mood, or emotional state), and anxiety (a feeling of fear, dread, and uneasiness that can be a normal reaction to stress); and mild intellectual disabilities (a condition that affects a person's ability to learn, think, and adapt to their environment). A quarterly Minimum Data Set (MDS) Assessment, dated 7/2/24, indicated Resident 2 was cognitively intact. An activities assessment, dated 6/19/24, indicated that it was very important to Resident 2 to do things with groups of people. 2. During an interview on 9/16/24 at 2:25 p.m., Resident 10 indicated that she missed the old staff because they had a new Activity Director now and no longer had activities like they used to. Now, she was bored all the time. On 9/17/24 at 1:36 p.m., observed a board with a posted activities calendar for the month of September 2024. The posted activities calendar indicated the facility would have the following activities for 9/16/24: 9:00 a.m. Manic Monday, 10:00 a.m. EZ does it, 11:00 a.m. Devotion, and 2:00 p.m. Fancy Nails. None of the activities were observed to have taken place for 9/16/24. During an interview on 9/18/24 at 1:24 p.m., Resident 10 indicated that she was interested in participating in the scheduled activities today because they were not what they used to be, and they were no longer fun. A record review was conducted for Resident 10 on 9/20/24 at 11:21 a.m. The profile indicated the resident diagnoses included, but were not limited to, multiple sclerosis (a chronic disease that affects the central nervous system, including the brain and spinal cord), major depressive disorder (a serious mood disorder that can impact a person's daily life), and dependence on wheelchair. A quarterly Minimum Data Set (MDS) assessment, dated 7/26/24, indicated that the resident was cognitively intact. During an interview on 9/20/24 at 12:00 p.m., Resident 10 indicated they did not have activities on the weekends at all. If they did, they would not be worth her time to attend anymore. During an interview on 9/20/24 at 11:38 a.m., Registered Nurse (RN) 13 indicated that when the Activity Director was not there, the facility designated Certified Nursing Assistant (CNA) 11, or someone else, for activities. During an interview on 9/20/24 at 2:22 p.m., CNA 11 indicated she was often assigned to fill in and conduct activities. There had been many times that she was not able to fulfill the activities schedule because she was pulled to the floor to work as a CNA approximately 30% of the time. It was impossible to do both. The facility cut the activity budget and decreased how much staff were compensated for it, now nobody wanted to work doing activities for that kind of money. Due to census, they also cut back how many CNAs they scheduled from 3 per shift down to 2. This morning, she was supposed to fill in for activities, but she was again pulled to the floor instead. The Activity Director was gone twice per week for her schooling, she was going to school to be a Nurse and working on her Administrator's license. A lot of the residents complained about not having activities, it was a big concern for them. Nothing was left out for them to do or have access to on the weekends. The door was always open, and the light would be on, but nobody initiated the activities for them. Unless someone brought the residents to the activities room, they would not do it on their own. 35317 3. During an interview, on 9/17/24 at 9:56 a.m., Resident 3 indicated the facility can get boring on the weekends because they do not have activities. She also indicated the Activity Director did not work every day and if she was not here, they did not have activities. No facility activities were observed being conducted during the hours of 9:45 a.m. to 3:15 p.m. on 9/16/24. Resident 3's record was reviewed on 9/17/24 at 1:28 p.m. The profile indicated the resident's diagnoses included, but were not limited to, type 2 diabetes mellitus with hyperglycemia (high blood glucose levels), paroxysmal atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow), and diverticulosis (a condition in which small, bulging pouches develop in the digestive tract). A quarterly Minimum Data Set (MDS) assessment, dated 7/29/24, indicated Resident 3 had no cognitive impairment. A care plan, dated 4/11/23, indicated the resident wished to participate in group activities of her choosing. Interventions included, but were not limited to, the resident would receive an activity calendar monthly that would allow the resident to choose activities that interest her. A care plan, dated 11/8/23, indicated the resident had personal preferences for activities. Interventions included, but were not limited to, she likes manicures, coffee socials, small, and large group activities. An activity evaluation, dated 6/19/24, the evaluation indicated it was very important to Resident 3 to do things with groups of people. It was also very important to Resident 3 to be involved in her favorite activities. During an interview, on 9/19/24 at 9:38 a.m., Licensed Practical Nurse (LPN) 14 indicated there were days where there were no activities being conducted for the residents. She indicated there was only 1 activity personnel that worked at the facility, and she wasn't there every day. 4. During an interview, on 9/16/24 at 1:58 p.m., Resident 12 indicated the facility didn't have a lot of activities and there were a lot of weekends when they didn't have anything. No facility activities were observed being conducted during the hours of 9:45 a.m. to 3:15 p.m. on 9/16/24. Resident 12's record was reviewed on 9/17/24 at 3:04 p.m. The profile indicated the resident's diagnoses included, but were not limited to, chronic obstructive pulmonary disease (COPD - a group of lung diseases that block airflow and make it difficult to breathe), pneumonia (infection that inflames air sacs in one or both lungs which may fill with fluid), hypertension (high blood pressure), and complete traumatic amputation at knee level, left lower leg (severe injury that results in the complete loss of the lower leg below the knee). A quarterly Minimum Data Set (MDS) assessment, dated 7/3/24, indicated Resident 12 had no cognitive impairment. A care plan, dated 12/23/20, indicated the resident would make her own decisions as to what activities she would like to participate in. Interventions included, but were not limited to, parties/social events, bible/church study, outdoor time, and provide me the opportunity to do things with groups of people. A point of care (poc) response history for the last 30 days indicated Resident 12 had only participated in one social/event party on the weekends. The record lacked any other activity involvement on the weekends for the last 30 days. During an interview, on 9/19/24 at 9:38 a.m., Licensed Practical Nurse (LPN) 14 indicated there were days where there were no activities being conducted for the residents. She indicated there was only 1 activity personnel that worked at the facility, and she wasn't there every day. 34525 5. During an interview, on 9/16/24 at 1:48 p.m., Resident 25 indicated the residents were not getting any activities on weekends unless they were self-initiated. They also usually only had one activity 1 per day during the week. No facility activities were observed being conducted during the hours of 9:45 a.m. to 3:15 p.m. on 9/16/24. Resident 25's record was reviewed on 9/18/24 at 8:50 a.m. The profile indicated the resident's diagnoses included, but were not limited to, type 2 diabetes mellitus with neuropathy (high blood sugar levels in the blood which cause nerve damage, also known as neuropathy, over time), Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills, and eventually the ability to carry out simple tasks), and stage 3 chronic kidney disease (a middle stage of kidney disease where the kidneys are mildly to moderately damaged and are less able to filter waste and fluid from the blood). An admission Minimum Data Set (MDS) assessment, dated 7/11/24, indicated the resident had moderate cognitive deficit. Review of the resident's care plans lacked documentation of an activity related care plan. An activity evaluation, dated 7/9/24, indicated it was somewhat important for the resident to do things with groups of people and to do her favorite activities. Review of the resident's individual activity tasks form, dated 8/20/24 through 9/15/24, indicated the resident had only participated in family visits on the weekends. The form lacked documentation that the resident had participated in any of the activities listed on the September 2024 Activity Calendar. During an interview, on 9/19/24 at 9:22 a.m., the Activity Director indicated the scheduler/Certified Nursing Assistant (CNA) 7 was scheduled to run the activities, during her absence on 9/16/24, but got pulled to work on the floor. CNAs 11 and 12 had been scheduled to run the activities on the weekends, but they also had been pulled to work the floor and have not been able to conduct the weekend activities as scheduled. Shortly after she began her position as Activity Director, the long-time Activity Assistant quit abruptly. She had not had an assistant since that time. 6. During an interview, on 9/17/24 at 9:11 a.m., Resident 13 indicated there were very little activities on the weekends. Anything that was done had to be a self-directed type of activity. They also had not had any activity staff during the evenings. On 9/16/24, the Activity Director was out of the building taking some tests and there was no one available to run the activities. She also had classes every Wednesday, and was not in the building, so the activities on those days were hit-and-miss. No facility activities were observed being conducted during the hours of 9:45 a.m. to 3:15 p.m. on 9/16/24. Resident 13's record was reviewed on 9/19/24 at 9:14 a.m. The profile indicated the resident's diagnoses included, but were not limited to, stage 4 chronic kidney disease (a severe stage of kidney disease that occurs when the kidneys are damaged and can't filter waste from the blood as well as they should) and type 2 diabetes mellitus with neuropathy (high blood sugar levels in the blood which cause nerve damage, also known as neuropathy, over time). An annual Minimum Data Set (MDS) assessment, dated 7/10/24, indicated the resident had no cognitive deficit. A care plan, dated 4/19/21 and revised on 2/7/24, indicated the resident had personal preferences and preferred leisure activities over group activities, but would occasionally participate. Interventions included, but were not limited to, offer the resident the opportunity to participate in her favorite activities, offer her the opportunity to participate in new activities, and provide an activity calendar monthly to allow her to choose activities that interest her. An activity evaluation, dated 9/7/24, indicated it was very important for the resident to keep up with the news, and somewhat important for her to do things with groups of people and participate in her favorite activities. Review of the resident's individual activity tasks form, dated 8/20/24 through 9/15/24, indicated the resident had only participated in listening to her radio. The form lacked documentation that the resident had participated in any of the activities listed on the September 2024 Activity Calendar. During an interview, on 9/19/24 at 9:22 a.m., the Activity Director indicated the scheduler/Certified Nursing Assistant (CNA) 7 was scheduled to run the activities, during her absence on 9/16/24, but got pulled to work on the floor. CNA's 11 and 12 had been scheduled to run the activities on the weekends, but they also had been pulled to work the floor and have not been able to conduct the weekend activities as scheduled. Shortly after she began her position as Activity Director, the long-time Activity Assistant quit abruptly. She had not had an assistant since that time. On 9/19/24 at 10:21 a.m., the Activity Director provided a copy of the September 2024 Activity Calendar and indicated it was the plan of the scheduled activities for the month. The calendar indicated activities had been scheduled for all days during the month, running at 9:00 a.m., 10:00 a.m., 11:00 a.m., 2:00 p.m., and 3:00 p.m., on most days. On 9/19/24 at 10:21 a.m., the Activity Director provided a copy of a document which she indicated was the proposed schedule for activity staff for September 2024. The schedule indicated a staff had been assigned to conduct the events on the activity calendar from 8:00 a.m., to 4:00 p.m., on Mondays and Wednesdays, from 7:00 a.m., to 4:30 p.m., on Tuesdays, Thursdays, and Fridays, and times ranging from as early as 6:00 a.m., and as late as 6:00 p.m., on Saturdays and Sundays. On 9/19/24 at 10:36 a.m., the Regional Director of Clinical Services (RDCS) provided a document, dated 3/2015, titled, Activities/Recreation Administration, and indicated it was the policy currently being used by the facility. The policy indicated, .Policy Interpretation: .11. Perform all recreational activities on the calendar 3.1-33(a) 3.1-33(c)

Based on record review and interview, the facility failed to ensure post dialysis (a medical procedure that removes waste products and excess fluid from the blood when the kidneys are no longer able to function properly) vital signs were documented for 1 of 1 residents reviewed for dialysis (Resident 13), and failed to ensure the administration of medications had been documented in the medication administration records (MAR) for 4 of 12 residents MARs reviewed (Resident 25, 2, 10, and 12). Finding includes: 1. Resident 13's record was reviewed on 9/19/24 at 9:14 a.m. The profile indicated the resident's diagnoses included, but were not limited to, stage 4 chronic kidney disease (a severe stage of kidney disease that occurs when the kidneys are damaged and can't filter waste from the blood as well as they should) and dependence on renal dialysis. An annual Minimum Data Set (MDS) assessment, dated 7/10/24 indicated the resident had no cognitive deficit and received dialysis services. A care plan, dated 4/29/21 and revised on 11/10/22, indicated the resident had end-stage renal disease (final stage of chronic kidney disease) and required dialysis. A physician's order, dated 1/26/24, indicated the resident was to receive dialysis treatment on Monday, Wednesday, and Friday. Review of the resident's dialysis communication forms, dated 4/22/24 to 9/18/24, indicated the pre and post dialysis (return to the facility) vital signs were to be completed and documented. The forms indicated the following: a. The April 2024 dialysis communication forms lacked documentation that the post dialysis vital signs had been obtained on 4/22/24, 4/24/24, and 4/26/24. b. The May 2024 dialysis communication forms lacked documentation that the post dialysis vital signs had been obtained on 5/1/24, 5/3/24, 5/27/24, 5/29/24, and 5/31/24. c. The June 2024 dialysis communication forms lacked documentation that the post dialysis vital signs had been obtained on 6/5/24, 6/7/24, 6/10/24, 6/12/24, 6/14/24, 6/17/24, 6/19/24, 6/24/24, and 6/28/24. d. The July 2024 dialysis communication forms lacked documentation that the post dialysis vital sign had been obtained on 7/3/24, 7/5/24, 7/8/24, 7/10/24, and 7/12/24. e. The September 2024 dialysis communication forms lacked documentation that the post dialysis vital signs had been obtained on 9/4/24, 9/6/24, 9/13/24, 9/16/24, and 9/18/24. During an interview, on 9/19/24 at 1:21 p.m., the Regional Director of Clinical Services (RDCS) indicated she had reviewed all dialysis communication documents scanned into the resident's electronic medical record and could not see where the post dialysis vital signs had been completed on the documents. It was the expectation that the vital signs would be taken when the resident returned to the facility from dialysis. On 9/19/24 at 2:12 p.m., the RDCS provided a document, dated 1/10/18, titled, Hemodialysis, and indicated it was the policy currently being used by the facility. The policy indicated, .Post-dialysis: 1. If pre/post dialysis vital signs not obtained by the dialysis center before and after the treatment, obtain the resident vitals 2. Resident 25's record was reviewed on 9/18/24 at 8:50 a.m. The profile indicated the resident's diagnoses included, but were not limited to, hypothyroidism (a condition where the thyroid gland in the neck doesn't produce enough thyroid hormone), essential hypertension (high blood pressure), and gastro-esophageal reflux disease (GERD- a condition that occurs when stomach contents flow backward into the esophagus, or food pipe). Review of the resident's August 2024 and September 2024 medication administration records (MARs) indicated the following: A physician's order, dated 7/1/24, indicated to administer one 20 milligram (mg) delayed release capsule of omperazole (medication to prevent GERD) by mouth one time a day. The August 2024 MAR lacked documentation of the medication having been administered at 5:00 a.m., on 8/11/24, 8/12/24, and 8/31/24. The September 2024 MAR lacked documentation of the medication having been administered at 5:00 a.m., on 9/11/24. The record lacked documentation of a resident refusal. A physician's order, dated 7/1/24, indicated to administer one 50 mg tablet of metoprolol tartrate (medication to lower blood pressure) by mouth two times a day, at 5:00 a.m., and 4:00 p.m. The August 2024 MAR lacked documentation of the medication having been administered at 5:00 a.m., on 8/11/24, 8/12/24, and 8/31/24. The September 2024 MAR lacked documentation of the medication having been administered at 5:00 a.m., on 9/11/24. The record lacked documentation of a resident refusal. A physician's order, dated 7/9/24, indicated to administer one 175 microgram (mcg) tablet of levothyroxine sodium (medication to increase thyroid hormone) tablet by mouth one time a day. The August 2024 MAR lacked documentation of the medication having been administered at 5:00 a.m., on 8/11/24, 8/12/24, and 8/31/24. The September 2024 MAR lacked documentation of the medication having been administered at 5:00 a.m., on 9/11/24. The record lacked documentation of a resident refusal. 49068 3. A record review for Resident 2 was conducted on 9/18/24 at 11:16 a.m. The profile indicated the resident diagnoses included, but were not limited to, hyperlipidemia (too much fatty substance in the blood), type 2 diabetes mellitus (the body doesn't produce enough insulin or doesn't use insulin properly, resulting in high levels of glucose in the blood), hypothyroidism thyroid [gland in the neck] does not create and release enough thyroid hormone into the bloodstream), generalized edema (swelling), iron deficiency anemia (a condition that occurs when the body doesn't have enough iron to produce healthy red blood cells). Review of the resident's August 2024 and September 2024 medication administration records (MARs) indicated the following: a. A physician's order, dated 11/2/21, indicated to administer fenofibrate micronized (lowers fatty substance content in the blood [cholesterol]) capsule, 134 milligrams (mg), give one capsule by mouth one time a day at 5:00 a.m. for diagnosis of hyperlipidemia. The August 2024 MAR lacked documentation of the medication having been administered at 5:00 a.m. on 8/24/24 and 8/31/24. The September 2024 MAR lacked documentation of the medication having been administered at 5:00 a.m. on 9/5/24 and 9/11/24. The record lacked documentation of resident refusal. b. A physician's order, dated 11/2/21, indicated to administer ferrous sulfate (used to replace iron in the blood) 325 (65Fe) mg, give one tablet by mouth one time a day at 5:00 a.m. for diagnosis of iron deficiency anemia. The August 2024 MAR lacked documentation of the medication having been administered at 5:00 a.m. on 8/24/24 and 8/31/24. The September 2024 MAR lacked documentation of the medication having been administered at 5:00 a.m. on 9/5/24 and 9/11/24. The record lacked documentation of resident refusal. c. A physician's order, dated 1/11/23, indicated to administer hydrochlorothiazide (reduces the amount of water in the body [water pill]) 12.5 mg, give one tablet by mouth one time a day at 5:00 a.m. for diagnosis of generalized edema. The August 2024 MAR lacked documentation of the medication having been administered at 5:00 a.m. on 8/24/24 and 8/31/24. The September 2024 MAR lacked documentation of the medication having been administered at 5:00 a.m. on 9/5/24 and 9/11/24. The record lacked documentation of resident refusal. d. A physician's order, dated 5/11/24, indicated to administer synthroid (replaces thyroid hormone in the blood) 112 micrograms (mcg), give one tablet by mouth one time a day at 5:00 a.m. for diagnosis of hypothyroidism. The August 2024 MAR lacked documentation of the medication having been administered at 5:00 a.m. on 8/24/24 and 8/31/24. The September 2024 MAR lacked documentation of the medication having been administered at 5:00 a.m. on 9/5/24 and 9/11/24. The record lacked documentation of resident refusal. e. A physician's order, dated 4/5/22, indicated to administer metformin hydrochloride (reduces glucose [sugar] in the blood) 850 mg, give one tablet by mouth two times a day at 5:00 a.m. for diagnosis of type 2 diabetes mellitus without complications. The August 2024 MAR lacked documentation of the medication having been administered at 5:00 a.m. on 8/24/24 and 8/31/24. The September 2024 MAR lacked documentation of the medication having been administered at 5:00 a.m. on 9/5/24 and 9/11/24. The record lacked documentation of resident refusal. 4. A record review was conducted for Resident 10 on 9/20/24 at 11:21 a.m. The profile indicated the resident diagnoses included, but were not limited to, multiple sclerosis (a chronic disease that affects the central nervous system, including the brain and spinal cord), muscle spasms (involuntary contractions of a muscle), vitamin D deficiency (body does not produce enough vitamin D), and constipation (difficulty passing stool, can be painful). Review of the resident's August 2024 and September 2024 medication administration records (MARs) indicated the following: a. A physician's order, dated 11/2/21, indicated to administer aspirin (used for pain relief and to thin blood to prevent clots) 81 milligrams (mg), give one tablet by mouth one time a day at 5:00 a.m. for prophylactic use. The August 2024 MAR lacked documentation of the medication having been administered at 5:00 a.m. on 8/24/24 and 8/31/24. The September 2024 MAR lacked documentation of the medication having been administered at 5:00 a.m. on 9/11/24. The record lacked documentation of resident refusal. b. A physician's order, dated 9/10/24, indicated to administer docusate sodium (stool softener) 100 mg, give one capsule by mouth one time a day at 5:00 a.m. for diagnosis of constipation. The September 2024 MAR lacked documentation of the medication having been administered at 5:00 a.m. on 9/11/24. The record lacked documentation of resident refusal. c. A physician's order, dated 4/27/24, indicated to administer Mayzent (used to treats multiple sclerosis symptoms) 1 mg, give one tablet by mouth one time a day at 5:00 a.m. for diagnosis of multiple sclerosis. The August 2024 MAR lacked documentation of the medication having been administered at 5:00 a.m. on 8/24/24 and 8/31/24. The September 2024 MAR lacked documentation of the medication having been administered at 5:00 a.m. on 9/11/24. The record lacked documentation of resident refusal. d. A physician's order, dated 5/29/21, indicated to administer vitamin D (supplemental vitamin), give one tablet by mouth one time a day at 5:00 a.m. for diagnosis of vitamin D deficiency. The August 2024 MAR lacked documentation of the medication having been administered at 5:00 a.m. on 8/24/24 and 8/31/24. The September 2024 MAR lacked documentation of the medication having been administered at 5:00 a.m. on 9/11/24. The record lacked documentation of resident refusal. e. A physician's order, dated 7/9/24, indicated to administer Zanaflex (muscle relaxer that treats muscle spasms) 2 mg, give one capsule by mouth two times a day at 5:00 a.m. for diagnosis of muscle spasms. The August 2024 MAR lacked documentation of the medication having been administered at 5:00 a.m. on 8/24/24 and 8/31/24. The September 2024 MAR lacked documentation of the medication having been administered at 5:00 a.m. on 9/11/24. The record lacked documentation of resident refusal. 35317 5. Resident 12's record was reviewed on 9/17/24 at 3:04 p.m. The profile indicated the resident diagnoses included, but were not limited to, chronic obstructive pulmonary disease (COPD - a group of lung diseases that block airflow and make it difficult to breathe), pneumonia (infection that inflames air sacs in one or both lungs which may fill with fluid), hypertension (high blood pressure), and complete traumatic amputation at knee level, left lower leg (severe injury that results in the complete loss of the lower leg below the knee). Review of the resident's August 2024 and September 2024 medication administration records (MARs) indicated the following: a. A physician's order, dated 8/15/24, indicated to administer lisinopril (blood pressure lowering medication) 20 mg (milligram) by mouth one time a day. The August 2024 MAR lacked documentation of the medication having been administered at 5:00 a.m. on 8/24/24 and 8/31/24. The September 2024 MAR lacked documentation of the medication having been administered at 5:00 a.m. on 9/5/24 and 9/11/24. The record lacked documentation of resident refusal. b. A physician's order, dated 8/15/24, indicated to administer vitamin c (water-soluble vitamin found in citrus and other fruits, berries and vegetables) 500 mg by mouth one time a day. The August 2024 MAR lacked documentation of the medication having been administered at 5:00 a.m. on 8/24/24 and 8/31/24. The September 2024 MAR lacked documentation of the medication having been administered at 5:00 a.m. on 9/5/24 and 9/11/24. The record lacked documentation of resident refusal. c. A physician's order, dated 8/15/24, indicated to administer zinc (supplement medication) 50 mg by mouth one time a day. The August 2024 MAR lacked documentation of the medication having been administered at 5:00 a.m. on 8/24/24 and 8/31/24. The September 2024 MAR lacked documentation of the medication having been administered at 5:00 a.m. on 9/5/24 and 9/11/24. The record lacked documentation of resident refusal. d. A physician's order, dated 8/15/24, indicated to administer gabapentin (medication to treat nerve pain) 300 mg by mouth two times a day. The August 2024 MAR lacked documentation of the medication having been administered at 5:00 a.m. on 8/24/24 and 8/31/24. The September 2024 MAR lacked documentation of the medication having been administered at 5:00 a.m. on 9/5/24 and 9/11/24. The record lacked documentation of resident refusal. e. A physician's order, dated 8/14/24, indicated to administer Zanaflex (medication to treat muscle spasms) 4 mg by mouth three times a day. The August 2024 MAR lacked documentation of the medication having been administered at 5:00 a.m. on 8/24/24 and 8/31/24. The September 2024 MAR lacked documentation of the medication having been administered at 5:00 a.m. on 9/5/24 and 9/11/24. The record lacked documentation of resident refusal. During an interview, on 9/18/24 at 9:54 a.m., the Regional Director of Clinical Services (RDCS) indicated the 5:00 a.m. medications should have been documented by the night shift nurse after the administration of the medication. RDCS indicated the night shift nurse was not completing her documentation, and she would be educated on the policy. During an interview, on 9/19/24 at 8:57 a.m., Licensed Practical Nurse (LPN) 14 indicated medications should be documented by the nurse as soon as they are administered. If a resident refused medications, then it would be documented as a refusal. On 9/18/24 at 9:50 a.m., the RDCS provided a document, dated 5/21/18, titled, Medication Administration General Guidelines, and indicated it was the policy currently being used by the facility. The policy indicated, .2. Documentation a. Documentation is completed on the MAR/eMAR (electronic) immediately after medication(s) ingested by resident and completed by licensed personnel who administer the medication(s) i. Initial paper MAR or electronically sign eMAR ii. Initials should be verified with a full signature with initials on the MAR or a master signature log b. After medication administration is completed, licensed personnel reviews the MAR/eMAR to ensure all necessary does were administered and documented i. Do not report off shift without ensuring documentation is complete 3.1-48(a)(3)

Based observation, interview, and record review, the facility failed to ensure expired medications were disposed of properly for 1 of 2 medication carts and 1 of 1 medication storage rooms reviewed for medication storage (Resident 3). Findings include: 1. On 9/19/24 at 9:23 a.m., the long hall medication cart contained an opened vial of Fiasp (medication used to lower blood sugar) insulin. The vial contained a handwritten name on it that indicated it was for Resident 3. The vial had an open date of 8/14/24. During an interview, on 9/19/24 at 9:25 a.m., Licensed Practical Nurse (LPN) 14 indicated the Fiasp insulin vial should have been discarded because it is over 30 days old. She indicated she thought the insulin was good for 30 days once opened. Resident 3's record was reviewed on 9/19/24 at 10:17 a.m. The profile indicated the resident's diagnosis included, but were not limited to, diabetes mellitus with hyperglycemia (a condition in which the level of glucose in the blood is higher than normal). A physician order, dated 2/16/24, indicated to administer Fiasp (insulin medication) injection solution 100unit/ml (milliliter). Inject per sliding scale subcutaneously (under the skin) with meals. Review of the September Medication Administration Record (MAR) indicated Resident 3 had received Fiasp insulin medication daily September 12 through 19, 2024. During an interview, on 9/19/24 at 10:30 a.m., the Regional Director of Clinical Services (RDCS) indicated insulin medication was good for 28 days once opened and the vial in the medication cart should have been disposed of since it was expired. On 9/19/24 at 10:30 a.m., the RDCS provided a document, dated 5/21/18, titled, Insulin Preparation and Administration, and indicated it was the current policy being used by the facility. The policy indicated, .ii. Check insulin vial to ensure correct type and expiration date 2. On 9/19/24 at 9:47 a.m., the medication storage room contained a clear plastic bag of facility stock vaccines. The bag contained a prefilled flu vaccine syringe. The flu vaccine contained a label with an expiration date of 6/30/24. During an interview, on 9/19/24 at 9:50 a.m., Licensed Practical Nurse (LPN) 14 indicated the flu vaccine should have been discarded because it was expired. During an interview, on 9/19/24 at 10:00 a.m., the Director of Nursing (DON) indicated the flu vaccine should have been discarded because it was expired, and she was not sure why it was not noticed by the pharmacy when they had completed their audits. On 9/19/24 at 10:00 a.m., the RDCS provided a document with a revised date of April 2007, titled, Storage of Medications, and indicated it was the policy currently being used by the facility. The policy indicated, .4. The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed 3.1-25(o)

Based on observation and interview, the facility failed to ensure facial hair restraints were used for 2 of 2 kitchen observations. Findings include: During the initial kitchen tour on 9/16/24 at 10:18 a.m., the Dietary Manager (DM) was observed to go into all areas of the kitchen, including the food storage and food preparation areas. He was observed to have facial hair, a visible mustache, without a hair restraint. During a kitchen observation on 9/19/24 at 11:00 a.m., the DM was observed in the food preparation area of the kitchen preparing puree food items. He was observed to have facial hair, a visible mustache, without a hair restraint. During an interview on 9/19/24 at 11:15 a.m., the DM indicated that they had facial hair coverings, but they were located downstairs. Staff were not required to wear facial hair coverings unless they had a full beard. He thought that if they only had a mustache, they were not required to wear facial hair coverings. On 9/19/24 at 11:36 a.m., the DM was observed in the kitchen checking food temperatures in the food preparation area, he was observed to have facial hair, a visible mustache, without a hair restraint. On 9/19/24 at 1:17 p.m., the Administrator (ADM) provided a policy with a revised date of 12/16/21, titled, Associate Conduct and Dress Code, and indicated it was the policy currently being used by the facility. The policy indicated, .Hair Restraints/Jewelry/Nail Polish - Mustaches can't extend more than half an inch from the corner of the mouth, below the jaw line. The lower lip must be visible when the mouth is closed. Dietary staff must wear hair restraints on their head and may need to wear facial coverings if the facial hair is long enough that may get into the food .The Food and Nutrition Services associates wear a hair covering, which covers all unpinned hair. This includes long facial hair 3.1-21(i)(3)

Based on observation, interview, and record review, the facility failed to ensure a resident had adequate pain control during a pressure ulcer dressing change for 1 of 1 reviewed for pain management (Resident 18). Finding includes: On 9/20/24 at 9:55 a.m., Resident 18 was observed sitting in her wheelchair in her room. Registered Nurse (RN) 13 and RN 24 were preparing supplies to complete a dressing change to the resident's wounds on her left heel. RN 13 and RN 24 completed a pressure ulcer dressing change to Resident 18's left heel and surrounding areas on 9/20/24 at 9:55 a.m. to 10:20 a.m. RN 24 removed an old dressing from Resident 18's left heel. After she removed the ace wrap and kerlix (gauze) wrap, she went to the bathroom to wash her hands. RN 13 then sat down and began to cleanse the wounds on the resident's left heel. When the nurse began to clean the wound the resident winced in pain, clenched her jaw and began to move her foot back away from the nurse. The resident indicated it was painful by verbalizing to the nurse that it hurt. The nurse continued with the dressing change. RN 13 indicated the resident had prn (as needed) pain medication and was pre-medicated prior to the dressing change with Norco (pain medication). At 10:13 a.m. RN 13 applied a lotion skin prep to the resident's top of her foot. The nurse was massaging her foot with the lotion and the resident winced again in pain, clenched her jaw, and jerked her foot away from the nurse. The resident again verbalized to the nurse that her heel hurt. The nurse indicated to the resident she would stop. RN 24 indicated to the resident that they were almost done with the dressing change, and they proceeded to complete the dressing change. The dressing change was completed at 10:20 a.m. During an interview, on 9/20/24 at 10:30 a.m., Licensed Practical Nurse (LPN) 25 indicated she had just given Resident 18 a pain pill. The pain pill was given after the dressing change was completed. During an interview, on 9/20/24 at 10:37 a.m., RN 13 indicated she had spoken to Resident 18 prior to the dressing change, and she had no complaints of pain, she had misspoken earlier and didn't mean to say the resident was pre-medicated prior to the dressing change. During an interview, on 9/20/24 at 11:14 a.m., Resident 18 indicated her left foot was sore and proceeded to lift it up to show which foot it was. Resident 18's record was reviewed on 9/18/24 at 2:19 p.m. The profile indicated the resident's diagnoses included, but were not limited to, pressure ulcer of unspecified heel (injury to skin and underlying tissue resulting from prolonged pressure on the skin). A significant change in status Minimum Data Set (MDS) assessment, dated 7/16/24, indicated the resident had severe cognitive deficit and had a pain assessment completed with a score of 8 out of 10. A care plan, dated 2/2/24, indicated the resident had acute/chronic pain. Interventions included, but were not limited to, anticipate the resident's need for pain relief and respond immediately to any complaint of pain and evaluate the effectiveness of pain interventions per policy. A physician order, dated 7/9/24, indicated to administer Norco 10/325 mg (milligram) one tablet by mouth every 4 hours as needed for pain. A physician order, dated 7/10/24, indicated to monitor for pain every shift, attempt non- pharmacological interventions for pain management such as, relaxation, light touch, imagery, exercise, music, etc. every shift two times a day. A physician order, dated 9/13/24, indicated to apply Santyl (used to remove damaged tissue from chronic skin ulcers) external ointment 250 unit/GM (gram) to wound beds topically one time a day for healing. Apply Santyl to heel and lateral wound bed of left foot, calcium alginate to wound bed, skin prep to surrounding skin, apply telfa (non-adherent dressing) and kerlix wrap, then ace bandage. A pain assessment completed on 9/18/24 at 10:26 a.m., Resident 18 indicated her pain was a 6 on a numerical scale. A pain assessment completed on 9/20/24 at 10:30 a.m., Resident 18 indicated her pain was a 6 on a numerical scale. The Medication Administration Record (MAR) indicated Resident 18 was given a Norco at 10:30 a.m. for pain. A weekly pressure ulcer evaluation, dated 9/12/24, indicated the resident complained of pain during the wound debridement and dressing change. A weekly pressure ulcer evaluation, dated 9/5/24, indicated the resident complained of pain during the wound debridement and dressing change. A weekly pressure ulcer evaluation, dated 9/29/24, indicated the resident complained of pain during the wound debridement and dressing change. During an interview, on 9/20/24 at 10:42 a.m., the Regional Director of Clinical Services (RDCS) indicated staff would be educated on assessing for pain prior to wound dressing changes. She indicated the nurse should have stopped the dressing change on Resident 18 as soon as she complained of pain and offered her a pain pill. The dressing change then could have been completed after the medication had time to decrease her pain. On 9/20/24 at 11:05 a.m., the RDCS provided a document, with a revised date of March 2015, titled, Level Pain Assessment and Management, and indicated it was the policy currently being used by the facility. The policy indicated, .a. Assessing the potential for pain; b. Effectively recognizing the present of pain; c. Identifying characteristics of pain .4. It is important to recognize cognitive, cultural, familial, or gender-specific influences on the resident's ability or willingness to verbalize pain .2. Possible Behavioral Signs of Pain: a. Verbal expressions such as groaning, crying, screaming; b. Facial expressions such as grimacing, frowning, clenching of the jaw etc; .f. Guarding, rubbing, or favoring a particular part of the body 3.1-37(a)

Based on interview and record review, the facility failed to ensure care plan meetings were conducted quarterly for 3 of 16 residents reviewed for care plan meetings (Residents 3, 6, and 12). Findings include: 1. During an interview, on 9/17/24 at 9:58 a.m., Resident 3 indicated she could not remember being invited to or attending a care plan meeting recently. She could not recall when the last one was. Resident 3's record was reviewed on 9/17/24 at 1:28 p.m. A quarterly Minimum Data Set (MDS) assessment, dated 7/29/24, indicated the resident had no cognitive impairment. A care plan note, dated 3/26/24 at 10:30 a.m., indicated a care plan meeting was conducted on this day for Resident 3. Resident 3's record lacked documentation of quarterly care plan meetings being conducted in the last 12 months. The resident only had one care plan meeting in the last year. During an interview, on 9/17/24 at 2:27 p.m., the Social Service Director (SSD) indicated she unable to find any additional documentation of quarterly care plan meetings being conducted for Resident 3. She indicated she had not been in this position long at this facility and she was aware they were behind on the meetings. The SSD indicated the care plan meetings should be conducted quarterly on each resident. 2. During an interview, on 9/16/24 at 10:59 a.m., Resident 6 indicated she was not aware if the facility had care plan meetings because she does not remember being invited to or attending one. Resident 6's record was reviewed on 9/17/24 at 2:52 p.m. A quarterly Minimum Data Set (MDS) assessment, dated 7/31/24, indicated the resident had no cognitive impairment. A care plan note, dated 2/19/24 at 2:23 p.m., indicated a care plan meeting was conducted on this day for Resident 6. A care plan note, dated 11/28/23 at 10:22 a.m., indicated a care plan meeting was conducted on this day for Resident 6. Resident 6's record lacked documentation of quarterly care plan meetings being conducted since 2/19/24. The resident only had two care plan meetings in the last year. During an interview, on 9/17/24 at 2:50 p.m., the Social Service Director (SSD) indicated she was unable to provide documentation of any care plan meetings being conducted since 2/19/24. 3. During an interview, on 9/16/24 at 2:01 p.m., Resident 12 indicated she did not remember being invited to or attend a care plan meeting recently. She indicated she had only remembered being to one the whole time she had been at the facility. Resident 12's record was reviewed on 9/17/24 at 3:04 p.m. A quarterly Minimum Data Set (MDS) assessment, dated 7/3/24, indicated the resident had no cognitive impairment. A care plan noted, dated 12/26/23 at 11:12 a.m., indicated a care plan meeting was conducted on this day for Resident 12. Resident 12's record lacked documentation of quarterly care plan meetings being conducted in the last 12 months. The resident only had one care plan meeting in the last year. During an interview, on 9/17/24 at 3:18 p.m., the Social Service Director (SSD) indicated she was unable to provide documentation of any care plan meetings being conducted since 12/26/23. On 9/17/24 at 3:09 p.m., the Director of Nursing (DON) provided a document, with a revised date of December 2016, titled, Resident Participation- Assessment/Care Plans, and indicated it was the policy currently being used by the facility. The policy indicated, .1. The resident and his or her legal representative are encouraged to attend and participate in the resident's assessment and in the development of the resident's person-centered care plan .7. A seven (7) day advance notice of the care plan conference is provided to the resident and his or her representative. Such notice is made by mail and/or telephone 3.1-35(e)

Based on record review and interview, the facility failed to ensure a care plan was created for dementia (the loss of cognitive functioning, thinking, remembering, and reasoning, to such an extent that it interferes with daily life and activities) for 1 of 1 residents reviewed for Preadmission Screening and Resident Review (PASRR) (Resident 2), and failed to ensure a person-center dementia care plan interventions were in place for 1 of 1 resident reviewed for dementia care (Resident 21). Findings include: 1. During an initial pool record review, on 9/17/24 at 9:41 a.m., a Level I PASRR was observed and indicated that Resident 2 required a Level II evaluation. Further review was required to locate the Level II evaluation information. A record review for Resident 2 was conducted on 9/18/24 at 11:16 a.m. The profile indicated the resident diagnoses included, but were not limited to, dementia with unspecified severity, without behavioral disturbance, psychotic (when you perceive or interpret reality in a very different way from people around you) disturbance, mood disturbance (a category of mental illnesses that affect a person's mood, or emotional state), and anxiety (a feeling of fear, dread, and uneasiness that can be a normal reaction to stress); and mild intellectual disabilities (a condition that affects a person's ability to learn, think, and adapt to their environment). A scanned document, dated 8/11/17, titled, Notice of PASRR Level I Screen Outcome, PASRR Level II Onsite Evaluation Required, indicated the PASRR Level I outcome required a Level II evaluation. The diagnoses evaluation indicated the resident had dementia/neurocognitive (a decrease in mental function caused by a medical disease, rather than a psychiatric illness) disorder, with significant short-term and long-term memory impairment. A scanned document, titled, Inappropriate Referral for PASRR/MI (mental illness) level II, dated 8/16/17, had #2 marked and indicated, Questions #2-5 would trigger a Level II assessment, but the person is excluded from the Level II because there is a diagnosis of dementia .without a primary diagnosis of major mental illness (MI) or any diagnosis of mental retardation/developmental disability A handwritten note below it indicated, dementia is primary impairment in executive functioning, memory impairment, and cognitive impairment A quarterly Minimum Data Set (MDS) Assessment, dated 7/2/24, indicated Resident 2 had a diagnosis of non-Alzheimer's dementia (a group of diseases characterized by progressive deficits in behavior, executive function, or language). During an interview on 9/19/24 at 2:17 p.m., the Regional Director of Clinical Services (RDCS) indicated she was unable to find information related to dementia or cognition in Resident 2's current or resolved/historical care plans. The resident had a diagnosis of dementia and should have had a related care plan. On 9/19/24 at 2:22 p.m., the RDCS provided a policy with a revised date of 7/23/09, titled, Care Planning and Interventions, and indicated it was the policy currently being used by the facility. The policy indicated, .Standard, the interdisciplinary team meets on a scheduled basis and develops an individualized care plan. Interdisciplinary means that professional disciplines, as appropriate, work together to provide the greatest benefit to the resident .Practice Guidelines .interventions for preventing avoidable declines in functioning or functional levels 34525 2. Resident 21's record was reviewed on 9/17/24 at 1:34 p.m. The profile indicated the resident's diagnoses included, but were not limited to, dementia with agitation (a condition where a person with dementia experiences restlessness and worry, and is unable to settle down), dementia with psychotic disturbance (occurs when a person with dementia experiences hallucinations and/or delusions), and anxiety disorder (a mental health condition that involves excessive and persistent feelings of fear, worry, dread, and uneasiness). A quarterly Minimum Data Set (MDS) assessment, dated 7/10/24, indicated the resident had moderate cognitive deficit and experienced behaviors of rejection of care and wandering. A care plan, dated 12/15/23 indicated the resident was at risk for exhibiting behaviors related to dementia diagnosis and had a history of behaviors. Interventions included, but were not limited to, code alert to right wrist and encourage resident to attend activities. The care plan lacked documentation of specific person-centered interventions. A care plan, dated 1/29/24, indicated the resident had behavior monitoring in place due to resident being resistive to care due to dementia. Interventions included, but were not limited to, allow the resident time to verbalize feelings and approach resident in non-threatening manner. The care plan lacked documentation of specific person-centered interventions. A review of the resident's Kardex (a system for organizing and referencing patient information, typically used by nurses), indicated the form lacked documentation of any person-centered information or interventions for the resident. A review of the staff assignment sheets indicated the sheets lacked documentation of any person-centered information or interventions for the resident. During an interview, on 9/17/24 at 3:08 p.m., the interim Director of Nursing (DON) indicated she had reviewed the resident's care plan, and she was unable to find any information that was specific to the resident. The care plan interventions were generic in nature. On 9/17/24 at 3:17 p.m., the interim DON provided a document, with a revised date of 9/2022, titled, Care Plans, Comprehensive Person-Centered, and indicated it was the policy currently being used by the facility. The policy indicated, .Policy Interpretation and Implementation .7. The care planning process will: .c. Incorporate the resident's personal and cultural preferences. 8 .Incorporate interventions to address cultural needs, psychosocial needs, mitigate/reduce risk for trauma related triggers .10. Identifying .and developing interventions that are targeted and meaningful to the resident 3.1-35(b)(1)

Based on record review and interview, the facility failed to ensure there was not a delay in treatment for a resident who had a fall with complaints of pain and discomfort for 1 of 1 resident reviewed for delay in treatment (Resident 18). Finding includes: Review of matrix form (a form with pertinent information regarding residents' condition provided by the facility) on 9/17/24 at 9:09 a.m., indicated Resident 18 had a fall with injury on 7/4/24. Resident 18's record was reviewed on 9/18/24 at 2:19 p.m. The profile indicated the resident's diagnoses included, but were not limited to, fracture of unspecified a part of neck of left femur (a serious injury that occurs when the top of the leg bone breaks below the hip joint), pressure ulcer of unspecified heel (injury to skin and underlying tissue resulting from prolonged pressure on the skin), and unspecified dementia (mild cognitive impairment as yet to be diagnosed as a specific type of dementia). A significant change in status Minimum Data Set (MDS) assessment, dated 7/16/24, indicated the resident had severe cognitive deficit and had a pain assessment completed with a score of 8 out of 10. The resident was marked yes as having a fall while in the facility. A care plan, dated 2/2/24, indicated the resident had acute/chronic pain. Interventions included, but were not limited to, anticipate the resident's need for pain relief and respond immediately to any complaint of pain and evaluate the effectiveness of pain interventions per policy. A care plan, dated 2/2/24, indicated the resident was a high risk for falls. Interventions included, but were not limited to, 2 staff assist with all transfers, follow facility fall protocol, and anticipate and meet the resident's needs. A nursing note, dated 7/4/24 at 5:22 p.m., indicated Resident 18 was yelling for help and was found to be laying on her left side on the floor. Resident attempted to transfer herself out of her recliner and fell . Resident was assessed for injury, and none noted. The resident was able to move all extremities normally. The resident did complain of left leg pain. The resident was assisted to the bathroom and then to dining room for dinner. A message was left on the on-call phone for MD (Medical Doctor) notification and left a message for Director of Nursing (DON) per note. A nursing note, dated 7/4/24 at 6:24 p.m., indicated Resident 18 was complaining of increased pain to left leg, and were awaiting the physician's response. The record lacked documentation of any new orders. A nursing note, dated 7/5/24 at 3:45 a.m., indicated the resident had denied pain but was favoring her left side while ambulating. The record lacked documentation of the physician being notified. A nursing note, dated 7/5/24 at 12:09 p.m., indicated the resident was resting in bed and had showed signs of pain while assessing her range of motion after recent fall. The resident groaned and stated she was in pain. The resident's pain appeared to be in the left hip. Physician was notified and an order for an x ray obtained. The record lacked documentation of an x-ray being completed on this day. A hospital triage notes, dated 7/6/24 at 12:41 a.m., indicated the resident had arrived to the emergency room from a fall 2 days ago at a facility with complaints of pain to buttocks and had tenderness to palpation to the left hip. An x-ray report, dated 7/6/24 at 2:10 a.m., indicated the resident had a left femoral neck fracture. A nursing note, dated 7/6/24 at 2:26 a.m., indicated the resident was sent to the hospital for a decline in her condition. The physician was notified and gave verbal orders to transfer her out to the hospital. During an interview, on 9/19/24 at 1:32 p.m., Licensed Practical Nurse (LPN) 14 indicated the nursing staff had several different ways they could contact the on-call physician. They had a secure messaging system they could use, and the physician can respond back on the system, there was an on-call cell phone number you could call, and during office hours they can call the physician's office. During an interview on 9/19/24 at 1:49 p.m., the Regional Director of Clinical Services (RDCS) indicated the facility had recently had a mock survey and they had identified a delay in treatment for Resident 18's fall on 7/4/24. They had already started an action plan during their QAPI (Quality Assurance and Performance Improvement) meeting. The licensed and certified nursing staff would be provided with education on fall prevention, post fall assessments, post fall pain management, delay in treatment, and send to emergency room if significant injury was suspected unless declined by physician. During an interview, on 9/19/24 at 3:15 p.m., the RDCS indicated the nursing staff may send out a resident without a physician order in the case of an emergency. On 9/19/24 at 2:02 p.m., the RDCS provided a document, with a revised date of March 2018, titled, Acute Condition Changes-Clinical Protocol, and indicated it was the policy currently being used by the facility. The policy indicated, .8. Nursing staff will contact the physician based on the urgency of the situation. For emergencies they will call or page the physician and request a prompt response (within approximately one-half hour or less). 9. The attending physician (or a practitioner providing backup coverage) will respond in a timely manner to notification of problems or changes in condition and status. a. The nursing staff will contact the medical director for additional guidance and consultation if they do not receive a timely or appropriate response 3.1-37

Based on interview and record review, the facility failed to provide adequate supervision to prevent falls for 1 of 3 residents reviewed for falls. Interventions were not implemented to prevent the resident from falling. The fall resulted in the resident hospitalized for [REDACTED]. (Resident 31) Findings include: On 1/18/18 at 2:15 P.M., Resident 31's clinical record was reviewed. The Progress Notes included, but were not limited to: 10/29/17 at 8:50 P.M.: Res (resident) has been confused with hallucinations all evening, told writer she knew where she was but with further questioning Res stated 'this is Indianapolis isn't it'. Re-orientation attempted without success. Res has been talking to '(husbands name)' who is not here, & (and) looking for her mother since supper. 2x's (two times) Res took off with her spouse pushing him down the hall toward his room, redirected ea (each) time & explained that is wasn't safe for her to push his chair d/t (due to) her being in a w/c (wheelchair). Res spouse was put to bed approx. (approximately) 8 (eight) pm (sic), Writer (sic) has explained to Res several times since then that spouse can't sleep in her bed . & she can't sleep in his . Returned Res to her room multiple times, have attempted re-orientation, offered food, fluids, TV, magazines, toilet, Res cont (continues) to think '(husbands name)' was in the room with her, has stopped looking for her mother. Res very restless, staff 1:1 (one to one) with Res for last 30 (thirty) min (minutes). Contacted (name of son) @ (at) this time, he stated he would come up & see if he could calm her down. 10/30/17 at 1:00 A.M.: Res got out of ed per self, writer found her in her room attempting to clean up water off of floor. Writer told Res that I would take care of it, Res stated 'Oh it's everywhere, in here, in bathroom, & in (male name) room', Writer assisted Res to recliner & cleaned up water. (sic) asked Res if she would like another drink, Res stated yes, handed writer a cup of pop & said 'this is (name of person) he left it a little while ago' (Name of person) has not been here. Res given fresh ice water, offered snack, refused. Res brought to nurse station. 10/30/17 at 3:00 A.M.: Res has been rolling around in w/c, fluids taken well, doesn't know where she is 10/30/17 at 5:52 A.M.: Res transferred self to w/c & came up front . Res wheeled self around for a while then went to spouse's room & got in recliner 10/30/17 at 3:05 P.M.: .Resident very confused this shift stating that she vomited every where and had to throw her sweater away, non compliant with asking for assistance stands up and transfers self-alarm sounds and summons staff to resident 10/30/17 at 10: 41 P.M.: patient (sic) is shutting off alarm and getting out of bed without asking for help. She is now changing out of her gown and into clothes saying that she wants to go to Indy. 10/31/17 at 3:18 A.M.: Stayed up until 0230 (2:30 A.M.). Keeps asking to leave building. Shuts off alarm. 11/3/17 at 9:08 A.M.: Reported to Physician about holding BP (blood pressure) meds (medication) this am (morning). d/t (sic) BP only 90/62 . 11/3/17 at 2:35 P.M.: Called to residents room by aid, resident laying on her back in bathroom floor. Resident was not responding, gasping for breath, and eyes rolled back VS (vital signs) 158/80 (blood pressure), pulse was 156. Ambulance called and report given to (Name of Hospital) ER (emergency room ) nurse. Has large hematoma on back of rt (right) side of head, but did start responding after getting her up in w/c. Speech was very slurred and not processing well. 11/3/17 at 4:15 P.M.: (Name of Hospital) ER nurse called to report resident has Bilat (bilateral) Subdural Hematoma and are life lining her to (Name of City) hospital . 11/5/17 at 9:17 A.M.: hospital called to inform facility that resident had just passed away . The Care Plans included, but were not limited to: The resident has potential for falls related to unaware of safety needs, unsteady gait. Had a fall at home 9/17/17. Walked without assistive device prior to admission, initiated on 11/1/17. The interventions included, but were not limited to: Encourage resident to call for assist with transfers if feeling dizzy or unsteady, initiated on 11/1/17, created on 11/6/17. Anticipate and meet the residents needs, initiated on 11/1/17, created on 11/6/17. Quarterly and prn (as needed) fall assessments, initiated on 11/1/17, created on 11/6/17, PT/OT as ordered, initiated on 11/1/17, created on 11/6/17. The resident requires assist with Activities of Daily Living due to weakness related to hospitalization for [MEDICAL CONDITION] and [MEDICAL CONDITION], initiated on 10/29/17. The interventions included, but were not limited to: The resident will complete transfers with limited assistance at times requires extensive assist of 2, initiated on 10/29/17, created on 10/30/17. The resident will complete toileting tasks with limited to at times requires extensive assistance, initiated on 10/29/17, created on 10/30/17. The Fall Risk Assessment, dated 10/29/17, indicated Resident 31 was a low risk for falls. The Fall Risk Assessment further indicated Resident 31 had no history of falls and was either alert and oriented or comatose. The PT (Physical Therapy) Treatment Note, dated 11/3/17, indicated Resident 31 seemed very confused. On 1/19/18 at 9:00 A.M., the fall incident report was reviewed. An undated timeline of events included, but was not limited to: 11/3/17: 9:00 A.M.: Blood pressure down, reported to MD. By noon: increased participation and blood pressure up. At approximately 1:50 p.m., resident was sitting up by nurses station holding husbands hand, approximately 2:05-2:10 P.M., CNA's were passing snacks and checking on residents, resident call light was on and they responded to it. The CNA asked if she wanted to go to bed and resident stated No. Resident was sitting in wheelchair. Approximately 10 minutes later resident call light came on again and staff responded before CNA could get to the nurses station the ER light sounded and staff immediately responded and found resident laying on back feet facing doorway and pants pulled down. A handwritten note, signed by RN 7 indicated on 11/3/17 at 5:00 P.M., RN 7 had spoke with the physician who had indicated there was a possibility Resident 31 had a brain bleed prior to the fall, especially where she had problems since admission. A CAT scan of Resident 31's brain at the first hospital, indicated Resident 31 had an acute bilateral subarachnoid hemorrhage, acute left subdural hematoma, and 2.4 mm 9 millimeter left to right submachine herniation likely represent of a contrecoup injury. Possible focal [MEDICATION NAME] versus subdural component of hemorrhage seen in the left frontal region. Large right parietal scalp hematoma. A Neurology Consultation, dated 11/4/17, included but was not limited to: History: She was found to have come traumatic subarachnoid hemorrhage +/- (plus or minus) some small contusions in the left sylvian region primarily. Today she is not responsive and she declined overnight and CAT scan shows a much larger hemorrhage Examination: .CAT scans were reviewed and the first one was not very dramatic but had a fair amount of subarachnoid hemorrhage and the following scan done this morning shows large amount of hemorrhage involving much of her temporal lobe on the left side toward the convexity quite a ways. There is a very impressive amount of blood. There is also some contusional injury on the opposite side I think her large hemorrhage is due to the Xarelto (a blood thinning medication) and just a lot of underlying injury as well as low brain density given her age. On 1/9/19 at 12:00 P.M., the DON indicated Resident 31 was confused upon admission. The DON indicated they had provided one to one supervision and brought the resident to the nursing station to prevent falls. The DON indicated the nursing staff had put alarms on the resident initially as a nursing measure. On 1/23/18 at 9:32 A.M., PTA 1 indicated Resident 31 was confused on 11/3/17, required contact guard or stand by assistance, and required frequent verbal cueing for safety awareness. PTA 1 indicated Resident 31's surface cognition appeared intact but further conversation revealed Resident 31 was confused. On 1/23/18 at 11:06, the Administrator provided the Safety and Supervision of Residents policy, revised 12/2007. The policy included, but was not limited to: Staff shall use various sources to identify risk factors for residents, including the information obtained from the medical history, physical exam, observation of the resident, and the MDS. The interdisciplinary care team shall analyze information obtained from assessments and observations to identify any specific accident hazards or risk for that resident. The care team shall target interventions to reduce the potential for accidents 3.1-45(a)(2)

Based on observation, interview, and record review, the facility failed to ensure effective safety interventions and/or supervision were provided, in that, effective interventions were not implemented to prevent further falls for a Resident identified as having cognitive impairment and assessed to be at risk for falls for 1 of 3 residents that were reviewed for falls. This deficient practice resulted in Resident #14 experiencing 6 falls and experiencing 3 fractures. (Resident #14) Findings include: On 12/15/14 at 10:32 A.M., Resident #14 was observed on the bed in her room. The clinical record of Resident #14 was reviewed on 12/16/14 at 2:00 P.M. The record indicated Resident #14 was admitted on [DATE] with [DIAGNOSES REDACTED]. The Quarterly MDS (Minimum Data Set) assessment dated [DATE] indicated Resident #14 experienced severe cognitive impairment, required the assistance of 2 staff with transfers, and was always incontinent and required the assistance of 2 staff for toileting. A Care Plan for falls dated 08/29/14 through 12/8/14 read as follows: "...Interventions...10/26/14 Fall Intervention to take to BR (bathroom) before putting in bed..." The Fall Risk Evaluation dated 6/10/14, provided by the Director of Nursing on 12/17/14, indicated Resident #14 was at risk for falls. The Incident Reports, provided by the Director of Nursing on 12/17/14 at 3:15 P.M., indicated Resident #14 fell on the following days: Fall # 1 occurred on 9/04/14 at 1445 (2:45 P.M.). "Resident #14 slid from the bed to the floor... Alarm batteries were replaced..." Fall # 2 occurred on 9/15/14 at 2245 (10:45 P.M.). "Resident's alarm sounded but she was on the floor when CNA and I arrived. Bed alarm was all the way on edge of bed..." Fall # 3 occurred on 10/26/14 at 11:30 A.M. "Resident was in bed...staff heard pressure pad alarm...resident was sitting on mat beside bed...said she had to go to BR (bathroom)...Staff took resident to the BR and she voided and was put back up in chair...Interventions take resident to BR before putting to bed." Fall # 4 occurred on 11/21/14 at 1310 (1:10 P.M.). "Res (Resident) found on mat beside bed with head facing floor. She had tried to get up without assist (assistance)...alarm was sounding...Has bed bolster et (and) a wedge which had come loose when she crawled over it..." A Nurse's Note dated 11/21/14 at 1420 (2:20 P.M.) read as follows: "Called Dr. (Doctor) et (and) reported NO (new orders) received to send to ER (emergency room ) for CT (Cat Scan)...forehead Eval hip to see if she needs x-ray..." Fall # 5 occurred on 11/22/14 at 1745 (5:45 P.M.). "Resident was in another residents room alarm was sounding found her sitting in front of her W/C (wheelchair) states she was trying to get in bed..." Fall # 6 A Nurse's note dated 12/07/14 at 1820 (6:20 P.M.) read as follows: "Resident was in the hallway in her w/c alarm was sounding found resident laying on the floor on her L (left) side in front of her wheelchair...cut...bridge of nose...nose swollen and bleeding out R (right) nostril. upper lip swollen...eyes closed and would not respond to me for 30-45 seconds...called the ambulance..." The ED (Emergency Department) Report dated 12/7/14 was provided by the Director of Nursing and read as follows: "...Chief complaint: Fall...History of falls...Closed fracture of malar and/or maxillary bones; Closed fracture of nasal bones; Closed fracture of rib..." During an interview on 12/15/14 at 11:15 A.M., CNA #1 indicated Resident #14 recently fell out of her wheelchair and experienced a fractured rib and nose. CNA #1 said, "when Resident #14 gets in her wheelchair she takes off fast." On 12/17/14 at 3:57 P.M., the Health Care Administrator provided a copy of the Policy and Procedure "FALL RISK/FALL POLICY AND PROCEDURE" and it read as follows: "...5. Residents who have fallen will be reviewed by the Fall Committee to evaluate the effectiveness of the interventions..." During an interview on 12/17/14 at 3:15 P.M., the MDS nurse indicated Resident #14 should have been toileted before lying down in bed, but she failed to add toileting before bed to the care plan. During an interview with the DON on 12/17/14 at 4:00 P.M., the DON indicated more supervision was needed to prevent the falls and fractures Resident #14 experienced. During an interview on 12/17/14 at 4:15 P.M., the Health Care Administrator indicated more supervision was needed to prevent the problems Resident #14 with her falls. 3.1-45(a)(2)

Based on observation, interview, and record review, the facility failed to ensure the Administrator was immediately notified of alleged sexual abuse, for 1 of 7 residents reviewed for abuse, in a sample of 8. (Resident D) This deficient practice had the potential to affect 26 of 26 residents residing in the facility who were at risk being abused by the accused staff member (LPN # 1). This deficient practice resulted in Immediate Jeopardy. The Immediate Jeopardy was identified on 5/21/14 and began on 5/19/14. The Administrator was notified of the Immediate Jeopardy at 2:38 P.M. on 5/21/14. The Immediate Jeopardy was removed on 5/23/14, but the facility remained out of compliance at the lower scope and severity level of widespread, no actual harm with potential for more than minimal harm that is not immediate jeopardy, because all staff had not been re-inserviced on the policy of abuse and where the posted numbers of administrative staff were located. Findings include: 1. On 5/20/14 at 3:30 P.M., the clinical record of Resident D was reviewed. [DIAGNOSES REDACTED]. An admission Minimum Data Set (MDS) assessment, dated 4/24/14, indicated the resident had no speech, was rarely/never understood, and rarely/never understands others. The MDS assessment indicated the resident was unable to perform a brief interview for mental status, and was severely impaired in cognitive skills for daily decision making. The resident was totally dependent on two+ staff for bed mobility, transfer, and personal hygiene. On 5/20/14 at 12:40 P.M., the Administrator provided an "Indiana State Department of Health Incident Report Form," dated 5/19/14. The form included: "Incident Date: 5-19-14, Incident Time: 2:05 A.M., Resident Name: (Resident D)...Diagnosis: [REDACTED].# 1), Staff Name: (CNA # 1), Brief Description of Incident: "6am - I received a call from (CNA # 1) (Night Shift CNA) stating that he took a smoke break at 2 am on Monday 19th and got back at 2:05 am. He then reported to (Resident D's) room. The door was shut and he proceeded to knock twice and enter the room to see if (LPN # 1) (Night Shift LPN) needed assistance. When he entered the room the privacy curtain was pulled to block the foot of the bed but the blinds were open and (CNA # 1) reported to have witnessed (LPN # 1) pull his pants up really fast through the reflection of the glass window. (CNA # 1) continued around the privacy curtain and found (LPN # 1) positioning a pillow under (Resident D). When he stood up his shirt was tucked in the front of his pants. (Resident D) was positioned on her left side facing the wall with her night gown half on ((Resident D) is known for coming out of her clothes). Her bottom was uncovered or exposed facing (LPN # 1). (CNA # 1) asked (LPN # 1) what he was doing. (LPN # 1) said he was cleaning her peg tube. (LPN # 1) then went to the bathroom to wash hands while (CNA # 1) covered up (Resident D) and lowered her bed. They then exited the room. (LPN # 1) became shaky and started following (CNA # 1) around consistently asking him what he was doing. (CNA # 1) attempted to call the Administrator and DNS (Director of Nursing Services) but felt intimidated by (LPN # 1's) size. (CNA # 1) reported that he in-turn started following (LPN # 1) around to keep an eye on him. (CNA # 1) left the faciity on ce day shift reported to duty around 6 a.m. This is when (CNA # 1) called the Administrator and the Director of Nursing to report what he allegedly saw. Administrator (name) and DNS (name) educated (CNA # 1) on the importance of reporting allegations of abuse or neglect immediately...." On 5/20/14 at 12:45 P.M., CNA # 1 was interviewed. CNA # 1 indicated he was working the night shift with LPN # 1. CNA # 1 indicated there was usually 1 nurse and 1 CNA who worked night shift. He indicated he had stepped outside for a smoke break, and came back in at approximately 2:05 A.M. He indicated he saw Resident D's door shut, and so he knocked and then walked in. He indicated the privacy curtain was pulled, but he could see the reflection in the window of LPN # 1 pulling his pants up "real quick." He indicated LPN # 1 had pulled up his pants so quickly that his shirt was still tucked part way in his pants. CNA # 1 indicated the resident was lying on her side, with her bare bottom exposed and her gown up around her neck. He indicated this was not unusual, as the resident did not sleep with a brief on, and she frequently tried to remove her gowns. He indicated he asked LPN # 1, "What are you doing?" and LPN # 1 responded that he was fixing the resident's peg tube. He indicated LPN # 1 "got real shaky." CNA # 1 indicated he called the Administrator and the Director of Nursing (DON) when he got off work at 6:00 A.M. He indicated he knew he should have called the Administrator and the DON immediately, but that he had to find their numbers, and that LPN # 1 kept watching him. On 5/20/14 at 4:00 P.M., the Administrator was interviewed. He indicated he received a phone call at approximately 6:00 A.M. from CNA # 1. CNA # 1 informed him of what he witnessed at approximately 2:00 A.M. The Administrator indicated he immediately counseled CNA # 1 that he should have called him immediately. On 5/21/14 at 9:45 A.M., hospital RN # 2 was interviewed. She indicated she was the "SANE" (Sexual Assault Nurse Examiner) who examined Resident D on 5/19/14. She indicated she performed several swabs of the resident's genital area, which were pink-tinged, and which would "indicate possible blood." RN # 2 indicated her exam revealed 2 lacerations in the "vaginal vault." RN # 2 indicated there was no other reason besides penetration that would have caused those lacerations. An Emergency Department record was reviewed at that time. The record, dated 5/19/14 at 9:00 A.M., indicated, "Neglect/Abuse...Exam of the perineum between anus and vagina reveals noted small amount of bright red blood. Superficial vaginal tear approximately 0.5 cm (centimeters) affected area is located at approximately 4 O'clock. Second superficial vaginal tear approximately 0.5 cm noted at 9 O'clock...Scant amount of blood noted in vaginal vault...." On 5/21/14 at 11:30 A.M., the DON was interviewed. She indicated she received a call on 5/19/14 from CNA # 1 at approximately 6:00 A.M. She indicated CNA # 1 informed her that he had something to tell her; that he had gone out for a smoke break, and when he came back in, he saw Resident D's door closed. He informed the DON he knocked, then pushed the door open, and saw a reflection in the mirror of (LPN # 1) pulling up his pants real fast. He indicated he thought LPN # 1 "was doing something to (Resident D)." The DON indicated she asked CNA # 1 when this happened, and he at first responded around 3:00 A.M, but then changed the time to 2:00 A.M. She indicated she immediately asked the CNA if he had informed the Administrator, and he indicated he had not. The DON indicated she told CNA # 1 he needed to call the Administrator right then, and she also contacted the Administrator. The DON indicated she called the facility, and LPN # 1 was giving LPN # 2 an end-of-shift report. The DON indicated she told LPN # 1 he needed to leave the facility immediately. 2. On 5/20/14 at 12:15 P.M., the Administrator provided the current facility policy on "Resident Abuse Policy and Procedure," undated. The policy included: "...Purpose: To ensure that all employees, residents, family members, consultants, physicians, and visitors are aware that mistreatment, neglect, and abuse of residents...is strictly forbidden by this facility. Definitions: 1. Abuse: The willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish...3. Sexual Abuse: Includes, but is not limited to sexual harassment, sexual coercion or sexual assualt...Procedure of Investigation Allegiations (sic) of Abuse:...2. Staff members of this facility who have concerns regarding abuse, neglect...are to report their concerns immediately to the charge nurse. The charge nurse will immediately notify Administrator and Director of Nursing...7. If the alleged concern involves the charge nurse, the allegations will be immediately reported to the Administrator, Director of Nursing and/or Social Services...." An Immediate Jeopardy was identified on 5/21/14. The Immediate Jeopardy began on 5/19/14 when staff who witnessed alleged sexual abuse did not immediately notify the Administrator. The Administrator was notified at 2:38 P.M. on 5/21/14 of the Immediate Jeopardy related to failure to immediately notify the Administrator of the alleged abuse, which allowed the alleged staff member to continue to work in the facility for approximately 4 additional hours. The Immediate Jeopardy was removed on 5/23/14 when through observations, interviews, and record reviews, it was determined the facility had implemented the plan of action to remove the Immediate Jeopardy and that the steps taken removed the immediacy of the problem. The facility suspended LPN # 1, reinserviced staff on the abuse policy, and posted the Administrator's phone number, along with other administrative staff, in different locations throughout the facility. Staff verbalized knowledge of the abuse prohibition policy, including immediately notifying the Administrator of suspected abuse. Even though the facility's corrective actions removed the Immediate Jeopardy, the facility remained out of compliance at a reduced scope and severity level of isolated, no actual harm with potential for more than minimal harm that is not immediate jeopardy. This Federal tag relates to Complaint IN 463. 3.1-28(c)

Based on observation, interview, and record review, the facility failed to implement their policy to ensure the Administrator was immediately notified of alleged sexual abuse, for 1 of 7 residents reviewed for abuse, in a sample of 8. (Resident D) This deficient practice had the potential to affect 26 of 26 residents residing in the facility who were at risk being abused by the accused staff member (LPN # 1). This deficient practice resulted in Immediate Jeopardy. The Immediate Jeopardy was identified on 5/21/14 and began on 5/19/14. The Administrator was notified of the Immediate Jeopardy at 2:38 P.M. on 5/21/14. The Immediate Jeopardy was removed on 5/23/14, but the facility remained out of compliance at the lower scope and severity level of widespread, no actual harm with potential for more than minimal harm that is not immediate jeopardy, because all staff had not been re-inserviced on the policy of abuse and where the posted numbers of administrative staff were located. Findings include: 1. On 5/20/14 at 3:30 P.M., the clinical record of Resident D was reviewed. [DIAGNOSES REDACTED]. An admission Minimum Data Set (MDS) assessment, dated 4/24/14, indicated the resident had no speech, was rarely/never understood, and rarely/never understands others. The MDS assessment indicated the resident was unable to perform a brief interview for mental status, and was severely impaired in cognitive skills for daily decision making. The resident was totally dependent on two+ staff for bed mobility, transfer, and personal hygiene. On 5/20/14 at 12:40 P.M., the Administrator provided an "Indiana State Department of Health Incident Report Form," dated 5/19/14. The form included: "Incident Date: 5-19-14, Incident Time: 2:05 A.M., Resident Name: (Resident D)...Diagnosis: [REDACTED].# 1), Staff Name: (CNA # 1), Brief Description of Incident: "6am - I received a call from (CNA # 1) (Night Shift CNA) stating that he took a smoke break at 2 am on Monday 19th and got back at 2:05 am. He then reported to (Resident D's) room. The door was shut and he proceeded to knock twice and enter the room to see if (LPN # 1) (Night Shift LPN) needed assistance. When he entered the room the privacy curtain was pulled to block the foot of the bed but the blinds were open and (CNA # 1) reported to have witnessed (LPN # 1) pull his pants up really fast through the reflection of the glass window. (CNA # 1) continued around the privacy curtain and found (LPN # 1) positioning a pillow under (Resident D). When he stood up his shirt was tucked in the front of his pants. (Resident D) was positioned on her left side facing the wall with her night gown half on ((Resident D) is known for coming out of her clothes). Her bottom was uncovered or exposed facing (LPN # 1). (CNA # 1) asked (LPN # 1) what he was doing. (LPN # 1) said he was cleaning her peg tube. (LPN # 1) then went to the bathroom to wash hands while (CNA # 1) covered up (Resident D) and lowered her bed. They then exited the room. (LPN # 1) became shaky and started following (CNA # 1) around consistently asking him what he was doing. (CNA # 1) attempted to call the Administrator and DNS (Director of Nursing Services) but felt intimidated by (LPN # 1's) size. (CNA # 1) reported that he in-turn started following (LPN # 1) around to keep an eye on him. (CNA # 1) left the faciity on ce day shift reported to duty around 6 a.m. This is when (CNA # 1) called the Administrator and the Director of Nursing to report what he allegedly saw. Administrator (name) and DNS (name) educated (CNA # 1) on the importance of reporting allegations of abuse or neglect immediately...." On 5/20/14 at 12:45 P.M., CNA # 1 was interviewed. CNA # 1 indicated he was working the night shift with LPN # 1. CNA # 1 indicated there was usually 1 nurse and 1 CNA who worked night shift. He indicated he had stepped outside for a smoke break, and came back in at approximately 2:05 A.M. He indicated he saw Resident D's door shut, and so he knocked and then walked in. He indicated the privacy curtain was pulled, but he could see the reflection in the window of LPN # 1 pulling his pants up "real quick." He indicated LPN # 1 had pulled up his pants so quickly that his shirt was still tucked part way in his pants. CNA # 1 indicated the resident was lying on her side, with her bare bottom exposed and her gown up around her neck. He indicated this was not unusual, as the resident did not sleep with a brief on, and she frequently tried to remove her gowns. He indicated he asked LPN # 1, "What are you doing?" and LPN # 1 responded that he was fixing the resident's peg tube. He indicated LPN # 1 "got real shaky." CNA # 1 indicated he called the Administrator and the Director of Nursing (DON) when he got off work at 6:00 A.M. He indicated he knew he should have called the Administrator and the DON immediately, but that he had to find their numbers, and that LPN # 1 kept watching him. On 5/20/14 at 4:00 P.M., the Administrator was interviewed. He indicated he received a phone call at approximately 6:00 A.M. from CNA # 1. CNA # 1 informed him of what he witnessed at approximately 2:00 A.M. The Administrator indicated he immediately counseled CNA # 1 that he should have called him immediately. On 5/21/14 at 9:45 A.M., hospital RN # 2 was interviewed. She indicated she was the "SANE" (Sexual Assault Nurse Examiner) who examined Resident D on 5/19/14. She indicated she performed several swabs of the resident's genital area, which were pink-tinged, and which would "indicate possible blood." RN # 2 indicated her exam revealed 2 lacerations in the "vaginal vault." RN # 2 indicated there was no other reason besides penetration that would have caused those lacerations. An Emergency Department record was reviewed at that time. The record, dated 5/19/14 at 9:00 A.M., indicated, "Neglect/Abuse...Exam of the perineum between anus and vagina reveals noted small amount of bright red blood. Superficial vaginal tear approximately 0.5 cm (centimeters) affected area is located at approximately 4 O'clock. Second superficial vaginal tear approximately 0.5 cm noted at 9 O'clock...Scant amount of blood noted in vaginal vault...." On 5/21/14 at 11:30 A.M., the DON was interviewed. She indicated she received a call on 5/19/14 from CNA # 1 at approximately 6:00 A.M. She indicated CNA # 1 informed her that he had something to tell her; that he had gone out for a smoke break, and when he came back in, he saw Resident D's door closed. He informed the DON he knocked, then pushed the door open, and saw a reflection in the mirror of (LPN # 1) pulling up his pants real fast. He indicated he thought LPN # 1 "was doing something to (Resident D)." The DON indicated she asked CNA # 1 when this happened, and he at first responded around 3:00 A.M, but then changed the time to 2:00 A.M. She indicated she immediately asked the CNA if he had informed the Administrator, and he indicated he had not. The DON indicated she told CNA # 1 he needed to call the Administrator right then, and she also contacted the Administrator. The DON indicated she called the facility, and LPN # 1 was giving LPN # 2 an end-of-shift report. The DON indicated she told LPN # 1 he needed to leave the facility immediately. 2. On 5/20/14 at 12:15 P.M., the Administrator provided the current facility policy on "Resident Abuse Policy and Procedure," undated. The policy included: "...Purpose: To ensure that all employees, residents, family members, consultants, physicians, and visitors are aware that mistreatment, neglect, and abuse of residents...is strictly forbidden by this facility. Definitions: 1. Abuse: The willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish...3. Sexual Abuse: Includes, but is not limited to sexual harassment, sexual coercion or sexual assualt...Procedure of Investigation Allegiations (sic) of Abuse:...2. Staff members of this facility who have concerns regarding abuse, neglect...are to report their concerns immediately to the charge nurse. The charge nurse will immediately notify Administrator and Director of Nursing...7. If the alleged concern involves the charge nurse, the allegations will be immediately reported to the Administrator, Director of Nursing and/or Social Services...." An Immediate Jeopardy was identified on 5/21/14. The Immediate Jeopardy began on 5/19/14 when staff who witnessed alleged sexual abuse did not immediately notify the Administrator. The Administrator was notified at 2:38 P.M. on 5/21/14 of the Immediate Jeopardy related to failure to immediately notify the Administrator of the alleged abuse, which allowed the alleged staff member to continue to work in the facility for approximately 4 additional hours. The Immediate Jeopardy was removed on 5/23/14 when through observations, interviews, and record reviews, it was determined the facility had implemented the plan of action to remove the Immediate Jeopardy and that the steps taken removed the immediacy of the problem. The facility suspended LPN # 1, reinserviced staff on the abuse policy, and posted the Administrator's phone number, along with other administrative staff, in different locations throughout the facility. Staff verbalized knowledge of the abuse prohibition policy, including immediately notifying the Administrator of suspected abuse. Even though the facility's corrective actions removed the Immediate Jeopardy, the facility remained out of compliance at a reduced scope and severity level of isolated, no actual harm with potential for more than minimal harm that is not immediate jeopardy. This Federal tag relates to Complaint IN 463. 3.1-28(a)

Based on observation, interview, and record review, the facility failed to ensure a resident was free from sexual abuse, for 1 of 7 residents reviewed for abuse, in a sample of 8. (Resident D) This deficient practice resulted in Immediate Jeopardy. The Immediate Jeopardy was identified on 5/21/14 and began on 5/19/14. The Administrator was notified of the Immediate Jeopardy at 2:38 P.M. on 5/21/14. The Immediate Jeopardy was removed on 5/23/14, but the facility remained out of compliance at the lower scope and severity level of isolated, no actual harm with potential for more than minimal harm that is not immediate jeopardy, because all staff had not been re-inserviced on the policy of abuse and where the posted numbers of administrative staff were located. Findings include: 1. On 5/20/14 at 3:30 P.M., the clinical record of Resident D was reviewed. [DIAGNOSES REDACTED]. An admission Minimum Data Set (MDS) assessment, dated 4/24/14, indicated the resident had no speech, was rarely/never understood, and rarely/never understands others. The MDS assessment indicated the resident was unable to perform a brief interview for mental status, and was severely impaired in cognitive skills for daily decision making. The resident was totally dependent on two+ staff for bed mobility, transfer, and personal hygiene. Nurse's Notes included the following notations: 5/19/14 at 7:15 A.M.: "DON (Director of Nursing) called facility said she had talked (with) (physician name) on an allegation of sexual abuse and has an order to send resident to (hospital name) ER to have rape kit used...." 5/19/14 at 8:00 A.M.: "(Ambulance service) here to take resident per stretcher to (hospital name) sent staff member (with) resident." 5/19/14 at 8:45 A.M. "L.E. (late entry) for 5-19-14 @ 0555 (5:55 A.M.). Rc'd (received) call @ home per (CNA # 1), who informed DON that night nurse (LPN # 1) was acting in an inappropriate manner in res. (resident) room this a.m...." 5/19/14 at 3:00 P.M.: "Res. returned from (hospital) @ this x (time)...." On 5/20/14 at 12:40 P.M., the Administrator provided an "Indiana State Department of Health Incident Report Form," dated 5/19/14. The form included: "Incident Date: 5-19-14, Incident Time: 2:05 A.M., Resident Name: (Resident D)...Diagnosis: [REDACTED].# 1), Staff Name: (CNA # 1), Brief Description of Incident: "6am - I received a call from (CNA # 1) (Night Shift CNA) stating that he took a smoke break at 2 am on Monday 19th and got back at 2:05 am. He then reported to (Resident D's) room. The door was shut and he proceeded to knock twice and enter the room to see if (LPN # 1) (Night Shift LPN) needed assistance. When he entered the room the privacy curtain was pulled to block the foot of the bed but the blinds were open and (CNA # 1) reported to have witnessed (LPN # 1) pull his pants up really fast through the reflection of the glass window. (CNA # 1) continued around the privacy curtain and found (LPN # 1) positioning a pillow under (Resident D). When he stood up his shirt was tucked in the front of his pants. (Resident D) was positioned on her left side facing the wall with her night gown half on ((Resident D) is known for coming out of her clothes). Her bottom was uncovered or exposed facing (LPN # 1). (CNA # 1) asked (LPN # 1) what he was doing. (LPN # 1) said he was cleaning her peg tube. (LPN # 1) then went to the bathroom to wash hands while (CNA # 1) covered up (Resident D) and lowered her bed. They then exited the room. (LPN # 1) became shaky and started following (CNA # 1) around consistently asking him what he was doing. (CNA # 1) attempted to call the Administrator and DNS (Director of Nursing Services) but felt intimidated by (LPN # 1's) size. (CNA # 1) reported that he in-turn started following (LPN # 1) around to keep an eye on him. (CNA # 1) left the faciity on ce day shift reported to duty around 6 a.m. This is when (CNA # 1) called the Administrator and the Director of Nursing to report what he allegedly saw...." On 5/20/14 at 12:45 P.M., CNA # 1 was interviewed. CNA # 1 indicated he was working the night shift with LPN # 1. CNA # 1 indicated there was usually 1 nurse and 1 CNA who worked night shift. He indicated he had stepped outside for a smoke break, and came back in at approximately 2:05 A.M. He indicated he saw Resident D's door shut, and so he knocked and then walked in. He indicated the privacy curtain was pulled, but he could see the reflection in the window of LPN # 1 pulling his pants up "real quick." He indicated LPN # 1 had pulled up his pants so quickly that his shirt was still tucked part way in his pants. CNA # 1 indicated the resident was lying on her side, with her bare bottom exposed and her gown up around her neck. He indicated this was not unusual, as the resident did not sleep with a brief on, and she frequently tried to remove her gowns. He indicated he asked LPN # 1, "What are you doing?" and LPN # 1 responded that he was fixing the resident's peg tube. He indicated LPN # 1 "got real shaky." CNA # 1 indicated he called the Administrator and the DON when he got off work at 6:00 A.M. On 5/21/14 at 9:45 A.M., hospital RN # 2 was interviewed. She indicated she was the "SANE" (Sexual Assault Nurse Examiner) who examined Resident D on 5/19/14. She indicated she performed several swabs of the resident's genital area, which were pink-tinged, and which would "indicate possible blood." RN # 2 indicated her exam revealed 2 lacerations in the "vaginal vault." RN # 2 indicated there was no other reason besides penetration that would have caused those lacerations. An Emergency Department record was reviewed at that time. The record, dated 5/19/14 at 9:00 A.M., indicated, "Neglect/Abuse...Exam of the perineum between anus and vagina reveals noted small amount of bright red blood. Superficial vaginal tear approximately 0.5 cm (centimeters) affected area is located at approximately 4 O'clock. Second superficial vaginal tear approximately 0.5 cm noted at 9 O'clock...Scant amount of blood noted in vaginal vault...." On 5/21/14 at 11:30 A.M., the DON was interviewed. She indicated she received a call on 5/19/14 from CNA # 1 at approximately 6:00 A.M. She indicated CNA # 1 informed her that he had something to tell her; that he had gone out for a smoke break, and when he came back in, he saw Resident D's door closed. He informed the DON he knocked, then pushed the door open, and saw a reflection in the mirror of (LPN # 1) pulling up his pants real fast. He indicated he thought LPN # 1 "was doing something to (Resident D)." The DON indicated she asked CNA # 1 when this happened, and he at first responded around 3:00 A.M, but then changed the time to 2:00 A.M. On 5/21/14 at 12:10 P.M., CNA # 2 was interviewed. He indicated he started work at 5:00 A.M. on 5/19/14. He indicated CNA # 1 "looked really upset." He indicated he finally asked CNA # 1 what was wrong, and CNA # 1 told him he had gone out for a smoke break, and when he came back in at approximately 2:00 A.M., he saw Resident D's door closed. He indicated he went inside and saw a reflection in the window of LPN # 1 pulling up his pants really fast. CNA # 1 told him that LPN # 1 got "overly nervous" and red-faced. CNA # 2 indicated CNA # 1 was "visibly shaken and scared." CNA # 2 indicated he told CNA # 1 that he needed to call the DON "right now." CNA # 2 indicated he thought LPN # 1 "was acting strange, almost babbling," and talking to himself. CNA # 2 indicated CNA # 1 left the facility at that time, and called the Administrator and DON. 2. On 5/20/14 at 12:15 P.M., the Administrator provided the current facility policy on "Resident Abuse Policy and Procedure," undated. The policy included: "...Purpose: To ensure that all employees, residents, family members, consultants, physicians, and visitors are aware that mistreatment, neglect, and abuse of residents...is strictly forbidden by this facility. Definitions: 1. Abuse: The willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish...3. Sexual Abuse: Includes, but is not limited to sexual harassment, sexual coercion or sexual assualt...." An Immediate Jeopardy was identified on 5/21/14. The Immediate Jeopardy began on 5/19/14 when staff who witnessed alleged sexual abuse did not immediately notify the Administrator. The Administrator was notified at 2:38 P.M. on 5/21/14 of the Immediate Jeopardy related to failure to immediately notify the Administrator of the alleged abuse, which allowed the alleged staff member to continue to work in the facility for approximately 4 additional hours. The Immediate Jeopardy was removed on 5/23/14 when through observations, interviews, and record reviews, it was determined the facility had implemented the plan of action to remove the Immediate Jeopardy and that the steps taken removed the immediacy of the problem. The facility suspended LPN # 1, reinserviced staff on the abuse policy, and posted the Administrator's phone number, along with other administrative staff, in different locations throughout the facility. Staff verbalized knowledge of the abuse prohibition policy, including immediately notifying the Administrator of suspected abuse. Even though the facility's corrective actions removed the Immediate Jeopardy, the facility remained out of compliance at a reduced scope and severity level of isolated, no actual harm with potential for more than minimal harm that is not immediate jeopardy. This Federal tag relates to Complaint IN 463. 3.1-27(a)(1)

Based on observation, interview, and record review, the facility failed to ensure care was provided to a resident who was admitted to the facility without a pressure wound, for a resident who was assessed as high risk for development of a pressure wound, in that it resulted in the resident developing an unstageable pressure wound to the left outer foot for 1 of 1 residents who met the criteria for review of pressure. (Resident #21) Findings include: Resident #21 was observed on 10/22/13 at 10:00 A.M., lying in a reclining chair on her left side with the left foot encased in a podus boot (a device to relieve pressure to the heels). The left side of the podus boot was observed, at that time, to be in direct contact to the surface of the reclining chair. Resident #21 was observed on 10/23/13 at 12:30 P.M., lying in a reclining chair on her left side with the left foot encased in a podus boot. The left side of the podus boot was observed, at that time, to be in direct contact to the surface of the reclining chair. Resident #21 was observed on 10/23/13 at 1:15 P.M., in a bed with a podus boot on the left lower leg. The left side of the podus boot was observed to be in direct contact to the surface of the bed. During an interview, at that time, LPN #2 indicated Resident #21 had experienced a Stage 3 (A full thickness of skin is lost, exposing the subcutaneous tissues-presents as a deep crater with or without undermining adjacent tissue) wound to the left outer foot that measured approximately 1.5 cm (centimeters) X 1.5 cm. The wound bed was then observed to have necrotic tissue and minimal serous drainage. The clinical record of Resident #21 was reviewed on 10/23/13 at 2:00 P.M. The record indicated Resident #21 was admitted on [DATE]. The record further indicated the [DIAGNOSES REDACTED]. The most recent quarterly MDS (Minimum Data Set Assessment) dated 09/11/13 indicated Resident #21 experienced moderate cognitive impairment. The Assessment further indicated Resident #21 required total staff assistance of two for bed mobility and had a Stage 3 pressure wound. A Braden Scale Assessment (a tool to determine a resident's risk of developing areas of pressure) dated 04/10/13 indicated Resident #21 was a high risk to develop pressure. A Braden Scale assessment dated [DATE] indicated Resident #21 was a high risk to develop pressure. A Wound Care Nurse Progress Note dated 09/19/13 indicated, "High risk for skin breakdown. Has Stage 3 OA (open area) lt (left) outer foot. Podus boot with foam on at all times...Turned et (and) repositioned q (every) 2 hrs (hours)..." The most recent physician's orders [REDACTED]. A Wound Log dated 10/18/13 indicated Resident #21 experienced a facility acquired unstageable wound to left outer foot on 06/24/13. The log further indicated the interventions included, but were not limited to, "...positioning pillows, turning/positioning program..." The Wound Care Consultant notes dated 09/06/13 for the wound on the left outer foot indicated, "...Daily dressing change needed due to dressing becoming dislodged/compromised at site due to sheer (sic) and friction...Evaluation Comments...pressure relief to area." The Wound Care Consultant (WCC) notes dated 10/01/13 for the wound on the left outer foot indicated, "...Daily dressing change needed due to dressing becoming dislodged/compromised at site due to sheer (sic) and friction...Evaluation Comments...pressure relief to area." A Care Plan dated 06/24/13 and updated on 09/11/13 for Unstageable Area on Left outer foot included, but was not limited to, interventions of "Provide measures to decrease pressure...to skin: Pressure reducing mattress...". The care plan lacked any revision related to providing pressure relief to the left outer foot. During an interview on 10/23/13 at 2:40 P.M., the LPN #1 indicated the left foot of Resident #21 should have been floated to provide pressure relief. During an interview on 10/23/13 at 2:47 P.M., the DON indicated complete pressure relief should have been provided to the left outer foot of Resident #21. Resident #21 was observed on 10/28/13 at 11:13 A.M., lying in bed on her left side with the left foot encased in a podus boot. The left side of the podus boot was observed, at that time, to be in direct contact with the surface of the bed. During an interview on 10/28/13 at 11:15 A.M., CNA #3 indicated the left foot of Resident #21 had not been floated for pressure relief because he had not been instructed to float the left foot. During an interview on 10/28/13 at 11:19 A.M., the WCC #1 indicated the left foot of Resident #21 should be floated to promote healing. WCC #1 further stated, at that time, "...The best intervention for pressure (wounds) is to relieve the pressure...There should be something placed between the left lower leg and the surface of the bed or chair, so the left foot is floated..." The WCC #1 then indicated Resident #21 had been discovered in June 2013 and had been facility acquired. During an interview on 10/28/13 at 3:00 P.M., the DON (Director of Nursing) indicated the care plan had not been revised to included pressure relief to the left outer foot. The policy and procedure for Decubitus Ulcer-Prevention provided by the DoN on 10/28/13 at 2:30 P.M., indicated "... B. Moderate risk...Positioning...e. Use pillows, ...under...bony prominences..." 3.1-40 (a)(1)

Based on interview and record review, the facility failed to ensure a resident with a suprapubic catheter received appropriate care, in that the wrong port was used to flush the catheter, resulting in pain and discomfort, and also resulted in the need for a surgical procedure to be performed to remove a piece of a catheter balloon lodged in the bladder, for 1 of 1 residents reviewed with urinary catheters, in a sample of 12. Resident A Findings include: 1. On 6/13/13 at 11:00 A.M., LPN # 2 indicated Resident A was the only resident in the facility who had a urinary catheter. The clinical record of Resident A was reviewed on 6/13/13 at 3:55 P.M. [DIAGNOSES REDACTED]. Physician orders, initially dated 6/22/11 and on the May 2013 orders, indicated, "Flush suprapubic cath with 60 ml normal saline each night," and "Flush suprapubic cath (with) 10 ml normal saline as needed to maintain patency." A physician's orders [REDACTED]." An additional physician's orders [REDACTED]." Nurses notes included the following notations: 5/19/13 at 7:30 P.M.: "Res. (resident) c/o (complains of) feeling a 'pop' when cath flushed the last time et (and) now having extensive pain et discomfort. Foley catheter (changed). Noted that bulb on Foley did not appear to be intact. Notified (primary physician). N.O. (new order) UA C&S (urinalysis, culture and sensitivity), contact urology in AM. Notified DON (Director of Nursing). New 18F Foley inserted into suprapubic site using sterile technique, patent draining clear yellow urine...." 5/20/13 at 2:00 P.M.: "Called (Urologist) R/T (related to) res cath et bulb (not) intact. (Urologist) will do cystoscopy on 6/4/13 @ noon. Will order 3 way cath for res et (and) inservice nurses individually on flush procedure...." 5/22/13 at 1:00 P.M.: "Paged (primary physician) resident c/o burning and feeling like she has to void constantly...." 5/22/13 at 3:15 P.M.: "(Primary physician) return (sic) call. New order [MEDICATION NAME] (antibiotic)...for UTI (urinary tract infection)...." 6/3/13 at 5:00 P.M.: "Res in pain (with) catheter, flushed x 3, changed drsg (dressing) had odor...red around site...." 6/4/13 at 1:45 P.M.: "Return from hospital had a piece of cath in bladder was removed no new orders...." A hospital operating record, dated 6/4/13, indicated, "...presents with a history of suprapubic catheter. Recently at the nursing home her catheter was irrigated but irrigated through the wrong port. The balloon was inflated, popped, and when the catheter was removed there was a piece of balloon missing. She is brought at this time for cystourethroscopy and removal of the piece of the balloon...Cystourethroscopy was performed...A piece of latex was identified in the bladder consistent with the piece from her catheter balloon...." On 6/17/13 at 10:00 A.M., during interview with the Urologist, he indicated he was informed by the facility staff that a young nurse instilled water into the balloon port and a piece of the balloon ruptured. He indicated he removed the balloon piece, and "she should be fine." The Urologist indicated the facility had informed him the nurse was a young nurse who "didn't have a lot of Foley catheter experience." On 6/17/13 at 10:45 A.M., during interview with the current DON, she indicated she had been at the facility for approximately 3 weeks, and was not present during the incident with Resident A. She indicated she had been told that a nurse new to the facility, but not a "new nurse," flushed the wrong port on Resident A's catheter, causing the balloon to rupture. The DON indicated she did not know if LPN # 1 was nervous, or if it was dark in the room, or what the exact circumstances were. The DON indicated she was informed that LPN # 1 and all of the nurses were inserviced on the proper procedure of flushing a catheter, and that different catheters were ordered. 2. On 6/17/13 at 1:30 P.M., the DON provided a document, dated 5/21/13, which included: "(LPN # 1) was inserviced this dated in a one-to-one inservice by (RN # 1) DON regarding the proper flush procedure for (Resident A's) supra pubic catheter. DON demonstrated in a step by step fashion the proper procedure and port with which to flush (Resident A's) catheter without actually flushing the catheter. (LPN # 1) repeated process back to DON and flushed (Resident A's) catheter while being monitored. No errors were made and resident tolerated flush well without complaints." This federal tag relates to Complaint IN 252. 3.1-41(a)(1)

Based on observation, interview, and record review, the facility failed to ensure a resident was safely propelled in a wheelchair, causing the resident to fall forward and suffer multiple skin tears and bruising on her right leg, and pain in her foot, resulting in an emergency room visit, for 1 of 3 residents dependent on locomotion, in a sample of 4. Resident A Findings include: 1. On 4/22/13 at 11:20 A.M., Resident A was observed sitting in a wheelchair by the nursing station. Her right leg was observed to be wrapped The clinical record of Resident A was reviewed on 4/22/13 at 2:55 P.M. [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) assessment, dated 3/22/13, indicated the resident scored a 13 out of 15 for cognitive status, with 15 indicating no memory impairment. The MDS assessment indicated Resident A required total dependence of two+ staff for transfer, and did not ambulate. An Occupational Therapy progress report, dated 4/9/13, indicated, "Sitting Balance...Current Level of Function, Patient is...unable to maintain balance without mod/max (moderate/maximum) support...for 3 minutes due to balance dysfunction...." Nurse's Notes included the following notations: 4/14/13 at 9:45 A.M.: "Aide was bringing resident back into facility from smoking. Resident was in a regular w/c (wheelchair). Resident went to the right side aide had a hold of her coat she slide (sic) our of w/c on right side. Hit Rt (right) leg on leg rest as she went to the ground causing 2 skin tears on Rt leg under Rt knee one 3 cm (centimeter) and one 8 cm long by 4.5 cm wide...No c/o (complaints of) pain moves all extremities well...Paged (physician)...Intervention bring resident in and out of building in w/c backwards and to take resident out on front porch to smoke...." 4/14/13 at 6:50 P.M.: "Res (resident) c/o (complains of) (left) foot et (and) ankle pain. MD pages et awaiting return call...." 4/14/13 at 7:20 P.M.: "(Physician) notified of c/o pain. N.O. (new order) rec'd (received) send to (hospital) ER to (evaluate and treat)...." The resident was transferred to the emergency roiagnom on [DATE] at 7:55 P.M., and returned the same date at 10:55 P.M. A hospital instruction sheet indicated the resident obtained a "hematoma, contusion, bruise." A Nursing Care Plan, dated 4/14/13, indicated: "4/14/13, Problem, Resident fell out of w/c when CNA tried to bring in from smoking...Interventions, Pull Resident backward in w/c in and out of doors. Have maintenance man fix area w/c got caught on. 2 people to assist to get to smoking area safely to and from smoking...." On 4/23/13 at 10:15 A.M., during interview with the acting Director of Nursing (DON), she indicated on 4/14/13, Resident A was coming back in the facility from smoking, there was a dip in the threshold, and the wheelchair tipped forward. The DON indicated CNA # 1 grabbed the resident's coat to keep her from falling hard forward, but that Resident A still hit her leg on the leg rest. The DON indicated that maintenance "fixed it." At that time, the DON demonstrated where Resident A fell from her wheelchair. The DON pointed out where the facility parking lot met the sidewalk, there was a dip in the concrete. She indicated after the resident fell , the area was filled in with asphalt. A rubber mat was observed over this area. On 4/23/13 at 10:20 A.M., during interview with CNA # 1, she indicated on 4/14/13, she was assisting Resident A back in from the outside smoking area. CNA # 1 indicated someone else took Resident A out, and that she did not usually bring "the smokers back in." CNA # 1 indicated there was a dip in the concrete, and the front wheel of the wheelchair got caught in the dip, tipping the resident out. CNA # 1 indicated, "I guess I should have backed her over." On 4/23/13 at 11:25 A.M., a skin assessment was requested. Both lower legs were bruised and discolored. A hematoma and 3 large skin tears with multiple steri strips intact were observed on the resident's right lower leg. Resident A indicated the right leg didn't hurt "as bad as it looks," but that her left foot hurt worse. This federal tag relates to Complaint IN 593, Complaint IN 803, and Complaint IN 828. 3.1-45(a)(1)

Based on observation, interview, and record review, the facility failed to ensure a resident dependent for care did not develop an unstageable pressure area on his right heel and failed to implement interventions to promote healing of the pressure area, for 1 of 3 residents reviewed with pressure areas, in a sample of 4. (Resident #A) Findings include: 1. On 1/29/13 at 9:50 A.M., during the initial tour, the Director of Nursing (DON) indicated Resident #A was admitted to the facility with open areas on his legs and his heels. On 1/29/13 at 11:05 A.M., a skin assessment was requested. LPN # 1 indicated she was the Wound Care nurse who measured the areas weekly. Resident #A was observed lying in bed. LPN # 1 removed Resident #A's socks. A pressure area, approximately quarter-sized and 100 % black-gray in color, was observed on the resident's right outer heel. A dressing was not covering the area. The resident was not wearing any pressure-relieving boots. The resident's heels had not been floated off of the bed. LPN # 1 indicated the treatment to the pressure area was skin prep three times daily. LPN # 1 indicated the resident was admitted to the facility with the pressure area. On 1/29/13 at 11:50 A.M., LPN # 1 provided a "Weekly Pressure Ulcer Progress Report" for Resident #A. She indicated she was mistaken, that the pressure area was not present on admission, but was found on 1/7/13. LPN # 1 indicated she "probably should have obtained a change in treatment," but that there had been no change in the appearance of the area. The "Weekly Pressure Ulcer Progress Report" included the following: "...Rt (right) heel, 1/7/13, Unstageable, Size in cm (centimeters) (Length x Width) 1.2 x 1.5, Depth 0...Color black, Response to Treatment/Comments, Skin prep TID (three times daily)...Preventive Measures/Progress: Turned q (every) 2 hours..." Documentation regarding "Nutrition/Hydration Status" was left blank. The report indicated the same measurements, description, and treatment on 1/14/13, 1/21/13, and 1/28/13. A notation, dated 1/28/13, indicated, "Float heels." The clinical record of Resident #A was reviewed on 1/29/13 at 1:45 P.M. The resident's [DIAGNOSES REDACTED]. A care plan, dated 12/27/12, indicated a problem of "Potential for Skin Breakdown, Related to: Immobility, Braden Scale Assessment (left blank). 1/13 CP (care plan reviewed). 1/7/13 Has unstageable black area Rt heel..." Interventions included: "Provide measures to decrease pressure/irritation to skin: Pressure reducing mattress...Position with pads and cushions to prevent pressure...Maintain adequate nutrition and hydration. Assess skin per facility policy. Tx (treatment) to heels as ordered." A re-Admission Nursing Assessment, dated 12/28/12, indicated the resident had no pressure areas on his heels. A Minimum Data Set (MDS) assessment, dated 1/4/13, indicated the resident scored a 2 out of 15 for cognitive status, with 15 indicating no memory impairment. The MDS assessment indicated the resident required total dependence of two+ staff for bed mobility and transfer, and had no pressure ulcers. Nurse's Notes included the following notations: 1/7/13 at 10:00 A.M.: "Has multiple abrasions et (and) scabs on bil. (bilateral) (upper) extremities et bil. knees. Has scabs on bil. heels.(Physician) notified. New orders received...." A physician's orders [REDACTED]." Further documentation of the resident's pressure areas on his heels was not located in the nursing notes. A Monthly Summary, dated 1/26/13, included: "...Cognitive Patterns... Short-Term Memory: Memory problems, Long-Term Memory: Memory problems, Daily Decision Making Skills Moderately impaired - decisions poor; cues/supervision required...Skin Conditions, Ulcers None...Skin Treatments (left blank)...." On 1/29/13 at 2:45 P.M., during interview with the DON, she indicated the facility should have called the physician and obtained a change in treatment after a couple of weeks of no improvement in the pressure area. The DON indicated she was unsure how the measurements of the area could be exactly the same each week. The DON indicated she thought the facility had tried "blue booties" for pressure relief, but that the resident had kicked them off. 2. "STAGES OF PRESSURE ULCERS," AMDA - 2008, includes: "Unstageable: Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green, or brown) and/or eschar (tan, brown or black) in the ulcer bed..." The "Quick Reference Guide for Clinicians," Number 3, "Pressure Ulcers in Adults: Prediction and Prevention," published by the US Department of Health and Human Services and dated May 1992, indicated: "A pressure ulcer is defined as any lesion caused by unrelieved pressure that results in damage to underlying tissue...those with impaired ability to reposition should be assessed for additional factors that increase risk for developing pressure ulcers. These factors include immobility, incontinence, nutritional factors such as inadequate dietary intake and impaired nutritional status and altered level of consciousness... Skin care and early treatment- all individuals at risk should have a systematic skin inspection at least daily, paying particular attention to bony prominences...skin injury due to friction and skin shearing should be minimized through proper positioning, transferring, and turning techniques. In addition, friction injuries may be reduced by the use of lubricants such as corn starch and creams, protective films and protective dressing and protective padding..." The "Quick Reference Guide for Clinicians," Number 15, "Pressure Ulcer Treatment," published by the US Department of Health and Human Services and dated December 1994, indicated: "Pressure ulcers require dressings to maintain their physiologic integrity..." 3. On 1/29/13 at 2:25 P.M., the Administrator provided the current facility policy on the "Skin Management Program," revised 6/06. The policy included: "......If a new skin condition is identified the Charge Nurse is responsible for assessing the area, obtaining measurements and documenting in the nurses' notes concerning the skin condition... The Charge Nurse will also develop a care plan for the treatment of [REDACTED]. The results will be reviewed to assure that healing is progressing. If after two weeks the skin condition is not improving the Wound nurse will notify the physician for possible change in treatment...." This federal tag relates to Complaint IN 481. 3.1-40(a)(1) 3.1-40(a)(2)

Based on interview and record review, the facility failed to ensure a resident with a leg immobilizer did not develop a stage 3 pressure sore underneath the immobilizer for 1 of 1 resident reviewed with an immobilizer who developed a pressure sore. Resident #3 Findings include: The clinical record of Resident #3 was reviewed on 8/28/12 at 10 A.M. [DIAGNOSES REDACTED]. On 8/29/12 at 2 P.M., nurses' notes were reviewed. On 5/8/12 at 0200 (2 A.M.) nurses' notes indicated the following: "...knee immobilizer cont (continues)..." On 5/10/12 at 1300 (1 P.M.) "...immobilizer intact..." At 3:30 P.M. on 5/10/12, nurses notes indicated "increased [MEDICAL CONDITION] to bil (bilateral) lower extremities +2..." Nurses' notes on 5/11/12 at 9 A.M. indicated the following: "Dr. (physician name) notified of area (sic) having an area on left lower leg which brace has rubbed skin off 2 cm x 2 cm area...intervention put fleece to keep leg from rubbing on brace..." Nurses' notes dated 5/14/12 at 10 P.M. indicated the following: "CNAs (certified nursing assistants) reported seeping from L (left) leg on change of shift..." On 5/15/12 at 8 P.M. nurses notes indicated the following: "CNA alerted this nurse to area on resident's L lower leg. Res (resident) has had immobilizer to LLL (left lower leg) for fx (fracture). Area was a 3 cm (centimeters) x 2 cm pressure are with serous draining noted and red in color with no drainage noted..." Nurses' notes dated 5/19/12 at 12 P.M. indicated the following: Res has O/A (open area) on LLE (left lower extremity) area yellow/red with scant amt (amount) serous drainage noted measures 6 (cm) x 1 (cm) x 0.1 (cm)..." On 8/29/12 at 2:20 P.M., the MDS (minimum data set assessment) nurse was interviewed. She indicated the resident went to the hospital with the [DIAGNOSES REDACTED]. She indicated upon return to the facility, the resident did not have any pressure areas to her left leg. She indicated when the resident returned to the facility, she had an immobilizer on her left leg. She indicated the immobilizer extended from the left mid thigh to just above the resident's left ankle area. She stated the lower end of the immobilizer "ended about where she has the open area." A physician order, dated 4/30/12 indicated the following: "Immobilizer to lt (left) leg when moving res (resident)..." At this time, the MDS nurse indicated she was unsure if the facility left the immobilizer on all the time or not. The MDS nurse indicated she was unable to find a documented pressure sore assessment for the pressure sore identified in the nurses notes on 5/11/12. She indicated there should have been a pressure assessment sheet started for this area to start monitoring it. She indicated if the floor staff nurses find a skin area, they are to put the assessment on the skin sheet and give it to her. The MDS nurse indicated she does the wound measurements and skin assessments on a weekly basis. At this time, the MDS nurse provided current copies of the resident's "weekly pressure ulcer progress reports." The first documented entry on this form was dated 5/19/12 with the following information: stage 3 (a full thickness of skin is lost, exposing the subcutaneous tissues-presents as a deep crater with or without undermining adjacent tissues." The size was documented as "6 cm x 1.8 cm, depth 0.1 cm, new area..." The MDS indicated at this time, on 6/8/12, the area had "healed in the middle and split into 2 open areas." She indicated one of these open areas healed on 7/20/12. The most recent measurements of the remaining are were 1 cm x 0.7 cm with a "zero" depth. The MDS nurse indicated when the resident was not admitted with this area and it was initially found at a stage 2 (partial thickness loss of skin layers that presents clinically as an abrasion, blister or shallow crater)." She indicated this pressure sore was from the immobilizer. The MDS nurse indicated as far as she knew, the resident didn't have her immobilizer on when she was in bed. The MDS nurse indicated when staff removed the immobilizer, they should have been checking the status of the skin. She indicated this should have been documented on the Treatment sheet/medication administration record. At this time, the MDS nurse reviewed the current clinical record and indicated documentation was lacking for a care plan that addressed staff assessing the skin area under the immobilizer. At this time, a copy of the care plan which addressed the following was reviewed: "At risk for skin breakdown due to skin very fragile, bruises et (and) tears easily NWB (non weight bearing) status Fx (fracture) Lt (left) femur." This care plan was updated 6/12/12 and 7/12/12. Approaches included, but were not limited to, the following: "weekly skin assessment, preventative treatment as ordered..." Documentation was lacking of assessment of the area underneath the immobilizer and/or management of the immobilizer. A progress note from the wound care specialist, dated 5/31/12, indicated the area to the left lower leg was a stage 3 (Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling). A physician order [REDACTED]. On 8/29/12 at 2:55 P.M., CNA #10 was interviewed. She indicated she was familiar with Resident #3 and had cared for her upon the resident's return from the hospital after her femur fracture. CNA #10 indicated "at first she (Resident #3) did have the immobilizer on at all times because she was afraid for us to take it off." CNA #10 then indicated the resident even had it on when she was in bed, and they had it propped up. CNA #10 then indicated she doesn't remember when they started removing the immobilizer at times. On 8/29/12 at 3 P.M. a copy of the current policy and procedure for "Skin Management Program" was received from the MDS nurse. This policy was undated but was indicated by the MDS nurse to be current. The policy included, but was not limited to, the following: "If a new skin condition is identified, the Charge nurse is responsible for assessing the area, obtaining measurements and documenting in the nurses notes concerning the skin condition....The charge nurse will also develop a care plan for the treatment of [REDACTED]. The medication/treatment records for April 30th and May 2012 were reviewed at 3 P.M. on 8/29/12. These both indicated the following: "Immobilizer to lt (left) leg when moving pt (patient)." This was initialed on the form for the one day in April and all days of May 2012. On 8/30/12 9:33 A.M., the DON (director of nursing) was interviewed. She indicated the staff should have been monitoring this area closer and found it before it was a stage 2. The DON stated this immobilizer should have been removed and assessed at least once a shift. She indicated documentation was lacking of this having been done. 3.1-40(a)(1)

Based on observation, interview and record review, the facility failed to ensure interventions were formulated, revised or implemented to address multiple falls for 2 of 5 residents reviewed for falls in the sample of 10. This practice resulted in Resident #1 falling and sustaining a hip fracture. In addition, the facility failed to ensure measures were in place to prevent environmental hazards posed by the facility vacuuming system Resident #1 and 18 Findings include: 1. The clinical record of Resident #1 was reviewed on 6/15/11 at 11:15 A.M. [DIAGNOSES REDACTED]. The admission MDS (Minimum Data Set assessment), dated 10/19/10, indicated the following for the resident: severe cognitive impairment; transfers and ambulation required extensive assistance; limited assistance was required for toileting. The resident was admitted to the facility on [DATE]. A care plan, dated 10/7/10, identified the following problem: "At risk for falls due to hx of falls et (and unsteady gait." Interventions included, but were not limited to, the following: "Transfer et (and) walk with one assist; pull alarm at all times; call light within reach; up in wc (wheelchair) prn (as needed) when unsteady on feet; pressure pad alarm at all times..." Documentation was lacking as to the dates of implementation of the interventions. Nurses notes indicated the following for the resident: 10/6/10 at 4:20 P.M.: "...Resident is alert but confused, pressure pad alarm placed on resident's bed at this time..." 10/6/10 at 7 P.M.: "...Taking other resident's alarm off had to sit her where she can not reach other resident's alarms..." 10/7/10 at 5:50 A.M.: "...This nurse has answered her alarm 9 x in under 30 minutes. Will cont (continue) to monitor et (and) provide interventions..." 10/9/10 at 7 P.M.: "...very confused. Attempting to stand et walk 12 x's (times) in 30 minutes..." 10/9/10 at 8:30 P.M.: "...yelling at staff et other res. Res cont (continue) to try to get up out of chair. Staff having to provided 1:1 with res." 10/10/10 at 1:30 A.M.: "...Res requires a lot of one on ones d/t (due to) increased confusion...Pressure pad in place et working properly but res still stands up per self et ambulates." 10/10/10 at 10 A.M.: "...has been standing up several times this A.M..." 10/10/10 at 7:10 P.M.: "...up in chair at nurses station, cont to try to get out of chair, 1:1 attention given..." 10/11/10 at 2:55 A.M., ( Fall #1): "Resident was found on the floor at the north side of the nurses station. The alarm (pressure pad) was sounding. The fall was not witness (sic)...a pull alarm was added..." 11/3/10 at 9:10 P.M., (Fall #2): "Res got up et as CNAs (Certified Nursing Assistants) were going to assist res to ambulate et before CNAs could reach res she fell backwards et hit head on wall on way to floor..." 11/4/10 at 1 A.M.: "Nurse of (hospital name) ER (emergency room ) called (sic) reported res has hematoma to back of head. CT (computerized tomography) scan neg (negative)..." 11/4/10 9 A.M.: "...cont with knott (sic) et bruise on back of head..." 11/5/10 at 9:20 A.M., (Fall #3): This nurse was alerted by res alarms sounding. Res was standing in west hall way. This nurse attempted to reach res. Unable to stop res from falling on bottom. Fall witnessed by this nurse..." 11/5/10 at 2 P.M., "Pressure floor mat alarm next to bed to alert staff to movement...PPA (pressure pad alarm) while up in w/c (wheelchair) or chair. D/C (discontinue) pull tab alarm d/t res. removes per self..." 11/5/10 at 6:30 P.M., (Fall #4): This CNA was assisting another res in the east wing bathroom et (and) heard alarm sounding. As I walked out of bathroom observed res lying on floor at nsg station et alarms sounding. Res was lying in fetal position..." 11/9/10 at 7:05 P.M., (Fall #5): "Resident was lying in bed...Aide was going down the hall with another resident when he heard pressure pad ringing and mat alarm ringing. Aide tried to get to resident before aide could reach her. Resident fell backwards and hit head on the wall..." 11/11/10 at 4 P.M., "...up and down the hall in w/c, standing up setting off alarm..." 11/11/10 at 12:10 A.M., (Fall #6): "Heard res alarm sounding et went to check res. Upon entering rm (room) found her on floor beside bed. Unable to obtain infor (information) from res r/t (related to) fall..." 11/12/10 at 5:10 P.M., (Fall #7): "Resident was sitting at nurses station, had been up and down all shift. Pressure pad alarm ringing. Saw resident fall, landed on bottom. Did not hit head..." 11/14/10 at 5:20 A.M., (Fall #8): "This nurse was approaching nsg. station et hskg (housekeeping) alerted this nurse to res sitting on floor with alarm sounding..." 11/14/10 at 6:50 A.M., (Fall #9): "This nurse was on east wing hall when personal alarm sounded, alerting this nurse. Noted at NS (nurses station) res laying on floor on r (right) side with R side of head on edge of w/c next to res's (residents)...slight inward rotation of the R leg..." 11/14/10 at 10:30 A.M., "Res admitted to (hospital name) ..." A policy and procedure for "Incident/Accident Report" was dated 3/8/07 and was received from the DON on 6/17/11 at 7:50 A.M. The purpose of this policy, included but was not limited to, the following: "...Document the events of an incident/accident...To investigate and evaluate such occurrences with the intent of minimizing the likelihood of recurrence." Policy included but not limited to the following: "...Complete all information on the Incident/Accident report form. Do not leave blanks...Follow up documentation is to be done by the nurse on each shift...Fill out post fall assessment form for 3 consecutive days following the incident/occurrence and when form is completed turn into DON." On 6/16/11 at 1:20 P.M., the DON was interviewed. He indicated the resident had a history of [REDACTED]. He also indicated the following information: Regarding the 11/3/10 fall (Fall #2), he didn't know what intervention was put into place after this fall as a preventative measure. Also with the 11/3/10 fall, the DON indicated the resident was found in the hall, but didn't know which alarm was sounding. Regarding the 11/5/10 fall (Fall #3), the DON indicated he didn't know what, if any, preventative intervention was put into place and if one was put into place, it wasn't documented. For the fall on 11/5/10 (Fall #4) and 11/9/10 (Fall #5) and 11/11/10 (Fall #6) and 11/12/10 (Fall #7) and 11/14/10 at 5:20 A.M. (Fall #8), the DON indicated no new preventative intervention was documented. The DON indicated that the facility "tried to keep her occupied." He indicated the fall on 11/14/10 at 6:50 A.M., resulted in a fracture to the resident's right hip. The DON indicated at this time that the resident's room was on the West hall. 2. The clinical record of Resident # 18 was reviewed on 6/15/11 at 11:00 A.M. [DIAGNOSES REDACTED]. The Minimum Data Set Assessment MDS) of 3/16/11 indicated the resident had fallen since the last assessment. The nurses' notes reflected a fall since the 3/16/11 assessment. Accounts of each fall were provided by the Director of Nursing (DON) on 6/15/11 at 1:00 P.M. The accounts were Fall Investigation Reports. The Fall Investigation Reports indicated falls were related to facility hazards. One on 1/26/11 at 9:35 P.M., indicated the resident had fallen on a roll of carpet in West hallway due to "new carpet being put in the building." The prevention strategy initiated to prevent additional falls was "Move carpet over to wall and observe residents closely in hallway with rolls of carpet." Another fall on 3/21/11 at 11:00 A.M., occurred when according to the report, the resident slipped on the dining room floor, which was wet from mopping. The planned intervention was for housekeeping to dry mop flooring in the dining room after wet mopping it. During interview with the DON on 6/15/11 at 1:45 P.M., he indicated the carpet obstacle and the wet floor were not recognized in general hazard prevention until after the incidents occurred. 3. The facility system of vacuuming floors was observed on 6/16/11 and 6/17/11 between 7:55 A.M. and 8:20 A.M., when Housekeeper #1 was utilizing the internal wall suction ports in one of two halls with a 50 foot hose attached to the vacuum head to sweep hall carpeting. Throughout the process, she vacuumed the carpet with the hose trailing behind an expanse the length of 3-4 resident doorways, crossing each threshold. She was unable to view potential resident traffic in the area behind her. In interview, during the observation, Housekeeper #1 indicated she was aware the hose has to be watched since it's a tripping hazard. On 6/20/11 at 12:10 P.M., the Housekeeping Supervisor indicated the vacuuming system was installed in both resident halls and staff were instructed to keep good hose control. She indicated the vacuuming was to be done primarily "...when residents are eating and out of the halls but it doesn't always work that way and really it's done anytime of day." On 6/20/11 at 2:00 P.M. the Housekeeping Supervisor indicated the facility did not have a policy and procedure for carpet sweeping. 3.1-45(a)(1) 3.1-45(a)(2)