Every finding on record at Paddock Springs

Based on record review and interview, the facility failed to implement timely and effective interventions to prevent abrasions due to bed placement for 1 of 4 residents reviewed for skin alterations. (Resident B) Finding includes: A record review for Resident B was completed on 3/31/2025 at 9:58 A.M. Diagnoses included, but were not limited to: Alzheimer's disease, diabetes mellitus type 2, neuropathy, overactive bladder and peripheral angiopathy. A Quarterly MDS assessment, dated 1/8/2025, indicated Resident B had moderate cognitive impairment, required substantial/maximal assistance for bed mobility and had a pressure ulcer but no other treatments or open wounds. A Nursing Progress Note, on 12/20/2024 at 11:00 A.M., indicated Resident B had a fall and the intervention was to place the resident's bed against the wall. A Nursing Progress Note, on 1/6/2025 at 12:36 P.M., indicated Resident B had bilateral open areas on their knees. The right knee was scabbed, and the left knee was scabbed and red. Resident B complained of discomfort to the areas, but could not identify how the areas occurred. Triple antibiotic ointment was applied. There were no notes related to the MD/NP being notified or a treatment order. A Nurse Practitioner Progress Note, on 1/8/2025 at 8:04 A.M., indicated Resident B was seen for bilateral knee abrasions. Resident B was unaware of how the abrasions occurred and the abrasions were not related to the fall the resident had incurred the previous week. The plan of care included keeping the areas on the knees open to air and using bacitracin (ointment) sparingly. A Nursing Progress Note, on 1/8/2025 at 1:53 P.M., indicated the areas to the bilateral knees were still present. New orders from the nurse practitioner indicated to cleanse the bilateral knees with wound cleanser, pat dry, apply antibiotic ointment and leave the abrasions open to air. A Nursing Progress Note, on 2/14/2025 at 2:20 P.M., indicated Resident B had rolled to her left side and hit her knee on the wall which had caused an abrasion. The nurse practitioner was notified and an order for bacitracin (antibiotic ointment) was ordered. A Nursing Progress Note, on 3/6/2025 at 2:50 P.M., indicated Resident B had a small abrasion to her left lower leg as Resident B had her left lower leg against the wall when staff had noticed the abrasion. A Physician's Order, dated 3/6/2025, indicated staff were to place pillows against the wall when Resident B was lying towards the wall to prevent pressure sores from the wall. A Care Plan, initiated on 12/8/20022 and updated on 3/6/2025, indicated Resident B was at risk for skin breakdown. The goal was for the skin to stay intact. Intervention included, but were not limited to: have pillows on bed/against the wall dated 3/7/2025. During an interview, on 3/31/2025 at 2:42 P.M., the Director of Healthcare Services (DHS) indicated the facility was placing pillows against the wall for prevention of abrasions, but the pillows did not always stay in place. She indicated the bed was placed against the wall for a fall intervention. A current policy was provided, on 3/31/2025 at 4:17 P.M., by the DHS. The policy titled, Guidelines for General Wound and Skin Care, indicated, .To provide measures that will promote and maintain good skin integrity .4. Use pillows or wedges for positioning to avoid skin to skin contact .Utilize skin protection such as lambs wool This citations relates to Complaint IN00455619 3.1-37(a)

Based on record review and interview, the facility failed to identify a pressure ulcer until it was necrotic and deemed an unstageable ulcer, implement orders for treatment timely and obtain and implement timely nutritional interventions for 1 of 4 residents reviewed for pressure ulcers. (Resident B) Finding includes: A record review for Resident B was completed on 3/31/2025 at 9:58 A.M. Diagnoses included, but were not limited to: Alzheimer's disease, diabetes mellitus type 2, neuropathy, overactive bladder and peripheral angiopathy. A Quarterly Minimum Data Set (MDS) assessment, dated 10/8/2024, indicated Resident B had moderate cognitive impairment, required substantial/maximal assistance for bed mobility and was at risk for pressure ulcer development. A care plan related to the resident's potential for impaired skin, initiated on 12/8/2024 included interventions to conduct weekly skin assessments, use a pressure reducing mattress and pressure reducing chair cushion, use a moisture barrier product to the perineal area as needed, use a lift sheet to avoid sheering, encourage and assist to turn and reposition, float heels as needed and keep resident and linens clean and dry. Resident B had an as needed physician's order for Riley's butt cream, but there was no documentation of the cream used as needed. A Quarterly MDS assessment, dated 1/8/2025, indicated Resident B had an unstageable pressure ulcer that had not been present on admission. A Point of Care (CNA care documentation) entry, dated 12/23/2024, indicated Resident B had received a partial bath. There was no documentation of any impaired skin issue. However, Nursing Progress note, on 12/24/2024 at 7:51 A.M., indicated while changing Resident B an open area to the buttock with blackness in the middle was observed. The Nurse Practitioner was notified, and Riley's butt cream was ordered. An Interdisciplinary Team Progress Note, on 12/26/2024 at 10:25 A.M., indicated a buttock area with one-hundred percent eschar, reddened peri-wound and no drainage was identified. Interventions included skin measurements and weekly reviews at the clinically at-risk meeting. Documentation titled Wound Information, dated 12/27/2024 at 10:13 A.M., indicated an unstageable pressure ulcer, measuring 2.5 centimeters by 2 centimeters was present to the left buttock with necrotic tissue. A Physician's Order, dated 12/27/2024, indicated the following: Riley's butt cream apply a small amount to the open area on the buttock until healed three times a day. A Nutritional Review Progress note, on 12/30/2024 at 4:11 P.M., indicated a recommendation for LiquaCel protein supplement 30 milliliters daily until the wound heals was suggested. A Physician's Order, dated 1/7/2025, indicted the LiquaCel 30 milliliters daily for wound healing had been ordered. A Care Plan initiated, on12/30/2024, indicated Resident B had a left buttock pressure ulcer. Intervention included, but were not limited to: obtain a dietary consult, provide diet, supplements, vitamins and minerals as ordered and treatment per MD order. During an interview, on 3/31/2025 at 1:38 P.M., Certified Resident Care Assistant (CRCA) 3 indicated she was familiar with Resident B care. She indicated she did not need to do much for the resident reagrding bed mobility needs and she was not aware of any pressure ulcer. During an interview, on 3/31/2025 1.43 P.M., LPN 4 indicated weekly skin assessments were completed on shower days and her buttock had turned into something quick. During an interview, on 3/31/2025 at 2:42 P.M., the Director of Healthcare Services (DHS) indicated Resident B was diagnosed with shingles and did not want to get out of bed. She indicated the pressure ulcer was observed during incontinence care. The nurse practitioner was notified and an order for Riley's butt cream was obtained. The DHS indicated the treatment should have started right away when it had been ordered. The DHS indicated the dietician communicated with the facility for nutritional recommendations. A current policy was provided by the DHS, on 3/31/2025 at 4:17 P.M. by the DHS. The policy titled, Guidelines for Pressure Prevention, indicated, .To maintain good skin integrity and avoid development of pressure ulcers .Hygiene .Inspect the skin daily during care for signs of breakdown or changes to the skin. Notify Nurse of changes .Nutrition .Obtain dietary consult to ensure adequate calories, protein, vitamins, minerals, supplements, and/or if deficiencies are noted This citations relates to Complaint IN00455035 3.1-40(a)(1) 3.1-40(a)(2)

Based on interview and record review, the facility failed to clarify conflicting hospital discharge orders and previous medication orders for appropriate dosing of a blood pressure medication. This deficient practice resulted in a significant medication error which required hospitalization for 1 of 3 residents reviewed for hospitalization . (Resident 9) Finding includes: A record review was completed for Resident 9 on 10/10/2024 at 8:29 A.M. Diagnoses included, but were not limited to: congestive heart failure, hypertensive heart disease with heart failure, and essential hypertension Resident 9's record indicated she returned to the facility on [DATE] at 1:30 P.M. after a hospitalization for sepsis, urinary tract infection and acute kidney injury. A hospital Discharge Documentation form, dated 6/24/24, was provided to the facility from the hospital for her readmission to the facility. The form listed Resident 9's hospital discharge medications, including the following medication order: lisinopril (medication to treat high blood pressure) 20 milligrams, one-half tablet (10 mg) every day. There was another section of the form titled Discharge Plan which stated lisinopril 20 milligrams 40 milligrams equals two tablets daily. The Medication Administration Record (MAR), dated June 2024, indicated an order for lisinopril 40 milligrams, 2 tablets (80 mg). Lisinopril 80 milligrams was marked as administered to the resident on 6/25/2024 and 6/26/2024. On 6/26/2024, the order was discontinued and a new order for lisinopril 40 milligrams, administer 10 milligrams once a day was written. This dose was given on 6/27/2024. A Nurse's Note, dated 6/27/2024 at 2:10 P.M., indicated Resident 9 was lethargic, could not keep her eyes open, her blood pressure continued to drop and she had increased shortness of breath. An order was received to send Resident 9 to the emergency room for an evaluation and treatment. A History and Physical Report from the hospital, dated 6/27/2024, indicated the Emergency Medical Services (EMS) reported Resident 9 had altered mental status, bradycardia (slow heartbeat) and hypotension (low blood pressure). Resident 9 was found with a systolic (top number of a blood pressure reading indicating maximum pressure in the arteries) blood pressure of 60, a heart rate of 30, and the EMS administered atropine 0.5 milligrams resulting in an increase of her blood pressure to 75/36 mmHg (millimeters of mercury) and pulse to 50 bpm (beats per minute). The report indicated the nursing home staff had reported Resident 9's blood pressure had been running low since her readmission to the facility with the systolic blood pressure ranging from 103-121. The staff also reported Resident 9 had blood pressures of 95/61 mmHg and 96/60 mmHg. The staff reported Resident 9's blood pressure had dropped to 98/50 mmHg and her lisinopril medication had been held on 6/25/2024 and 6/26/2024. The report indicated there was significant confusion regarding the Discharge Documentation and the lisinopril dosage. Resident 9 was readmitted to the hospital on 6/27/24 with diagnoses including, but not limited to: - Hypotension secondary to medications with subsequent bradycardia and hypotension with a degree of dehydration. - Acute kidney injury due to hypoperfusion with bradycardia and hypotension and most likely a degree of dehydration. A Minimum Data Set (MDS) assessment, dated 9/24/2024, indicated Resident 9 had moderate cognitive impairment. During an interview, on 10/11/2024 at 10:54 A.M., Pharmacy Technician 26 indicated on 6/25/2024, the pharmacy dispensed lisinopril 40 milligrams 2 tablets for Resident 9's daily medication packaging. During an interview, on 10/15/2024 at 9:14 A.M., RN 5 indicated when Resident 9 returned from the hospital on 6/24/2024, there were many discrepancies with her medications. Resident 9 was on lisinopril 10 milligrams prior to her hospitalization and should have been on 10 milligrams when she returned to the facility, but another nursing staff member had erroneously transcribed the order for 80 milligrams from the discharge plan. RN 5 indicated the staff should have used the Discharge Documentation orders, not the Discharge Plan for readmission physician orders. Resident 9 was sent back to the hospital for low blood pressures mixed with her other co-morbidities. A professional reference from the National Library of Medicine, https://www.ncbi.nlm.nih.gov/books/NBK482230/, indicated the recommended initial adult dose of lisinopril was 10 mg daily and could be increased to 40 mg daily. Potential side effects included impaired renal (kidney) function and hypotension. A professional reference at Mayoclinic.org indicated the same adult dosing parameters of 10 - 40 mg per day with the added geriatric warning: . elderly patients are more likely to have age-related kidney problems, which may require caution and an adjustment in the dose for patients receiving lisinopril. A policy, titled Guidelines for Medication Orders, was provided by the Director Nursing as current on 10/15/2024 at 1:14 P.M., and was. The policy indicated, .Procedures .2. A current list of orders will be maintained in the electronic clinical record of each resident .4. Medication orders a. When recording medication orders specify: 1. The type, route, dosage, frequency, strength, of the medication and reason 3.1-48(c)(2)

Based on record review and interview, the facility failed to notify the physician of medications held for 1 of 1 resident reviewed for physician notification (Resident 4). Finding includes: The clinical record for Resident 4 was reviewed on 10/9/2024 at 1:27 P.M. Diagnoses included, but were not limited to: chronic obstructive pulmonary disease, chronic kidney disease, heart failure, schizoaffective disorder, psychotic disorder with known delusions, hypertension, bipolar disorder, depression, anxiety, diabetes mellitus, dementia and borderline personality disorder. A Quarterly Minimum Data Set (MDS) assessment, dated 7/18/2024, indicated the resident was taking an antidepressant medication, an antianxiety medication and a diuretic medication. The current Physician's Orders for Resident 4, initiated on 8/22/2023, included Bumetanide medication (diuretic) 1 mg (milligram) 1 tablet orally, twice a day for chronic systolic and diastolic congestive heart failure. A current Care Plan, revised on 7/17/2024, indicated Resident 4 received diuretic medication. Interventions included, but were not limited to: medications per physician orders and report adverse drug reaction as needed. The June 2024 Medication Administration Record (MAR) indicated Resident 4 had the evening Bumetanide dose held due to low blood pressure on the following dates: 6/22/2024 and 6/24/2024. The August MAR indicated Resident 4 had the evening Bumetanide dose held due to low pressure on 8/4/2024. The September MAR indicated Resident 4 had Bumetanide dose held on 9/21/2024 in the evening for low blood pressure, on 9/22/2024 in the morning for low blood pressure and on 9/22/2024 in the evening for a low heart rate. There was no documentation the physician had been notified of the need to hold the Bumetanide medication due to Resident 4's low blood pressure or heart rate. During an interview, on 10/11/2024 at 10:59 A.M., QMA 1 indicated there was no policy or physician orders for parameters to hold diuretics for blood pressure or heart rate for Resident 4. QMA 1 indicated nursing staff should have notified the MD to obtain hold order for the Bumetanide medication. During an interview, on 10/11/2024 at 1:30 P.M., the Director of Nursing (DON) indicated staff should have notified the provider and documented the notification in the Electronic Medical Record (EMR). On 10/11/2024 at 1:34 P.M., the DON provided a policy titled, Physician: Provider Notification Guidelines, dated 12/31/2023 and indicated the policy was the one currently used by the facility. The policy indicated, ensure the resident's physician or practitioner is aware of .change in condition in a timely manner to evaluate condition for need of provision of appropriate interventions for care . 3.1-5(a)(1) 3.1-5(a)(2) 3.1-5(a)(3) 3.1-5(a)(4)

Based on record review, observation and interview, the facility failed to ensure interventions were in place to prevent a deep tissue injury (DTI) wound after admission for 1 of 2 residents reviewed for pressure ulcers. (Resident 105) Finding includes: The record for Resident 105 was reviewed on 10/10/2024 at 1:37 P.M. Diagnoses included, but were not limited to, right hip fracture, diabetes, chronic congestive heart failure and depression. A Hospital Transfer form, dated 10/4/2024, indicated Resident 105 had no skin issues to his heels at the time he was transferred to the facility. Resident 105 had been hospitalized for an acute right hip fracture with surgical repair. A facility Admission Observation form, dated 10/4/2024, indicated Resident 105's pedal (feet) pulses were present to both feet and the resident had weakness to both lower extremities. Under the section of the form, titled, Skin impairment, Yes was documented and the form indicated an Occurrence progress note was to be completed and include an assessment. There was no skin impairment assessment completed for Resident 105's right heel upon admission. A pressure ulcer risk assessment, dated 10/4/2024, indicated Resident 105 was a low to moderate risk to develop pressure injuries. A Baseline Care Plan, dated 10/4/2024, indicated a goal for the resident not to develop a pressure ulcer, or if a pressure ulcer was present, the wound would not worsen. Interventions included, but were not limited to, turn and reposition for care and use devices to optimize independent repositioning and transfers. There were no interventions to provide pressure relief to the resident's heels. A Wound Management Detail Report, dated 10/4/2024, indicated Resident 105 had a DTI (deep tissue injury, damage to the soft tissue beneath the skin caused by pressure or shear forces) to the right heel that was present on admission. The wound measured 5 cm (centimeter) length x 5 cm width. There was no other description of the wound. Physician's Orders, dated 10/4/2024, included: Skin prep (fast drying protective dressing) to the right heel 3 times a day as a preventative measure. There was also an order for a preventative foam dressing to the right heel and it was to be changed every 3 days. The orders included instructions to provide pressure relief to the resident's right heel. A Care Plan, initiated on 10/6/2024, indicated Resident 105 was at risk for skin breakdown related to: (the area to indicate where the area was located was left blank). Interventions included, but were not limited to, avoid shearing skin during positioning, turning, and transferring, conduct weekly skin assessments, pay particular attention to resident's bony prominences, encourage and assist the resident to turn and reposition for comfort and as needed and to keep bed linens clean and dry. The plan did not specifically include interventions to prevent pressure on the resident's heels. A Care Plan, initiated on 10/10/2024, indicated the resident had a pressure ulcer, DTI, to the right heel. Interventions included, but were not limited to: Assess and record the condition of the skin surrounding the pressure ulcer, administer analgesics per physicians order, observe and report signs of infection (e.g., localized pain, redness, swelling, tenderness, drainage, odor, and fever), observe for and report signs of pain related to the pressure ulcer, pressure reducing cushion to the wheelchair, treatment per physicians order, notify physician if treatment is not effective, weekly skin assessment, measurement and observation of the pressure ulcer and record, keep the resident as clean and dry as possible, minimize skin exposure to moisture and use a lifting device as needed for bed mobility (e.g. lift sheet, etc.) There were no specific interventions to ensure pressure relief to the resident's right heel. An NP Progress Note, dated 10/11/2024, indicated the resident had undergone a right hip replacement on 9/28/2024. The facility's wound nurse had called and discussed concerns regarding a possible DTI for Resident 105 on 10/6/2024. The wound NP indicated she had given the facility's wound nurse recommendations for the skin prep treatment and routine offloading procedures. The note indicated when she had assessed the resident on 10/11/2024, she noted a stage II pressure ulcer to the resident's right heel. She wrote treatment orders and recommended off-loading heel booties. During an observation, on 10/11/2024 at 9:32 A.M., Resident 105 was observed with shoes on both feet, seated in his wheelchair. The resident's shoes were positioned on the footrest pedals of the wheelchair. During an observation, on 10/11/2024 at 10:40 A.M. with the Wound Nurse Practitioner (NP) and the facility wound nurse, the following was observed on Resident 105's right heel: an opened wound approximately 5 cm (length) x 5 cm (width) with red granulation tissue and specs of a dark purple/black color in the middle and along the right side of the wound bed. The open wound had a white ring around the outside edge of the wound. The Wound NP indicated the area did not have any dead/necrotic tissue and staged it as a stage II pressure ulcer (an open sore or blister that indicated partial thickness loss of the skin). During an interview, on 10/11/2024 at 1:25 P.M., the Director of Nursing (DON) indicated the pressure area to the heel was not present on admission. The nurse had made a mistake when she documented it as present on admission as an ulcer. There was no other documentation in the chart that indicated the DTI was found on admission. The DON indicated the nurse realized she had coded the wound incorrectly on the Wound Management Detail Report, completed on 10/4/2024. The nurse had contacted the Wound NP and the wound should have been identified as in-house acquired. When questioned as to why the current care plan for the foot ulcer did not include specific interventions to prevent pressure on the resident's heels, such as floating his heels, the DON indicated the resident's mattresses were pressure relieving. During an observation, on 10/15/2024 at 12:02 P.M., Resident 105 was seated in the dining room with his feet covered with regular socks and his heels/feet resting on the floor. During an interview, on 10/15/2024 at 1:47 P.M., Resident 105 indicated he wore socks on his feet when he went to bed, but did not wear anything else on his feet. Resident 105 did not indicate staff ever placed a pillow underneath his lower legs to elevate his heels or staff placed booties on his feet. During an observation, on 10/16/2024 at 9:03 A.M., Resident 105 was observed in his wheelchair. His right foot was resting on the floor with a foam dressing adhered to the middle of his foot and his heel exposed. There were no offloading booties in his room, even though the NP had recommended them on 10/11/2024. During an interview, on 10/16/2024 at 9:05 A.M., RN 5 indicated there were no booties located in the room and the resident should have had a bootie on his right foot. On 10/11/2024 at 2:45 P.M., the Director of Nursing provided the policy titled, Guidelines for Pressure Prevention, dated 12/31/2023, and indicated the policy was the one currently used by the facility. The policy indicated . To maintain good skin integrity and avoid development of pressure ulcers. Care plan interventions shall be implemented based on risk factors identified in the nursing assessment. Interventions may include, but not be limited to: .float heels as needed .Elevate heels off the bed- avoid use of heel protectors On 10/11/2024 at 2:45 P.M., the Director of Nursing provided the policy titled, Guidelines for General Wound and Skin Care, dated 12/31/2023, and indicated the policy was the one currently used by the facility. The policy indicated .5. Evaluate the need for a pressure reduction surface for bed/chair .or float heels/boots 3.1-40

Based on record review and interview, the facility failed to administer a physician ordered medication for 1 of 5 residents reviewed for unnecessary medications. (Resident 12) Finding includes: The record for Resident 12 was reviewed on 10/11/2024 at 10:17 A.M. Diagnoses included, but were not limited to: heart failure, dementia, anxiety, depression and Bipolar disorder. The current Physician's orders for Resident 12 included an order for the resident to receive Lorazepam 0.5 mg daily for anxiety and agitation. The Medication Administration Record (MAR), dated August 2024, indicated the resident was to receive Lorazepam 0.5 mg daily for anxiety and agitation. The MAR indicated the resident did not receive the ordered Lorazepam from 8/4/2024 through 8/12/2024. On the section labeled Reasons/Comments was documented Med Not Available, from 8/4/2024 to 8/12/2024, for the Lorazepam. During an interview, on 10/15/2024 at 10:26 A.M., the Director of Nursing indicated the physician should have been notified of the missed doses. During an interview, on 10/15/2024 at 1:38 P.M., the Director of Nursing indicated the nurse should have obtained the medication from the facility's Emergency Drug Kit (EDK) and called the Pharmacy. During an interview, on 10/15/24 at 1:49 P.M., LPN 11 indicated if a medication was not available in the medication cart, she would get in the EDK (emergency drug kit) to get the medications or call the pharmacy. On 10/15/2024 at 4:05 P.M., the Director of Nursing provided the policy titled, Unavailable Medications, undated, and indicated the policy was the one currently use by the facility. The policy indicated .The facility must make every effort to ensure that medications are available to meet the needs of each resident .B. Facility personnel shall: 1). Notify the attending physician of the situation and explain circumstances, expected availability and optional therapy(ies) that are available . 2). Obtain a new order and cancel/discontinue the order for the non-available medication. 3). Notify the pharmacy of the replacement order 3.1-25(a)

Based on observation, interview and record review, the facility failed to ensure infection control practices were followed related to lack of changing gloves and handwashing during perineal care and when administering insulin for 1 of 1 resident observed for incontinence care and 1 of 1 resident observed for insulin injection. (Resident 15) Findings include: 1. During an observation, on 10/10/2024 at 7:25 A.M. Certified Nursing Assistant (CNA) 7 was observed to provide incontinence/catheter care to Resident 15. She washed her hands and donned gloves. She used a washcloth and cleaned the catheter. CNA 7 turned the resident over to her right side, and with wet wipes, she washed the residents' buttocks. There was a smear of feces around the resident's rectum. She then placed the dirty wipes on the soiled brief and removed the brief. Lastly, the aide applied a clean brief and pulled up the resident's pants. CNA 7 then removed her gloves and placed them in the trash can and washed her hands. During an interview, CNA 7 indicated she should have removed her gloves and washed her hands after washing the resident's buttocks. 2. During an observation on 10/10/2024 at 8:55 A.M., QMA 8 washed her hands and donned gloves. She cleansed an area on the resident's right lower abdomen with an alcohol pad and with an opened hand, she fanned the area she had just cleansed During an interview, on 10/10/2024 at 8:56 A.M., QMA 8 indicated she should not have fanned the area. On 10/25/2024 at 4:05 P.M., the Director of Nursing provided the policy titled, Perineal Care for Incontinence, dated 12/31/2023, and indicated the policy was the one currently used by the facility. The policy indicated .7. Pay particular attention to infection prevention and control techniques when performing pericare, to prevent the introduction of contamination that may lead to a urinary tract infection A policy for glove use was requested but none was not provided prior to the survey exit. On 10/15/2024 at 4:05 P.M., the Director of Nursing provided a policy titled, Injectable Medication Administration, with a revision date of 11/2018, and indicated the policy was the one currently used by the facility. The policy indicated: .Expose the area to be injected and clean with an alcohol wipe 3.1-18(b)(1)

Based on interview and record review the facility failed to ensure comprehensive mental health services twere obtained for 1 of 1 resident reviewed. (Resident 29) Findings include: Resident 29's record review, began on 7/20/22 at 1:16PM. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The most recent MDS (minimal data set) indicated the resident's brief interview for mental status score was 15. The score of 15 indicated there was no cognitive deficit. The MDS (minimal data set) dated May, 30, 2022 indicated under mood his mood severity was 15.The section for behavior the residnet had no hallucinations or delusions In the asseessment dated July 11, 2022, the score for mood severity was documented as 17 and the residnet had hallucinations, delusions and increased rejection of care. The facility indicated in a resident interviewable list Resident 29 was interviewable. Resident 29's current care plan had problems listed related to mental health including: Resident may experience signs and symptoms of depression including tearfulness, isolating himself to room, staying in bed all day, etc. This problem was dated 7/21/22. Interventions included; Refer to psych services as needed dated 7/18/22. Resident was at risk for adverse consequences related to receiving antipsychotic medications for [CONDITION(S)] disorder, dated 2/2/22. Resident demonstrates altered behaviors including hallucinations and or delusions, dated 1/5/22. interventions included; record triggers for hallucinations in resident's medical record. Resident met PASRR inclusion criteria because he had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The goal was stated as the resident's needs will be met through the necessary rehabilitation services. Interventions iincluded provide resident with supportive counseling to help resident through hard moments, support well being, and refer for individual therapy dated 3/10/20. Resident may demonstrate non compliance with physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The problems, goals, and interventions did not include refusals of appointments. A review of Resident 29's physician order [MEDICAL RECORD OR PHYSICIAN ORDER] 2/12/22 Resident to be evaluated and treated by mental health services. 4/23/22 Resident has an appt with hospital heart pavilion please have ready for transport 4/30/22 Resident has an appointment with NP please have ready for transport 6/8/22 Resident has an appoint with Dr. please have ready for transport 7/17/22 Resident has an appointment with NP please have ready for transport. A review of Resident 29's behavior analysis report from certified nurse aids charting dated from 1/1/22 to 7/25/22 indicated 3 shifts daily indicated no behavior occurred, not applicable for the intervention, not applicable for the intervention effectiveness, and no comments. Except for rejection of care documented consistently by one staff member as follows: 1/3/22 on 2nd shift with intervention of offering food or fluids, intervention not effective and with a comment refused x3. 1/6/22 on 2nd shift intervention redirection, intervention not effective, and comment of refused x3. 3/7/22 on 2nd shift intervention redirection, intervention not effective, and comment refused shower x3 and refused to sign shower sheet. 6/27/22 on 2nd shift intervention redirection, intervention not effective and comment refused shower x3 nurse witnessed. 7/4/22 on 2nd shift intervention redirection, intervention not effective, and comment refused shower and dressing x3 nurse witnessed. No other refusals or behaviors were documented. A review of the event reports and observation reports indicated the following reports: An event report on 1/21/22 regarding hallucinations and delusions, possible triggers recent med change, intervention provide snack, and intervention refused. An observation detail list report on 2/2/22 was a discussion of recent [CONDITION(S)] medication changes and no referrals. An event report dated 4/13/22 regarding picking at skin due to bugs, no possible triggers determined, one on one care for intervention, and not applicable of intervention successful. An even report dated 6/27/22 regarding delusions and hallucinations, with triggers of recent med changes, intervention one on one support, and the intervention successful indicated offer validations and reassurance. No other events or observations were noted. Resident 29 was hospitalized for psychiatric illness in late January and discharged early February. A thorough review of Resident 29's progress notes from February 1, 2022 to present indicated; 2/1/22 Resident was tearful and wanted to know if there was anyone who could help him decide where to go with his life. He was tired of sitting in that room. No event was triggered. 3/4/22 Resident had recent hospital stay and had been isolating to his room. No event was triggered. 3/30/22 Resident stated he was seeing bugs in his room at this time. Staff checked no bugs noted. No event was triggered. 4/13/22 Resident noted picking at scabs to arms and leg stating they are bugs that keep growing back. Resident indicated the bugs are living under his skin. 4/15/22 Resident reported he had small crab like bug crawling in and out of his skin. 4/22/22, 4/28/22, and 5/12/22 team meeting regarding medication changes. 5/13/22 Resident said to nurse, I am feeling a little down 5/22/22 Resident asked, what is going on next door and expressed that he could hear several men talking about him. No event was triggered. 6/9/22 team meeting regarding psych medication changes. 6/23/22 team meeting regarding recent decline and has been refusing to eat or get out of bed. 6/24/22 Resident continues to refuse oral medications related to nausea. Resident stated There are two men in the vents above my bed and I do not know what they want or what they are doing here. Resident indicated he feels safe. 6/28/22 effect is flat. Reports I am not doing well. Resident reports concerns about medical and mental health. 7/5/22 Reports visual hallucinations, I seen a cat and a dog. No event was triggered. 7/5/22 Resident declined shower x3. Strong body odor was noted. No event was triggered. 7/7/22 Resident is exit seeking. Resident voiced a man was standing behind my bed and just stared at him. He is able to go thru the wall and I think he stays in the room behind me. He can see me and talk to you thru the call lights and vents in the ceiling. I know you think I am crazy, maybe you are crazy. Resident stated Call the police, ok if not just let hm go and keep doing what he is doing. No event was triggered. 7/7/22 team meeting resident refusing care and has been withdrawing to room. 7/7/22 still has not showered. 7/8/22 Resident stated, do you see those bugs on the floor and the wall over there. Did not see any bugs in residents room. No event was triggered. 7/8/22 told staff, there are cats. Nursing trapped them in that oxygen machine. No event report triggered. 7/11/22 Resident has been having delusions and hallucinations. Resident has also refused care. 7/12/22 Resident put on call light and when entered room resident was tying his bed sheet to the handle of his closet and could not explain what he was in the process of doing. No event report was triggered. In an interview on 7/20/22 at 9:59AM, Resident 29 indicated he went to a psych hospital and did not like it there. Resident 29 indicated he had asked nursing and social services three times since discharge to speak with someone; a therapist or counselor about his life. Resident 29 indicated he had not seen any mental health advocates, counselors, or therapists. Resident 29 indicated he frequently saw the psych nurse doctor to change his meds. Resident 29 indicated he had frequent med changes, was unsure which ones worked, and which ones caused more issues. Resident 29 indicated he had not refused any therapy appointments either in house or in community. In an interview on 7/22/22 at 3:16 PM the Director of Health Services indicated Resident 29 refused many appointments and had been fired from pain management in the past. During an interview on 7/25/22 at 9:46AM the Director of Social Services (DSS) indicated Resident 29's behaviors were tracked during morning meeting, weekly team meetings, care notes, and progress notes. The DSS indicated Resident 29's psych medications had been changed frequently lately due to hospitalization , pharmacy suggestion secondary to genetic testing, and symptom management. The DSS indicated Resident 29 was set up with counseling services with a provider to come to facility. The provider came once, did not leave any session notes, did not return, and the company had not followed through on getting another therapist to come to facility. The DSS indicated she had no record of when that one session occurred due to lack of documentation. The DSS indicated she had attempted to contract with another provider. The DSS indicated Resident 29 frequently was seen by a psych provider and they had a good relationship. The DSS indicated they had not discussed Resident 29 going out for therapy. A letter provided by the Director of Health Services on 7/25/22 at 12:48PM from a psych nurse practioner, indicated .had may times been referred to and appointments made, for outpatient therapy and he continually refused to go At time of exit there was no further documentation provided of the therapy appointments made or refused by Resident 29. A policy, titled Guideline for Mental Health Wellness Program provided by Director of Health services on 7/22/22 at 1:12 PM, indicated .1.Behaviors that required interventions shall be defined as: a b. A behavior that negatively affects the resident's quality of life 8. The social services director or nursing staff shall initiate a Mental Health Event that will include a 72 hour follow-up.9. The Social Services Director shall review the documentation to determine if the behavior is isolated, causative factor identified, and if re-direction is successful. 3.1-37

Based on observations, interview and record review, the facility failed to follow a resident's fall care plan interventions and safety measures, in 1 of 3 residents reviewed for accidents/falls. This deficient practice resulted in a fall requiring hospitalization , for a traumatic dental injury, and oral surgery. (Resident E) The deficient practice was corrected on May 15, 2021, prior to the start of the survey, and was therefore Past Noncompliance. Finding includes: On 6/3/21 at 11:35 A.M., Incident #244 was received from the Administrator. The incident indicated, on 5/11/21 at 6:45 A.M., Resident E was in a wheelchair and resident fell from chair and was transferred to an Emergency Department for an evaluation. During an interview, on 6/3/21 at 11:49 A.M., Resident E's mother indicated the resident fell out of her wheelchair, due to staff not applying her seatbelt. She indicated the resident was taken to the emergency room and had oral surgery the next day. On 6/3/21 at 11:59 A.M., a review of the clinical record for Resident E was conducted. The resident's diagnoses included, but were not limited to: [CONDITION(S)] (a disorder that affects movement and muscle tone or posture), focal [CONDITION(S)] with complex partial seizures, and history of falls. The Quarterly Minimum Data Set (MDS) Assessment, dated 2/21/21 indicated the resident was never understood, was totally dependant of 2 staff members with transfers and had impairments of both the upper/lower extremities. The assessment indicated a trunk restraint was used daily, on the resident, when she was in a wheelchair. A care plan, dated 12/2/19 and revised on 2/23/21, indicated the resident needs a seat belt restraint related to the diagnosis of [CONDITION(S)], when up in her wheelchair. The care plan goal was to use the restraint when the resident was in her wheelchair for safety and positioning. The interventions included, but were not limited to: assure the medical record contains documentation of the condition justifying the use of the restraint and monitor, document and report any negative outcomes. Another care plan, dated 12/21/17 and revised on 4/6/21, indicated the resident was at risk for a fall related to impaired mobility and safety awareness due to diagnoses of [CONDITION(S)] and [CONDITION(S)] disorder. The interventions included but were not limited to: .staff is educated on safe transfer practices for resident A Progress Note, dated 5/10/21 at 9:04 A.M., indicated the following: .Writer entered room at 6:45 A.M. to administer A.M. medications and again at 6:50 A.M. for routine nose swab for Covid test. At approximately 7 A.M. writer heard a loud noise and proceeded to go down hall way to find where it had come from. Resident was found laying face down on the floor in front of wheel chair. Writer went to get CRCA [Certified Resident Care Associate] re-entered room and initiated first aid and resident repositioned onto her back. Resident is moving all extremities per self and making eye contact per norm. Writer applied a cool compress and pressure to her mouth to slow the bleeding. After approximately 10 to 15 minutes staff used hoyer lift to transfer resident from floor and into her chair with writer continuing to apply pressure to area. once in chair staff cleaned resident up and changed her shirt while continuing to apply pressure to mouth. DHS [Director of Health Services] made aware at this time, NP [Nurse Practitioner] notified and order given to transport to dentist for evaluation. Initial call made to mother at approximately 720 A.M. Mom asked How did this happen? Writer explained that we were unsure and that it was under investigation. Mother requests that staff calls [name of dental office] and attempt to get resident in for an emergency visit. If they could not get resident in to be seen then send resident to [name of hospital] ER [emergency room ]. Writer called dental office at 745 A.M. and it does not open until 9 A.M. Writer called mother back at 750 A.M. and she request the ER transport .NP [Nurse Practitioner] updated on mother's request and gave order to send to ER for evaluation and treatment. At 755 A.M. resident was transferred per hoyer back to bed to get ready for ER transport. Resident's face cleaned again, gums are swollen and dark red/purple, and unable to visualize 2 front teeth d/t [due to] swelling. 8 A.M. writer called 911 for transport to ER. 805 A.M. writer called report to [name of hospital] ER. EMS arrived at that time . Resident left facility at 810 A.M. per stretcher via Lutheran EMS enroute to [name of hospital]. At 817 A.M. [name of hospital] ER called requesting ambulance be redirected to [name of hospital] in Ft. [NAME] d/t [due to] Oral surgeon would be on call there and [name of hospital] did not have one on call An emergency room Note, dated 5/10/21 indicated a wheelchair bound resident, fell out of her chair onto the ground causing mouth and tooth injury. Per the resident's mom, the patient had a broken tooth and a loose tooth; this is new from the fall. as the resident had a dental cleaning last week and she did not have lose teeth at that time. A Computerized Tomography (CT) x-ray of the Maxillofacial, on 5/10/21 indicated the following: . 1. Acute fracture/intrusion complex of the central maxillary incisors [teeth] and right lateral maxillary incisor with comminuted [reduced to minute particles or fragments] tooth socket fractures. Oral maxillofacial surgery consultation is recommended An Operative Report, dated 5/11/21, indicated the resident had to have number 7, 8,& 9 (upper top middle teeth) removed. The report stated the following: .It was noted that there was significant comminution [fragments]of the maxillary bone as well as significant mobility to the teeth. Due to the patient's oral hygiene, which was poor, as well as her medical status, the decision was made to remove the teeth in order to prevent long-term complications such as infection and need for root canal treatment. Once the teeth were removed, significant comminution [fragments] of the [MEDICATION(S)] plate [pertaining to surface of the tooth] extending up to the nasal floor was identified. These loose fragments of bone were removed and the site was irrigated copiously [large amounts] with normal saline Then closure of the area with sutures (holds the tissue together after an injury/surgery). During an interview, on 6/3/21 at 1:32 P.M., CNA 4 indicated there was a seat belt audit in the resident's room to ensure 2 staff members have verified the seatbelt was in place. CNA 4 indicated the procedure had been in place, since the resident had the fall. On 6/3/21 at 1:35 P.M., an observation of the resident and room was conducted. The resident was awake, and in her bed. The bed was in the low position and a cushioned mat was on the floor, on the left side of the bed. There were no side rails on the bed. The audit form was located, across from the resident, near the TV. The seatbelt audit stated .Every staff member who places resident in chair must have a second staff member verify seatbelt securement prior to leaving resident room During an interview, on 6/3/21 at 2:02 P.M., the Director of Nursing (DON) indicated the seatbelt was not in place when Resident E fell . The DON provided a form titled, Statement of Witness Form, dated 5/10/21. The statement from CNA 2 indicated the following: .Got [resident's name] up about 10 after 6 A, got her in w/c [wheelchair], pulled her back, locked wheelchair. I forgot resident had a seatbelt and I think I forgot to latch the buckle A statement from LPN 3, dated 5/10/21, indicated she had received report, at 6:30 A.M., and had been in Resident E's room, at 6:48 A.M., to complete a Covid test. LPN 3 was at the medication cart around 7:00 AM and heard a noise and went to investigate. LPN 3 found resident on the floor, face down. The DON indicated she had observed resident after the fall and her front teeth were jammed up into the gums. During an interview, on 6/3/21 at 2:15 P.M., CNA 2 indicated she had placed Resident E, in her wheelchair, the morning of her accident. CNA 2 indicated she did not latch the seatbelt. She indicated she was fairly new to her job, and wasn't aware the resident had a seatbelt. During an interview, on 6/3/21 at 3:18 P.M., the MDS Coordinator indicated, after the fall, the IDT team discussed the fall plan of care and new intervention, which was to have 2 staff members check the trunk seatbelt. The checks were to ensure the seatbelt was securely fastened. The MDS Coordinator had no explanation as to why the fall and/or seatbelt care plan was not updated with the new intervention. A facility policy titled,Fall Management Program Guidelines, effective 5/31/17 and reviewed on 5/22/18, indicated the following; .[name of facility] strives to maintain a hazard free environment, mitigate fall risk factors and implement preventative measures .Procedure 5. The resident care plan should be updated to reflect any new or change in interventions The Past Noncompliance of isolated harm began on May 11, 2021. The isolated harm tag was removed and deficient practice corrected by May 15, 2021 after the facility implemented a systemic plan that included the following actions: Dual verification seatbelt audit, employee counseling form with the CRCA involved in the incident, job description and checklist completed with the CRCA involved in the incident, nursing staff in-service information with sign in sheets attesting to education, and on going audit/monitoring tools in place. This Federal tag relates to complaint IN 536. 3.1-45(a)(1) 3.1-45(a)(2)

Based on record review, observation and interview, the facility failed to follow CDC (Centers for Disease Control) current guidance related to prevention of COVID-19 was being followed related to not wearing full PPE (personal protective equipment) when completing staff COVID testing in 57 of 58 staff tests completed. (RCA 4) Finding includes: On 11/24/2020 at 12:27 P.M., during an observation of staff COVID-19 testing the following was noted: the tester, RCA (Resident Care Assistant) 4 was observed to apply a gown and gloves. She then took the nasal swab and inserted into R N (Registered Nurse) 6's right nostril and twirl it around 4-5 times and then proceeded to complete the left nostril. She then placed the swab tip into the tube and snapped the applicator stick off, and placed the cap on the vial. RCA 4 then removed the gown and gloves and placed in a trash bag. During an interview, on 11/24/2020 at 12:32 P.M., RCA 4 indicated she had only worn the gown and gloves for the test she had just completed, and indicated she should have worn the gloves and gown for all the tests she had completed. Staff testing documentation, dated 11/24/2020, indicated RCA 4 had completed 58 staff tests as of 12:27 P.M. On 11/24/2020 at 2:03 P.M., a policy for PPE use during COVID-19 testing was requested, but one was not provided. 3.1-18(b)(2)

Based on interview and record review, the facility failed to ensure allegations of abuse and mistreatment were immediately reported to the facility Administrator for 4 of 4 residents reviewed for abuse. (Residents B, C, D & E) Finding includes: An incident report, dated 5/10/2019, indicated, .On 10 (MONTH) at 4:00 P.M., a CRCA (Certified Resident Care Assistant) alleged that they witnessed QMA (Qualified Medication Aide) (QMA's name) wrap Resident (Resident B's name) arms in her shirt during care so that she could not hit her during care. The same CRCA alleged that they heard QMA (QMA's name) yell at Resident (Resident B's name) and say you got in to a fist fight in front of Resident (Resident B's name) and this upset her A review of the facilities' investigation of the reported allegation, dated 5/10/2019, indicated other allegations had been made, on witness statements from residents and employees: Resident D indicated, .I wouldn't have to spend so much time in here if you would tell me what you want in order and .There is no arguing with this man. He is always right Resident E indicated, .I've stayed in stool for an hour Resident C indicated, .Both male and female yelled and rude Employee 2 indicated, .(Employee 3) shoved medication in Resident C's mouth without saying anything and that Resident C indicated he was told to just sit down. Employee 4 indicated, Resident C reported to her that he was told to sit down and not move, when he requested to use the bathroom to Employee 3. Employee 4 indicated on her witness statement, .wrote statement and put under DON's door Employee 5 indicated that Employee 3 said to Resident B, .This is ridiculous, you should have hit the call light before you s--- yourself. This crap stinks. Kids aren't even that stupid During Employee interviews, on 5/21/2019, the following was indicated: At 1:57 P.M., Employee 2 indicated that when she had gone into assist Resident C, after hearing Employee 3 tell Resident B to sit down and stay there, he was found with dry stool, sitting in his recliner and indicated he no longer wanted Employee 3 in his room. Employee 2 indicated she wrote out a statement of the allegation and slid it under the DON's (Director of Nursing) office door. At 2:15 P.M., Employee 5 indicated, following hearing Employee 3 tell Resident B This is ridiculous, you should have hit the call light before you s--- yourself. This crap stinks. Kids aren't even that stupid, Resident B was upset and putting her head in her hands and apologizing. He further indicated Employee 3 put Resident B's arms into her shirt to keep her from hitting Employee 3. Employee 5 indicated he should have told the Administrator of the allegations when they occurred, but that he did not. During an interview, on 5/21/2019 at 2:35 P.M., Resident D indicated, Employee 3 and Employee 6 mentally put me down. During an interview, on 5/21/2019 at 2:45 P.M., the facility Administrator indicated Employees' 3 & 6 were no longer working at the facility, and that he was unable to prove abuse took place or that it didn't. On 5/22/19 at 10:30 A.M., the Administrator provided the policy titled.Abuse, Neglect and Exploitation Procedural Guidelines, dated 10/10/2018, and indicated the policy was the one currently used by the facility. The policy indicated .2. The Executive Director and Director of Health Services are responsible for the implementation and ongoing monitoring of abuse standards and procedures and .iv. IMMEDIATELY notify the Executive Director This Federal tag is related to Complaint IN 030. 3.1-28(c)

Based on interview and record review, the facility failed to thoroughly investigate abuse allegations for 4 of 4 residents reviewed for abuse. (Residents B, C, D & E). Finding includes: An incident report, dated 5/10/2019, indicated, .On 10 (MONTH) at 4:00 P.M., a CRCA (Certified Resident Care Assistant) alleged that they witnessed QMA (Qualified Medication Aide) (QMA's name) wrap Resident (Resident B's name) arms in her shirt during care so that she could not hit her during care. The same CRCA alleged that they heard QMA (QMA's name) yell at Resident (Resident B's name) and say you got in to a fist fight in front of Resident (Resident B's name) and this upset her A review of the facilities' investigation of the reported allegation, dated 5/10/2019, indicated other allegations had been made, on witness statements from residents and employees: Resident D indicated, .I wouldn't have to spend so much time in here if you would tell me what you want in order and .There is no arguing with this man. He is always right Resident E indicated, .I've stayed in stool for an hour Resident C indicated, .Both male and female yelled and rude Employee 2 indicated, .(Employee 3) shoved medication in Resident C's mouth without saying anything and that Resident C indicated he was told to just sit down. Employee 4 indicated, Resident C reported to her that he was told to sit down and not move, when he requested to use the bathroom to Employee 3. Employee 4 indicated on her witness statement, .wrote statement and put under DON's door Employee 5 indicated that Employee 3 said to Resident B, .This is ridiculous, you should have hit the call light before you s--- yourself. This crap stinks. Kids aren't even that stupid During Employee interviews, on 5/21/2019, the following was indicated: At 1:57 P.M., Employee 2 indicated that when she had gone into assist Resident C, after hearing Employee 3 tell Resident B to sit down and stay there, he was found with dry stool, sitting in his recliner and indicated he no longer wanted Employee 3 in his room. Employee 2 indicated she wrote out a statement of the allegation and slid it under the DON's (Director of Nursing) office door. At 2:15 P.M., Employee 5 indicated, following hearing Employee 3 tell Resident B This is ridiculous, you should have hit the call light before you s--- yourself. This crap stinks. Kids aren't even that stupid, Resident B was upset and putting her head in her hands and apologizing. He further indicated Employee 3 put Resident B's arms into her shirt to keep her from hitting Employee 3. Employee 5 indicated he should have told the Administrator of the allegations when they occurred, but that he did not. During an interview, on 5/21/2019 at 2:35 P.M., Resident D indicated, Employee 3 and Employee 6 mentally put me down. During an interview, on 5/21/2019 at 2:45 P.M., the facility Administrator indicated Employees' 3 & 6 were no longer working at the facility, and that he was unable to prove abuse took place or that it didn't. On 5/22/19 at 10:30 A.M., the Administrator provided the policy titled,Abuse, Neglect and Exploitation Procedural Guidelines, dated 10/10/2018, and indicated the policy was the one currently used by the facility. The policy indicated .2. The Executive Director and Director of Health Services are responsible for the implementation and ongoing monitoring of abuse standards and procedures and .iv. IMMEDIATELY notify the Executive Director This Federal tag is related to Complaint IN 030. 3.1-28(e)

Based on record review and interview, the facility failed to thoroughly assess fall risk, provide adequate supervision & implement adequate interventions to prevent falls for a resident with a history of intermittent confusion and hallucinations with recent acute increase in confusion and hallucination frequency related to hypercapnia (elevated carbon [MEDICATION NAME]) resulting in a fall with unrepairable bilateral femur fractures for 1 of 6 residents reviewed for accidents. (Resident 3). The facility also failed to implement appropriate fall prevention interventions and supervision for 2 of 6 residents reviewed for accidents. (Residents 13 & 191) Findings include: 1. During an interview, on 3/21/19 at 1:48 P.M., Resident 3's daughter indicated the resident had a fall on 3/11/19 which resulted in femur fractures to both legs and the resident had not been bedridden prior. The resident was a known CO2 (carbon [MEDICATION NAME]) retainer and would have increasing confusion and delusions/hallucinations when her CO2 was elevated. The clinical record for Resident 3 was reviewed on 3/25/19 at 9:45 A.M. The [DIAGNOSES REDACTED]. The admission MDS, dated [DATE], indicated Resident 3 had severe cognitive impairment, no behaviors were noted during the assessment period, she was an extensive assist to total assist with transfers and was receiving oxygen therapy. A Care Plan for potential for complications, functional and cognitive status decline related to respiratory disease, dated 9/21/18, indicated it was related to [MEDICAL CONDITION] and [MEDICAL CONDITION]. Interventions included, but were not limited to, assess for change in level of consciousness, coherency and report changes, respiratory therapy as ordered, and monitor oxygen saturation. A Care Plan, dated 9/21/18, indicated risk for falling related to impaired mobility. Interventions included, but were not limited to, ensure the floor was free of liquids and foreign objects, keep call light in reach, provide non-skid footwear and staff to assist resident with transfers as needed. There was no risk for fall intervention related to increased confusion and delusions/hallucinations related to hypercapnia noted. A Hospital Consultation Report, dated 11/8/18, indicated Resident 3 had a major exacerbation in (MONTH) (YEAR) in which her blood gas levels indicated a pH of 7.33 (normal values 7.35-7.45), pCO2 of 73 (normal 35-45 mmHg), pO2 of 66 (normal 80-100 mmHg) and O2 saturation of 89%. She was extremely lethargic, she was placed on Bi-pap and on this regimen showed slow but steady improvement. She did have a long history of [MEDICAL CONDITION], history of sleep apnea and had been on [MEDICAL CONDITION] (continuous positive airway pressure, machine which delivers the same amount of pressure as you breathe in and out) and Bi-pap (bilevel positive airway pressure, machine which helps push air into the lungs with inhalation.) It was not clear if she had been using either in the nursing home recently. A facility Progress Note, dated 12/4/18 at 1:40 P.M., indicated Resident 3 would be returning to the facility from a local long term acute care hospital with continued Bi-pap use and oxygen therapy at 2 liters per nasal cannula. A Transfer of Care: Nursing Report, dated 12/4/19, indicated Resident 3 was to have a Bi-pap at night. The facility Physician order [REDACTED]. There was no written order present for bi-pap use upon readmission. The Medication and Treatment Administration History, dated 12/1/18 - 2/28/19, did not contain any documentation for Bi-pap use. A Progress Note, dated 12/6/18 at 2:34 P.M., indicated Resident 3 was making delusional statements and 1:1 was given with some positive effects. There was no new/worsening behavior documentation available. There were no updates noted in the plan of care for delusions. A Progress Note, dated 1/5/19 at 3:14 A.M., indicated Resident 3 was having hallucinations about cooking something in the oven and pointed to the side of the bed where she believed the area was hot. There was no new/worsening behavior documentation available. There were no updates noted the plan of care for hallucinations. A laboratory result, dated 1/16/19, indicated Resident 3 had a CO2 level of 33.7 mEq/L (milliequivalants per liter)(normal range 21-33). There was no physician notification documentation available of the abnormally high CO2 level. A Progress Note, dated 1/18/19 at 12:00 P.M., indicated Resident 3 was not responding to verbal stimuli. A Progress Note, dated 3/5/18 at 1:41 P.M., indicated the resident was talking to herself and 1:1 was given. She was asking for her husband and indicated that he still came to see her now and again There was no new or worsening behavior documentation available. There were no updates noted the plan of care for delusions/hallucinations. A Progress Note, dated 3/8/19 at 2:57 A.M., indicated Resident 3 had been making delusional comments and attempting to get out of bed without assistance and 1:1 was given concerning the need to transfer with assist of 2 staff members. Resident stated, I know but I wanted to try, my husband is out in the car waiting for me. Asked resident if she wanted to get up in wheel chair, resident stated I don't sit in a wheelchair, I am going home in my car. Resident closely watched for safety. There were no updates noted to the fall risk care plan for increased confusion and hallucinations. There was no new behavior documentation. A Progress Note, dated 3/8/19 at 10:58 A.M., indicated a new order for CBC, BMP and UA with C&S if indicated related to increased agitation and confusion. A laboratory report, dated 3/8/19, indicated Resident 3 had an elevated CO2 level of 34.3. There was no physician notification of the elevated level documented. There were no updates noted to the fall risk care plan for increased confusion and hallucinations. There was no new behavior documentation. A Progress Note, dated 3/11/19 at 12:40 A.M., indicated Resident 3 was found on the floor in her room next to her bed. Her head was at the foot end of the bed lying on her back. Legs were crossed right leg over the left leg, with the left leg rotated out. She complained of pain when attempting to move her legs. The resident had indicated someone was telling me to get out of bed. Transferred to the local emergency room . The Administration History, dated 3/1/19 - 3/25/19, indicated an order for [REDACTED]. The emergency room Report, dated 3/11/19, indicated Resident 3 presented to the emergency room and had multiple x-rays which indicated severe comminuted distal femur fractures. The physician recommended if any surgical procedure was to be performed it would be bilateral above the knee amputation, which would improve her quality of life by making transfers easier and have less pain postoperatively. If this was treated conservatively, there was a good change that for months the patient would have a lot of pain. She would not be able to bend her knees for months and months and would have a difficult time sitting out in a chair for a period of time. A Consult Note from the Hospital, dated 3/12/19, indicated Resident 3 had been evaluated by 2 separate orthopedic surgeons who felt, because of her chronic bedridden nature and severe [MEDICAL CONDITION], if any surgical intervention was to be performed, it should be a bilateral below-knee amputation. A Hospital Discharge Summary, dated 3/16/18, indicated Resident 3 was brought the emergency room after a fall at the nursing home. Orthopedics felt she was not a candidate for internal fixation (surgical repair) of her bilateral lower extremity fractures due to severe osteopenia and they recommended bilateral lower extremity above the knee amputation. The family and resident decided against surgery and agreed to continue pain management. She developed hemorrhagic shock and acute [MEDICAL CONDITION]; most likely the source of bleeding was her thighs when she had the fractures. The discharge instructions indicated it was very important to keep the Bi-pap mask on during sleep - at night and any time the resident was taking a nap. During an interview, on 3/25/19 at 2:41 P.M., LPN 3 indicated she was the nurse for Resident 3 for roughly 3 to 5 days per week. Resident 3 had a history of [REDACTED]. Signs of increased CO2 levels in Resident 3 were confusion, hallucinations and lethargy. She indicated Resident 3 had increased confusion and hallucinations in the past couple of weeks which were really bad. The resident was having delusions and talking to people in her room who were not there and this was becoming more and more frequent prior to the resident's fall. During an interview on 3/25/19 at 2:56 P.M., RN 4 indicated Resident 3 currently had 2 broken legs and required 4 people to turn and reposition her. The resident currently had a urinary catheter which she did not have prior to the fall. She used to use the bed pan and was able to make staff aware of her needs. Prior to 3/8/19, Resident 3 was alert and oriented to person, place and time. She did have intermittent confusion on the days she did not wear her Bi-pap. Prior to the fall, Resident 3 did not have history of attempting to transfer herself. She was not aware of the STAT CO2 lab draw order, but she was the nurse whom had received the order for CBC, UA and BMP. She indicated she had notified the NP because Resident 3 was demonstrating increased confused and screaming out and saying off the wall stuff. RN 4 called the daughter and she said if the resident got any type of infection, she tended to get septic (infection spread throughout the body) quick. Signs of increased CO2 levels were hallucinations and increased confusion. The resident did have history of UTI and she was not aware of UA results ordered on [DATE]. She indicated the only verbal report was given from shift to shift, there were no documented 24 hour reports. During an interview on 3/25/19 at 3:10 P.M., Resident 3's son indicated there was no order for the Bi-pap until 3/8/19. The facility had been instructed to notify family if the resident refused to wear her [MEDICAL CONDITION] and it wasn't put on as ordered. He indicated the family was notified on 3/11/18 around 12:30 A.M. regarding the fall and the staff had indicated her legs were bent in an uncomfortable way. He followed the ambulance to the local hospital and upon arrival, Resident 3 was hurting from all over. The physician had told the family she had two fractured femurs and that her life expectancy would not be great. There were no floor mats in place by her bed in her room until after Resident 3 returned from the hospital. Resident 3 had a history of [REDACTED]. He indicated the family had noticed the changes in Resident 3 and had requested side rails to prevent falls from the bed if she attempted to get up due to her delusions and hallucinations. Upon return from the hospital, Resident 3 was lifted in a hoyer lift to place an air mattress on the bed. During an interview, on 3/27/19 at 10:48 A.M., Resident 3's PCP (Primary Care Physician) indicated he had not been notified of the residents change of condition or elevated CO2 levels from 3/8/19 for the facility staff. The NP (Nurse Practitioner) who had been called was employed through the facility, not his office, and never communicated to him about the change of condition or STAT lab orders. During an interview, on 3/27/19 at 4:26 P.M., the MR (Medical Records) nurse indicated that Resident 3's behaviors on the weekend of 3/8/19 were abnormal for her. Resident 3 was talking about getting up and walking even though she had been a hoyer lift for transfers. During an interview, on 3/27/19 at 4:33 P.M., LPN 3 indicated she was aware the resident would move her bed up and down on her own with the bed remote. Resident 3 was pretty confused over the weekend starting 3/8/19, had a lot of delusions and was asking about kids running in the hallway. She indicated the family had talked to staff over that weekend several times and had asked to keep her bi-pap on because he CO2 levels would increase and confusion would worsen. She indicated no 1:1 interventions were currently implemented immediately prior to the resident falling. 2. A clinical record review for Resident 13 was completed on 3/25/19 at 12:59 P.M. The [DIAGNOSES REDACTED]. A quarterly MDS (Minimum Data Set) assessment, dated 1/16/19, indicated Resident 13 had severe cognitive impairment, required limited assist of 1 staff for bed mobility, transfers, dressing, toilet use and eating. A Fall Risk Assessment, dated 8/17/18, indicated Resident 13 was at risk for falls related to: lack of safety awareness, cognitive impairment that affects safety/judgment, history of falls, requires staff assistance and or assistive device for safe transfers and mobility. Interventions included, but were not limited to: therapy to evaluate and treat per orders, implement enabler to assist with fall prevention, keep call light in reach/ encourage to use and educate resident to utilize safety measures. A Nurses Progress Note, dated 2/15/19 at 8:49 P.M., indicated the resident had visitors this evening and family stated the resident was up walking around in his room. The staff talked with the resident about safety. At 4:30 P.M., Resident 13 was found on the floor. The resident was placed in the recliner after incontinent care was provided and his call light was placed in reach and was reminded to push the call light to have help. A Nurse's Progress Note, dated 3/11/19 at 10:30 P.M., indicated Resident 13 was found on the floor with his head near hear the recliner and a wheel chair tipped over on the left side of the resident. Resident 13 indicated he did not fall he just wanted to lay down. An IDT Note, dated 3/12/19 at 10:23 A.M., indicated the resident was confused at times and had a BIMS (Brief Interview for Mental Status) score of 5 indicating severe cognitive impairment. Intervention implemented was for staff to assist the resident to bed at night. A Nurse's Progress Note, dated 3/15/19 at 11:30 A.M., indicated Resident 13 was found lying on his side in the 200 hall spa and fell during a non-assisted transfer. The resident complained of right hip discomfort and had an outward rotation. A Progress Note, dated 3/15/19, indicated Resident 13 was sent out to the local ER (emergency room ). A current Care Plan, dated 9/17/18 and updated 3/22/19, indicated the resident was at risk for falls related to impaired safety awareness, dementia, weakness , history of falls including fall with fracture. Interventions included, but were not limited to, non skid footwear, staff to assist with transfers as needed, call light in reach, staff to assist resident to bed, staff to toilet every 2 hours and encourage resident to be in common area when awake. During an interview on, 3/27/19 at 5:40 P.M., the Corporate Nurse indicated the interventions for falls were not appropriate for this confused resident. 3. On 3/22/19 at 12:36 P.M., Resident 191's room was observed with 1 floor mat on the floor by the window and the call light was not visible in the room. On 3/25/19 at 7:55 A.M., Resident 191 was observed sitting in her wheel chair at the end of her bed covered with blankets. The call light was observed not pinned to her clothing and 1 floor mat was on the floor. On 3/25/19 at 8:09 A.M., Resident 191 was receiving her medications from the nurse. The resident's call light was not pinned to the clothing. On 3/26/19 at 9:58 A.M., Resident 191 was observed sitting in her recliner with her call light on the bed which was not in her reach. During an observation on 3/26/19 at 2:53 P.M., Resident 191 was observed sitting in her recliner with the call light on the bedside table at the end of the recliner, not in reach of the resident. During an interview at that time, LPN 7 indicated the resident did not have her call light clipped to her clothing. During an interview on 3/26/19 at 11:37 A.M., CNA 5 indicated she did not know about the call light being clipped to the residents clothing. During an interview, on 3/27/19 at 11:44 A.M., guest relation staff 10 indicated she had just brought the resident out of her room to the dining room. She stated the resident had been in her recliner and the call light was observed on the bed. The clinical record for Resident 191 was reviewed on 3/22/19 at 12:05 P.M. The [DIAGNOSES REDACTED]. A Nurse's Note, dated 3/13/2019 at 10:01 P.M., indicated Resident 191 was found sitting on the floor next to her bed. The resident stated she was getting up to go to the bathroom. She complained of pain to her left wrist, which was swollen and appeared injured. The resident stated she had a previous break and felt it was broken again. A Progress Note, dated 3/13/19, indicated Resident 191 was sent out to the local ER (emergency room ). A Nurse's Progress Note dated, 3/14/19 at 1:38 A.M., indicated the resident had a distal radial fracture to the left wrist. An IDT (Interdisciplinary Team) note, dated 3/14/19 at 11:30 A.M., indicated the IDT discussed the fall on 3/13/19 and staff were to toilet the resident before meals and before bed at night. A Nurse's Progress Note dated, 3/14/19 at 10:16 P.M., indicated Resident 191 was found on the floor. The bed was lowered to the floor and floor mats placed on each side of the bed. Resident 191's toileting record indicated the resident was incontinent at 10:45 P.M. and was toileted at 11:00 P.M. A Nurse's Progress Note dated, 3/15/19 at 5:40 A.M., indicated the resident had been attempting to get up several times without calling for assistance. The resident was re-educated on the use of the call light and importance of waiting for staff to help her. The resident voiced understanding but still fails to use light. An IDT note, dated 3/15/19, indicated the resident's daughter informed staff that she had walked into her mothers room and found her on the floor. Resident 191 was found face down on the floor and stated she was attempting to get her call light and fell forward our of her chair. The call light was not in front of the resident. The staff had placed it on the table beside the resident prior to leaving the room. Staff to ensure the call light is clipped to the residents clothing, bed is in lowest position and fall mats on the floor on each side of the bed. An admission MDS (Minimum Data Set) assessment, dated 3/18/19, indicated Resident 191 had severe cognitive impairment. A care plan, dated 3/14/19 and updated on 3/18/19, indicated Resident 191 was at risk for falls related to [DIAGNOSES REDACTED]. Interventions included, but were not limited to, call light in reach, assist to the bathroom before meals and bed time, bed in lowest position, call light clipped to clothing, floor mats to both sides of bed, and assist resident with transfers as needed. A current Care Plan, dated 3/22/19, indicated the resident was at risk for pain related to .recent fall resulting in wrist fracture During an interview on 3/27/19 at 8:35 A.M., the Corporate Nurse indicated the interventions for falls were not appropriate for this confused resident and the staff were not following the care plan. On 3/26/19 at 7:00 A.M., the Corporate Nurse provided the policy titled, Fall Management Program Guidelines, dated 5/22/18, and indicated the policy was the one currently used by the facility. The policy indicated .1. The fall risk assessment is included as part of the Admission and Quarterly Nursing Observation and other Events/Observation in EHR: a. Identified risk factors should be evaluated for the contribution they may have to the resident's likelihood of falling. b. Care plan interventions should be implemented that address the resident's risk factors. 2. Should the resident experience a fall the attending nurse shall complete the Fall Event. This includes an investigation of the circumstances surrounding the fall to determine the cause of the episode, a reassessment to identify possible contributing factors, interventions to reduce risk of repeat episode and a review by the IDT to evaluate thoroughness of the investigation and appropriateness of the interventions. 4. Any orders received from the physician should be noted and carried out. 5. The resident care plan should be updated to reflect any new change in interventions. 7. Discuss risks and interventions with resident and /or responsible party and communicate interventions during shift report 3.1-45(a)(2)

Based on record review and interview, the facility failed to provide written clinical documentation to communicate with the receiving facilities the reason for transfer for 3 of 5 residents reviewed for transfer/discharge. (Residents 13, 191, and 20) Findings include: 1. The clinical record for Resident 13 was completed on 3/25/19 at 12:59 P.M. The [DIAGNOSES REDACTED]. A progress note, dated 3/15/19, indicated Resident 13 was sent out to the local ER (emergency room ). There was no documentation regarding the resident's clinical condition being communicated to the receiving facility. 2. The clinical record for Resident 191 was reviewed on 3/22/19 at 12:05 P.M. The [DIAGNOSES REDACTED]. A progress note, dated 3/13/19, indicated Resident 191 was sent out to the local ER (emergency room ). There was no documentation regarding the residents clinical condition being communicated to the receiving facility. During an interview, on 3/25/19 at 3:40 P.M., the Corporate Nurse indicated there was no documentation of the residents clinical condition reported to the receiving facilities. 3. A clinical record review was completed, on 3/21/2019 at 2:04 P.M. Resident 20's [DIAGNOSES REDACTED]. A nurses note, dated 3/15/2019, indicated Resident 20 was admitted to the local hospital. There was no available information indicating the receiving facility obtained a clinical reason for his transfer. During an interview, on 3/27/2019 at 10:58 A.M., the Corporate Nurse #1 indicated no clinical information was transferred to the hospital with Resident 20. On 3/26/19 at 7:00 A.M. the Corporate Nurse provided the policy titled, Guidelines for Transfer and Discharge (including AMA), dated 5/23/18, and indicated the policy was the one currently used by the facility. The policy indicated .Emergency transfer procedures should include the following: a. Nursing should obtain physicians' orders for emergency transfer or discharge and may include stating the reason the transfer or discharge is necessary on an emergency basis. c. Nursing should print and send the resident's CCD (Continuum of Care Document) which includes current diagnosis, most recent vital signs, allergies [REDACTED]. e. Nursing should document information regarding the transfer in the medical record 3.1-12(a)(3)

Based on record review, interview and observation, the facility failed to develop a care plan with appropriate fall interventions, failed to implement updated interventions, and failed to develop a care plan for a fracture with cast for 2 of 19 residents reviewed for care plans. (Residents 13 & 191) Findings include: 1. A clinical record review for Resident 13 was completed on 3/25/19 at 12:59 P.M. The [DIAGNOSES REDACTED]. A quarterly MDS (Minimum Data Set) assessment, dated 1/16/19, indicated Resident 13 had severe cognitive impairment, required limited assist of 1 staff for bed mobility, transfers, dressing, toilet use and eating. A Fall Risk Assessment, dated 8/17/18, indicated Resident 13 was at risk for falls related to: lack of safety awareness, cognitive impairment that affects safety/judgment, history of falls, requires staff assistance and or assistive device for safe transfers and mobility. Interventions included, but were not limited to: therapy to evaluate and treat per orders, implement enabler to assist with fall prevention, keep call light in reach/ encourage to use and educate resident to utilize safety measures. A Nurse's Progress Note, dated 2/15/19 at 8:49 P.M., indicated the resident had visitors this evening and family stated the resident was up walking around in his room. The staff talked with the resident about safety. At 4:30 P.M., Resident 13 was found on the floor. The resident was placed in the recliner after incontinent care was provided and his call light was placed in reach and was reminded to push the call light to have help. A nurses progress note, dated 3/11/19 at 10:30 P.M., indicated Resident 13 was found on the floor with his head near hear the recliner and a wheel chair tipped over on the left side of the resident. Resident 13 indicated he did not fall he just wanted to lay down. A IDT note, dated 3/12/19 at 10 :23 A.M., indicated the resident is confused at times and had a BIMS (Brief Interview for Mental Status) score of 5 indicating severe cognitive impairment. Intervention implemented was for staff to assist the resident to bed at night. A Nurse's Progress Note, dated 3/15/19 at 11:30 A.M., indicated Resident 13 was found lying on his side in the 200 hall spa and fell during a non-assisted transfer. The resident complained of right hip discomfort and had an outward rotation. A progress note, dated 3/15/19, indicated Resident 13 was sent out to the local ER (emergency room ). A current care plan, dated 9/17/18 and updated 3/22/19, indicated the resident was at risk for falls related to impaired safety awareness, dementia, weakness, and history of falls including fall with fracture. Interventions included, but were not limited to, non skid footwear, staff to assist with transfers as needed, call light in reach, staff to assist resident to bed, staff to toilet every 2 hours and encourage resident to be in common area when awake. During an interview on, 3/27/19 at 5:40 P.M., the Corporate Nurse indicated the interventions for the falls were not appropriate for this confused resident. 2. During an observation on 3/22/19 at 10:04 A.M., Resident 191 was noted to have a pink cast to her left arm. The clinical record for Resident 191 was reviewed on 3/22/19 at 12:05 P.M. The [DIAGNOSES REDACTED]. A Nurse's Note, dated 3/13/2019 at 10:01 P.M., indicated Resident 191 was found sitting on the floor next to her bed. The resident stated she was getting up to go to the bathroom. She complained of pain to her left wrist, which was swollen and appeared injured. The resident stated she had a previous break and felt it was broken again. A progress note, dated 3/13/19, indicated Resident 191 was sent out to the local ER (emergency room ). A nurses progress note dated, 3/14/19 at 1:38 A.M., indicated the resident had a distal radial fracture to the left wrist. A current, 3/22/19, care plan problem indicated the resident was at risk for pain related to .recent fall resulting in wrist fracture The care plans lacked the documentation of any care of the cast or the need for staff assistance with her activities of daily living. During an interview on, 3/25/19 at 10:11 A.M., the Corporate Nurse indicated there should have been a care plan for the fracture/cast. An IDT (Interdisciplinary Team) note, dated 3/14/19 at 11:30 A.M., indicated the IDT discussed the fall on 3/13/19 and staff were to toilet the resident before meals and before bed at night. A Nurse's Progress Note, dated 3/14/19 at 10:16 P.M., indicated Resident 191 was found on the floor. The bed was lowered to the floor and floor mats placed on each side of the bed. Resident 191's toileting record indicated the resident was incontinent at 10:45 P.M. and was toileted at 11:00 P.M. A Nurse's Progress Note, dated 3/15/19 at 5:40 A.M., indicated the resident had been attempting to get up several times without calling for assistance. The resident was re-educated on the use of the call light and importance of waiting for staff to help her. The resident voiced understanding but still fails to use the call light. An IDT note, dated 3/15/19, indicated the resident's daughter informed staff that she had walked into her mother's room and found her on the floor. Resident 191 was found face down on the floor and stated she was attempting to get her call light and fell forward our of her chair. The call light was not in front of the resident. The staff had placed it on the table beside the resident prior to leaving the room. Staff to ensure the call light is clipped to the residents' clothing, bed is in lowest position and fall mats on the floor on each side of the bed. An admission MDS (Minimum Data Set) assessment, dated 3/18/19, indicated Resident 191 had severe cognitive impairment. A care plan, dated 3/14/19 and updated on 3/18/19, indicated Resident 191 was at risk for falls related to [DIAGNOSES REDACTED]. Interventions included, but were not limited to, call light in reach, assist to the bathroom before meals and bed time, bed in lowest position, call light clipped to clothing, floor mats to both sides of bed, and assist resident with transfers as needed. On 3/22/19 at 12:36 P.M., Resident 191's room was observed with 1 floor mat on the floor by the window and the call light was not visible in the room. On 3/25/19 at 7:55 A.M., Resident 191 was observed sitting in her wheel chair at the end of her bed covered with blankets. The call light was observed not pinned to her clothing and 1 floor mat was on the floor. On 3/25/19 at 8:09 A.M., Resident 191 was receiving her medications from the nurse. The residents call light was not pinned to the clothing. On 3/26/19 at 9:58 A.M., Resident 191 was observed sitting in her recliner with her call light on the bed which was not in her reach. During an interview, on 3/26/19 at 11:37 A.M., C.N.A 5 indicated she did not know about the call light being clipped to the residents clothing. During an observation on 3/26/19 at 2:53 P.M., Resident 191 was observed sitting in her recliner with the call light on the bed side table at the end of the recliner, not in reach of the resident. During an interview, on 3/26/19 at 2:54 P.M., LPN 7 indicated the resident did not have her call light clipped to her clothing. During an interview, on 3/27/19 at 11:44 A.M., guest relation staff 10 indicated she had just brought the resident out of her room to the dining room. She stated the resident was in her recliner and the call light was on the bed. On 3/26/19 at 7:00A.M., the Corporate Nurse provided the policy titled, Comprehensive Care Plan Guidelines, dated 5/22/18, and indicated the policy was the one currently used by the facility. The policy indicated . 1. d.iii. Interventions should be reflective of the individual's needs and risk influence as well and the resident's strengths. 2. Address problems that become ongoing or chronic with a new comprehensive care plan. 4. Pertinent care plan approaches are communicated to the nursing staff per the 24 hour CRCA assignment or the care tracker profile dependent on campus preference. 6. Comprehensive care plans need to remain accurate and current 3.1-35(d)(2)(B)

Based on record review, interview and observation, the facility failed to notify the physician of a worsening pressure ulcer and implement new interventions for 1 of 5 residents reviewed for pressure ulcers. (Resident 18) Finding includes: During an observation on 3/25/19 at 7:15 A.M., Resident 18 was lying in bed with her feet touching the foot board with 1 boot on her left foot and the right foot boot turned around not providing pressure relief. A clinical record review for Resident 18 was completed on 3/25/19 at 2:43 P.M. The [DIAGNOSES REDACTED]. An annual MDS (Minimum Data Set) assessment, dated 2/1/19, indicated Resident 18 was severely cognitively impaired. She required extensive staff assist of 2 for bed mobility, transfers, dressing and toilet use and 1 staff for eating. The resident currently had 1 unstageable pressure area to her right heel. A Nurse's Progress Note, dated 10/18/2018 at 10:47 A. M., indicated discoloration to heel remains intact. Tender to touch. Skin prep applied and heel protector in place. Pillow placed under bilateral feet. Hospice here and notified of area. A Nurse's Progress Note, dated 10/21/2018 at 8:15 P.M., indicated, (Recorded as Late Entry on 10/22/2018 6:52 PM) Resident with area to right heel which presents with purple/ brown firmly attached eschar. No drainage noted. Resident recently received a new wheelchair with a foot rest from Hospice. As she did not previously have a foot rest and it is believed the area was caused from pressing against the foot rest. The foot rests have been removed. Resident has pressure relieving boots to wear while in bed. Skin prep applied to heels. A Wound Note, dated 10/21/18, indicated the tissue type was necrotic with 100% of the wound covered by eschar tissue. A Wound Review Note, dated 10/26/2018 at 11:29 A.M., indicated, Reviewed newly acquired wound to right heel, SDTI (Suspected Deep Tissue Injury). Resident is long term resident, receiving hospice . Resident is combative with care at times, refuses weights and can be aggressive with staff. Recently hospice brought in a new wheelchair foot rests to new wheel chair believed to cause area with no pressure supporting device, pressure relieving boots to be worn to reduce pressure, off loading of heels while in bed. Area measures 3.0 cm (centimeter) x 4.0 cm, 100% necrotic tissue noted, surrounding peri area tissue is pink/normal, no odor or s/s (signs or symptoms) of infection noted. Treatment in place with interventions for pressure relief and healing. weights, consumption includes Hospice, MD and POA aware of area to right heel. Continue treatment. A Wound Note, dated 10/28/18, indicated the length was 4.5 cm, width was 3.5 cm and no depth. Unstageable deep tissue type with 100% of wound covered by clean, non granulation tissue. A Wound Note, dated 11/4/18, indicated the length was 5.8 cm, width was 4 cm and no depth. Unstageable deep tissue type with 100% of wound covered by clean, non granulation tissue. A Wound Note, dated 11/11/18, indicated the length was 9 cm, width was 8 cm and no depth. Tissue type was documented as necrotic tissue. Percent of wound covered by eschar tissue was 100%. A Wound Note, dated 11/18/18, indicated the length was 8 cm, width was 7.5 cm and no depth. Tissue type was documented as necrotic tissue. Percent of wound covered by eschar tissue was 100%. A Wound Note, dated 11/25/18, indicated the length was 7.8 cm, width was 7.2 cm and no depth. Tissue type was necrotic with 100% of the wound covered by eschar. Review of notes from 10/26/18 through 11/25/18 lacked documentation to show the physician was notified of the worsening of Resident 18's pressure area and to obtain new treatment orders. A Care Plan, dated 3/18/2016 and revised on 3/22/2019, indicated the resident was at risk for skin breakdown, including pressure ulcers, related to immobility, incontinence, history of pressure areas, had a tendency to scratch/itch her skin and bottom, and often refuse to be toileted/changed when soiled. A Care Plan, dated 2/11/19, indicated the resident had a pressure ulcer to the right heel. Interventions included, but were not limited to, assess area for signs/symptoms of infection, provide diet as tolerated, encourage fluids, treatment per order, weekly skin assessments and provide supplements, vitamins and minerals as ordered. A request of physician notification documentation for Resident 18's pressure area was made, but no documentation was provided. 3.1-40(a)(3)

Based on observation, interview, and record review, the facility failed to ensure a resident received range of motion services as necessary to maintain functional status for 1 of 3 residents reviewed for range of motion. (Resident 8) Finding includes: On 3/21/2019 at 1:21 P.M., Resident 8 was observed to have a limited range of motion to his upper and lower extremities. The resident indicated he was not receiving range of motion services. During an observation on 3/27/2019 at 10:12 A.M., Resident 8 was observed unable to move his lower extremities and his upper extremities were limited in mobility. During an interview at that time, Resident 8 indicated he would like to receive range of motion services on all his extremities and was not currently receiving services. A clinical record review was completed on 3/21/2019 at 1:21 P.M. Resident 8's [DIAGNOSES REDACTED]. A quarterly MDS (Minimum Data Set) assessment, dated 12/28/2018, indicated Resident 8 had range of motion impairment to both of his extremities. The resident was cognitively intact. Therapy notes indicated his last therapy ended 7/18/2018. There was no documentation in the record to indicate he was currently receiving any range of motion services. During an interview on 3/27/2019 at 10:23 A.M., Corporate Nurse #1 indicated providing range of motion services to Resident 8 may help to maintain his current mobility status. A policy was requested and one was not received. 3.1-42(a)(2)

Based on record review, observation and interview, the facility failed to ensure that a resident requiring a Bi-pap had an order upon readmission and ensure the Bi-pap was cleaned and free from sediment in the mask for 1 of 1 residents reviewed for respiratory care. (Resident 3) Finding includes: During an interview, on 3/21/19 at 1:48 P.M., Resident 3's daughter indicated the facility had been cleaning the Bi-pap mask. The clinical record for Resident 3 was reviewed on 3/25/19 at 9:45 A.M. The [DIAGNOSES REDACTED]. The admission MDS, dated [DATE], indicated Resident 3 had severe cognitive impairment, no behaviors were noted during the assessment period, she was an extensive to total assist with transfers and was receiving oxygen therapy. A Progress Note, dated 12/4/18 at 1:40 P.M., indicated Resident 3 would be returning to the facility from a local long term acute care hospital with continued Bi-pap use and oxygen therapy at 2 liters per nasal cannula. A Transfer of Care: Nursing Report, dated 12/4/19, indicated Resident 3 was to have a Bi-pap at night. The facility Physician order [REDACTED]. There was no written order present for bi-pap use upon readmission. A Care Plan for potential for complications, functional and cognitive status decline related to respiratory disease, dated 9/21/18, indicated it was related to [MEDICAL CONDITION] and [MEDICAL CONDITION] and included, but was not limited to the following interventions, assess for change in level of consciousness coherency and report changes, respiratory therapy as ordered, and monitor oxygen saturation. Bi-pap as ordered was dated 3/22/19. The Medication and Treatment Administration History, from 12/1/18 - 2/28/19, did not contain any documentation for Bi-pap use. The Medication and Treatment Administration History, dated 3/1/19 - 3/25/19, indicated an order for [REDACTED]. During an interview, on 3/25/19 at 2:41 P.M., LPN 3 indicated she was the nurse for Resident 3 for roughly 3 to 5 days per week. Resident 3 had a history of [REDACTED]. Signs of increased CO2 levels in Resident 3 were confusion, hallucinations and lethargy. During an interview 3/25/19 at 3:00 P.M., LPN (Licensed Practical Nurse) 8 indicated she was not aware of how to clean bi-pap mask and she indicated there was not order. During an interview on 3/25/19 at 3:10 P.M. Resident 3's son indicated there was no order for the Bi-pap until 3/8/19. During an interview on 3/25/19 at 4:20 P.M., QMA (Qualified Medical Aide) 9 indicated it was the responsibility of the nurses to clean the bi-pap mask. During an interview on 3/25/19 at 4:25 P.M., LPN 3 indicated she would wipe the bi-pap mask down with the cloth, not the bleach ones-but the other cloths. She indicated she did not document when it was cleaned. During an interview on 3/26/19 at 2:59 P.M., LPN 7 indicated the [MEDICAL CONDITION] masks were cleaned with vinegar water and were to air dry. During an observation 3/26/19 at 3:15 P.M., Resident 3's [MEDICAL CONDITION] mask was noted to have a white, cream colored substance located in the soft portion of the mask and particles/sediment were noted to the hard part of the mask. During an interview on 3/26/19 at 3:15 P.M., CNS (Clinical Nurse Specialist) 1 indicated Resident 3's mask was dirty and the order for cleaning the mask should have been in the computer. There also should have been on order for the [MEDICAL CONDITION] upon readmission on 12/4/18. During an interview on 3/26/19 at 3:26 P.M., the local respiratory company indicated it had completed respiratory training on [MEDICAL CONDITION] cleaning on 9/12/18. This education was provided to the facility annually and there was no train-the-trainer qualified staff in the facility currently. On 3/27/19 at 10:00 A.M., the CNS 1 provided the undated policy titled, Respiratory Specialists Policy and Procedure [MEDICAL CONDITION] and [MEDICAL CONDITION] and indicated this was the policy and training provided from the local respiratory company. The policy indicated the cleaning of headgear and mask should be completed weekly by nursing staff as follows: hand wash the mask with warm water with mild dishwashing detergent. DO NOT use bleach, alcohol, cleaning solutions containing any alcohol or strong household cleaners. DO NOT use cleaners containing conditioners or moisturizers. Rinse thoroughly. Air dry. Make sure mask is dry before use. Hand or machine wash the head gear and attached swivel clips with standard laundry detergent and warm water. Line dry or machine dry at medium heat setting. On 3/27/19 at 11:00 A.M., a policy on physician orders [REDACTED]. 3.1-47(a)(6)

Based on record review and interview, the facility failed to have a physician's order for self-administration of medication for 1 of 1 residents reviewed for self administration. (Resident 31) Findings include: During a medication storage observation on 3/23/18 at 2:13 P.M., an unopened bottle of [MEDICATION NAME] nasal spray was in the top drawer. During an interview, on 3/23/18 at 2:14 P.M., LPN (Licensed Practical Nurse) 10 indicated Resident 31 probably has the open bottle at her bedside because she uses it herself. A clinical record review was completed on 3/26/18 at 2:16 P.M., and indicated the resident's [DIAGNOSES REDACTED]. A MDS (Minimum Data Set) assessment, dated 2/12/18, indicated Resident 31 had a BIMS (Brief Interview for Mental Status) score of 15, cognitively intact. A current, 1/26/18, care plan problem indicated the resident self administers nasal spray, eye drops and TENS unit. The only intervention was, I will self administer my nasal spray, eye drops and TENS unit as ordered. The current MEDICATION ORDERS FOR [REDACTED]. The current physician orders lacked documentation for self administering of medications. A self administration of medication assessment, dated 3/15/17, indicated Resident 31 was cognitively intact. She had no limitations of upper extremities, had good vision and was able to self administer the nasal spray. During an interview, on 3/26/18 09:56 A.M., LPN 10 indicated that there should be an order for [REDACTED].>On 3/23/18 at 11:55 A.M., the Corporate MDS staff provided the policy titled, Guidelines for Self-Administration of Medications, dated 8/1/16, and indicated the policy was the current one used by the facility. The policy indicated .2. Results of the assessment will be presented to the physician for evaluation and an order for [REDACTED]. i.e. all oral meds, oral med with exception of ., nebulizer treatment only, all medications including injection, oral, inhalers, drops, etc 3.1-11(a)

Based on interview and record review, the facility failed to ensure a plan of care was developed for an abscessed tooth being treated with antibiotic medication for 1 of 23 residents whose care plans were reviewed. (Resident 15) Findings include: During an interview, on 3/19/18 at 11:58 A.M., Resident 15 indicated she was on an antibiotic for a tooth infection and was having pain. A clinical record review was completed on 3/22/18 at 9:44 A.M., indicating Resident 15's [DIAGNOSES REDACTED]. A MDS (Minimum Data Set) assessment, dated 1/1/18, indicated Resident 15 had a BIMS (Brief Interview for Mental Status) score of 9, moderately impaired. She required extensive assist of two staff for bed mobility, transfers, dressing, toileting, and one staff assist for eating. A nurses note dated 3/8/18 at 5:48 P.M., indicated the resident complained of tooth pain and swelling around the tooth. The physician was notified and an order for [REDACTED]. A nurses note dated 3/18/18 at 9:20 A.M., indicated Resident 15 was sent to the emergency room for treatment due to a swollen jaw. On 3/18/18 at 2:59 P.M., the resident returned to the facility after having her right lower jaw/tooth lanced and drained, and was referred to an oral surgeon. Resident 15's care plans indicated there was no care plan developed for the abscessed tooth and the antibiotic use. During an interview, on 3/22/18 at 11:55 A.M., the Director of Nursing indicated they do not have a care plan policy book but they use the RAI (Resident Assessment Instrument) manual for care planning. The Long Term Care facility Resident Assessment Instrument, 3.0 users manual version 1.15, dated (MONTH) (YEAR), for RAI and care planning, indicated the care plan must be reviewed and revised periodically, and the services provided or aranged, must be consistant with each residents written plan of care. During an interview, on 3/22/18 at 2:02 P.M., the Director of Nursing indicated there should be a care plan for the tooth and antibiotic use. 3.1-35(a)

Based on observation, record review and interviews, the facility failed to ensure 3 of 3 residents admitted with risk of developing pressure areas had interventions implemented to reduce the risk of pressure ulcer development. This deficient practice resulted in the development of pressure ulcers, one of which became infected and required antibiotic treatment. (Residents #26, #55 and #61) Finding includes: 1. The clinical record for Resident #26 was reviewed on 02/18/2016 at 11:19 A.M. Resident #26 was admitted to the facility on [DATE], with diagnoses, including but not limited to: [MEDICAL CONDITIONS] with simple partial [MEDICAL CONDITION], anorexia nervosa, [MEDICAL CONDITIONS] disease and muscle weakness. The admission nursing assessment, completed on 06/22/15, indicated the resident had no pressure areas or skin conditions when he was admitted . The initial MDS (Minimum Data Set) assessment, completed on 06/30/15, indicated the resident required extensive staff assistance for bed mobility and transfer needs, was non-ambulatory, was frequently incontinent of his bowels and bladder. Resident #26 was at risk for pressure ulcer development. The assessment indicated pressure ulcers had triggered as an area to care plan. A Monthly nursing assessment, completed on 07/23/16, indicated the resident had no skin areas or issues and did not require a plan of care related to skin. A Skin Impairment Circumstance Investigation form, completed on 09/02/15, indicated the resident had developed a Stage 2 (Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink ulcer bed without slough. May also present as an intact blister or open/ruptured serum filled blister.) pressure ulcer on his coccyx. The form indicated it was possibly caused by moisture and pressure as the head of his bed was elevated due to his tube feeding. After the development the interventions were to make sure he had appropriate treatment, reposition/offset pressure with pillows, encourage resident to lay down between meals and a wheelchair cushion. The Pressure/Stasis/Arterial/Diabetic Ulcer Assessment form, initiated on 09/02/15, indicated one of the pressure ulcer wounds was located on his upper coccyx, was 1 cm (centimeter) by 0.3 cm, depth was undetermined and was pink in color. The treatment was Calazyme (a skin protectant) every shift. The wound was documented as healed on 09/08/15. There was another Pressure/Stasis/Arterial/Diabetic Ulcer Assessment, also indicated on 09/02/15 for a Stage 2 pressure ulcer on the lower coccyx. The wound was 4 cm by 1 cm and and of undetermined depth. The wound was red and the treatment was calazyme every shift. The wound was documented as healed on 10/06/15. A Pressure/Stasis/Arterial/Diabetic Ulcer Assessment form, indicated a wound had been initially identified, on 11/30/15, as a Stage 2 pressure ulcer on the upper sacrum of Resident #26. The wound was 1 cm by 1 cm with no depth and was cleansed with A and D ointment (a skin protectant). The charting on 12/01/15, indicated Merged with other sacral wound. Another Pressure/Stasis/Arterial/Diabetic Ulcer Assessment form, indicated a Stage 2 pressure wound had been initially identified, on 11/30/15, on the lower sacral area. The wound was 1 cm by 1 cm and was cleansed with A and D ointment. The pressure ulcer assessment and tracking form indicated, on 12/01/15, the treatment was changed to hydogel gauze and opti foam wound dressing changed daily. Other interventions implemented were to turn and reposition with pillows in bed, wheelchair cushion in wheelchair and lay down between meals. On 12/07/15, a culture of the resident's sacral wound was ordered due to slough in the wound bed. The pressure ulcer assessment and tracking form indicated, on 12/09/15, the wound had a 0.1 centimeter depth and was a Stage 3 (Full thickness tissue loss) pressure ulcer. On 12/13/15, the physician ordered the antibiotic, [MEDICATION NAME] to be administered intramuscularly by injection due to the wound infection. On 12/14/15, the physician ordered the antibiotic, [MEDICATION NAME] to be given per the resident's gastrostomy tube for 10 days to treat the resident's sacral wound infection. On 12/22/15, the pressure ulcer assessment and tracking form indicated the Stage 3 pressure ulcer had increased in size and had slight moisture drainage. The treatment was changed to puracol (collagen dressing) and [MEDICATION NAME] (foam dressing). On 01/03/16, a protein supplement was added to the resident's nutritional regimen. On 01/26/16, a low air loss mattress was added to the resident's bed. The pressure ulcer for Resident #26 was observed on 02/19/2016 at 11:02 A.M. with the Assistant Director of Health Services, LPN (Licensed Practical Nurse) #20. Resident #26 had a small, approximately 1 inch long by 1/3 inch football shaped wound on his lower coccyx area. He had a pink slightly open area off to the right side of the wound that had almost healed. LPN #20 indicated there was very little exudates and the wound had really improved. 2. The closed clinical record for Resident #55 was reviewed on 02/22/2016 11:23 A.M. Resident #55 was admitted to the facility, on 10/02/15, with diagnoses, including but not limited to: diabetes, methacillin - resistant staph aurous infection (MRSA), [MEDICAL CONDITION], hypertension, acid reflux and dysphasia. The nursing admission assessment, completed on 10/02/16, indicated the resident had no pressure areas. There was no care plan implemented and no interventions documented as implemented to prevent pressure ulcers. The initial MDS assessment, completed on 10/09/15, indicated the resident was at risk for pressure ulcer development and had one stage one pressure ulcer, required extensive staff assistance for mobility, transfers, and dressing and was occasionally incontinent of bladder. A 10/08/15 Skin Impairment Circumstance, Assessment and Intervention form, completed on 10/09/15, indicated the resident had developed a Stage 1 (Intact skin with nonblanchable redness of a localized area, usually over a bony prominence.) pressure ulcer on his left buttocks. The form indicated the resident had pressure relief devices (unspecified), a care plan, and consumed adequate nutrition. The resident's pressure ulcer was documented to have increased to a Stage 2 pressure ulcer on 10/13/15, and the treatment was changed to A and D ointment every shift. The resident's wound healed on 10/27/15. A Skin Impairment Circumstance, Assessment and Intervention form, initiated on 11/11/15, indicated the resident had developed Stage 2 pressure areas on his right and left buttocks. The form indicated a hydrogel gauze and foam dressing was ordered. The form also indicated the resident had pain and was noncompliant with positioning devices as he refused a recliner cushion. A clinically at risk individual monitoring sheet, initiated on 11/11/15, indicated on the weekly follow up assessment the wound was worsening and was 4 cm by 1 cm on the right buttocks and was 5 cm by 4 cm on the left buttocks. The form indicated both wounds were healed on 12/21/15. The resident was discharged to the hospital on [DATE] and there were no open areas or skin issues designated on the transfer form, even though the resident had open areas on both his right and left buttocks. The resident was readmitted to the facility on [DATE] and had an old scar from a healed pressure ulcer but no other skin issues even though the resident's pressure ulcers, noted on 11/11/16, were not documented as healed until 12/21/15. The assessment review and considerations form, completed on 10/26/15 (sic) indicated the resident had impaired mobility which put him at risk for skin breakdown. The resident was discharge to an acute care center on 11/25/15 and readmitted on [DATE]. The nursing readmission assessment, completed on 11/26/15 indicated a circle located on the coccyx of the body diagram and open area was written on the assessment form. There was no assessment of the circled open area marked on the readmission nursing assessment completed on 11/26/15. There was no care plan implemented or interventions to prevent pressure ulcers until 12/11/15, after the resident had developed pressure areas 3 different times. During an interview on 02/22/16 at 111:00 A.M., RN (Registered Nurse) #1, a Corporate Nursing Consultant, indicated it was a nursing standard of care to turn and reposition all residents and the corporation's bed mattresses were all pressure relieving mattresses and some kind of cushion was placed in all wheelchairs even if the interventions were no documented. She indicated there were specific interventions implemented on the purple colored wound assessment and tracking forms after the wounds developed. Finally, she indicated care plans were not implemented until day 21 of the resident's stay at the facility. 3. A clinical record was completed on 2/22/2016 at 11:00 A.M., for Resident #61 and indicated Resident #61 was admitted on [DATE]. The [DIAGNOSES REDACTED]. A review of Resident #61's ICARE (a care plan that is written in first person) did not indicate any skin risk interventions. A SKIN IMPAIRMENT CIRCUMSTANCE ASSESSMENT AND INTERVENTION form, dated 9/28/2015, indicated Resident #61 developed two stage two pressure ulcers. During an interview on 2/22/2016 at 12:37 P.M., the Corporate Nurse indicated that the facility does not provide CNA (Certified Nursing Assistant) careguides. She further indicated that the CNAs would find the information they needed from the ICARE plans. During an interview on 2/22/2016 at 12:50 P.M., CNA #2 indicated she would go to the facilities ICARE plans to find out how to provide care to residents. The facility policy and procedure, titled, General Wound and Skin Care Guidelines, undated and provided on 02/22/16 at 3:30 P.M. by RN (Registered Nurse) #1, included the following: .2. Turn/reposition residents who are immobile according to their care plan requirements .5. Evaluate the need for a pressure reduction surface for bed/chair and the need for the elbow protectors and/or heel floats .22. Educate residents/significant others on weight shifting in bed/chair and other interventions to prevent skin breakdown. The Interdisciplinary Team Care Plan Guideline policy, revised on 06/15 and provided by RN #1, the Nursing Consultant on 02/22/16 at 3:30 P.M., indicated an initial care plan was to be included on the Admission Nursing Assessment initiated within 24 hours and completed within 72 hours of admission to address pertinent areas of care, treatment and risk. A comprehensive care plan was to be completed within 7 days of the completion of the admission comprehensive MDS assessment. 3.1-40(a)(1)

A. Based on interview and record review the facility failed to provide Resident #29 with a functioning call light and alarm which resulted in a fall with fracture. This had the ability to affect 1 of 4 residents reviewed for accidents. (Resident #29) B. Based on observation and interview, the facility failed to provide a safe environment for residents related to power strips observed on the floor for 4 of 31 resident rooms that had power strips in their room. (Rooms 102,106,108 and 202) Findings include: A. 1. A clinical record review was completed for Resident #29 on 2/18/2016 at 4:22 P.M. The diagnoses, included but were not limited to: kidney failure, enlarged prostate without lower urinary tract symptoms, malaise, fatigue, major depressive disorder, Parkinson disease, dementia without behavioral disturbance, difficulty in walking and muscle weakness. A physician's orders [REDACTED].#29 was to have a clip alarm when in wheelchair. A physician's orders [REDACTED].#29 was to have a clip alarm on his bed and chair. An incident report provided by the corporate nurse on 2/22/2016 at 12:36 P.M., indicated Resident #29 was found on the floor next to the bed after attempting to transfer himself to bed, on 2/7/2016 at 8:45 A.M. The incident report further indicated that Resident #29 was sent to the hospital and underwent a surgery to repair a right femoral neck fracture. A witness statement, dated 2/7/2016, indicated there was no alarm on the resident or in his room. The witness statement indicated the resident had a valid clip alarm while in chair order. Employee #3 also indicated the call light was malfunctioning. She indicated she tried to plug it in correctly 20-40 minutes prior to the incident but was unable to fix it. A witness statement by employee #4, dated 2/7/2016, indicated Resident #29's .call light wasn't working properly and I did not know that (Employee #5) was the one that told me that the call light wasn't working right. (Employee #6) was here that should of been reported to her. She would of went to get a new one, which she did after we found out it was not working right A review of the current care plan was conducted on 2/22/2016 at 2:50 P.M., and indicated Resident #29 was care planned to have tab alarms in place while in bed and in chair. The care plan further indicated to keep his call light within easy reach to prevent him from overstretching. During an interview on 2/22/2016 at 12:16 P.M., the corporate nurse indicated Resident #29 did not have an alarm in place nor did he have a functioning call light in his room at the time of his fall. B.1. On 2/22/16 from 9:15 A.M. to 9:50 A.M., an environmental tour was conducted of the facility with the Administrator, the Maintenance Director, the Environmental Services Director and the Housekeeping Supervisor, during which the following was observed: At 9:16 A.M., Resident room 102 bed A was observed with a power strip on the floor beside the resident's recliner. A floor lamp and a digital clock was plugged into the power strip. The electric cord from the floor lamp was tangled around the power strip. At 9:20 A.M., Resident room 106 bed B was observed with a power strip on the floor in front of a 3 drawer chest. The power strip was located in the resident's walking path to the 3 drawer chest. A television set was plugged into the power strip. At 9:30 A.M., Resident room 108 bed B was observed with a power strip on the floor located under the wall heater. A television set and a digital clock was plugged into the power strip. The electric cord for the television set was wrapped around the power strip. The power strip was located in the resident's walking path to her closet. At 9:40 A.M., Resident room 202 bed A was observed with a power strip on the floor at the end of the bed located under a bedside stand with wheels on it. A television set was plugged into the power strip the cord for the television set was tangled around the wheels of the bedside stand. During an interview on 2/22/16 at 9:55 A.M., the Maintenance Director indicated there is no current policy regarding the use of power strips in resident's rooms other than no medical equipment or appliances can be plugged into the powers strips. 3.1-45(a)(1) 3.1-45(a)(2)

Based on interview and record review, the facility failed to provide adequate supervision for Resident A while he was outside on the front porch of the facility. Resident A suffered dehydration and heat stroke/heat exhaustion as a result of the lack of supervision. This affected 1 of 1 residents, Resident A. Findings include: Resident A's clinical record was reviewed on 10/1/2014 at 4:00 p.m. Resident A's [DIAGNOSES REDACTED]. Resident A's Brief Interview for Mental Status (BIMS), dated 7/21/2014, indicated a score of 8, moderately impaired. The Minimum Data Set (MDS) assessment, dated 7/21/2014, indicated Resident A's ambulation status was total dependence with full staff performance. Resident has a non-electric wheel chair. On 10/1/2014 at 4:30 p.m., the DON (Director of Nursing) was interviewed. The DON indicated, "In regards to (Resident A's name) on 8/25/14. He was taken outside to the front porch by a Certified Resident Care Assistant (CRCA) after they finished feeding him lunch. The 2 CRCA's caring for him at that time were Staff name (CRCA #1) and Staff name (CRCA #2). The second shift CRCA Staff name (CRCA #3) checked on Resident name (Resident A) and noticed that he was not himself and took him inside to the nurse. The nurse taking care of him at that time was Staff name(RN #1)." The DON indicated she did not know who took Resident A outside on 8/25/2014, or what time Resident A was taken outside. A nursing note, dated 8/25/2014 at 2:30 p.m., indicated "Res (Resident A) brought to writer with CRCA noted that resident not acting himself. B/P (blood pressure) = 86/66, P (pulse) = 92, R (respiration) =14, T (Temperature) =100." "...unable to clear secretions in throat. Unresponsive (Name MD) notified. Order received to suction as need , transfer to (Hospital)..." "...suctioned sm (small) amt (amount) of thick clear secretion..." A following nurse's note indicated, "...Sent to (hospital). "Returned to facility per Emergency Medical Services (EMS) on 8/25/2014 at 9:30 p.m." "...Transferred to bed per two assist, resting comfortably..." A review of the hospital record was conducted on 10/2/2014 at 5:30 p.m. The Emergency Department Report admitted , "History of Present Illness," dated 8/25/2014, no time, indicated "...This is a patient who is chronically debilitated with multiple sclerosis who lives in a nursing home and was taken outside in the temperatures of 89 to 90 degrees Fahrenheit (F) with greater than 80% humidity. When they checked on the patient, his blood pressure was low and he was very hot. His temperature at that time was 100.1 (degrees F) and his blood pressure at Lakeland nursing home was 77/54. At that time EMS was contacted and the patient was brought in here. EMS started and intravenous (IV) and had given 1 liter (L) of fluid...." "...The patient is awake and he attempts to answer questions, but he is having trouble due to mouth being dry and him feeling so weak...." The Emergency Department Report admitted , "Medical Decision Making," dated 8/25/2014, no time, indicated, "...The patient most likely given his prolonged heat exposure, is dehydrated and potentially has either heat exhaustion or heat stroke. We will continue to resuscitate the patient with IV fluids, obtain laboratory studies,.." "...He did not have a fever before going outside. The patient in fact had no complaints this morning...." The Emergency Department Physician Assessment Record, dated 8/25/2014 at 3:50 p.m., indicated Resident A arrived at Emergency Department on 8/25/2014 at 3:50 p.m., and departed Emergency Department on 8/25/2014 at 8:48 p.m. The temperature for 8/25/14, for Goshen, Indiana (located near the facility) was retrieved from the website "http://www.accuweather.com/en/us/goshen-in/ /august-weather/ 1," on 10/3/2014 at 11:15 a.m., and indicated the outside temperature was 93 degree F. During an interview on 10/3/2014 at 11:29 a.m., RN #1 indicated it was very hot and humid outside that day. I was working second shift and CRCA #3 stated Resident was acting unusual. I did a complete assessment and my major concern was his respiration upon auscultation was gurgling, so I called the doctor for orders. I received an order to suction prn (as needed) and to transport to hospital. During an interview on 10/3/2014 at 11:55 a.m., CRCA #1 indicated she checked outside before end of shift and did not see Resident A. CRCA #1 indicated she did not take him outside, if I take someone outside who is alert and oriented I check on them every 20 minutes, if they are not alert and oriented I check on them every 15 minutes. During an interview on 10/3/14 at 12:05 p.m., CRCA #2 indicated she saw Resident A in the dinning room at lunch. She indicated she did not take him outside on 8/25/2014. She further indicated, "I check on the residents I bring outside every 15 minutes." During an interview with the Administrator and Corporate Nurse #1 on 10/3/2014 at 2:10 p.m., they both indicated that no investigation had been done to determine who took the resident outside. There was no determination as to who was responsible to monitor and/or supervise the resident after having been taken outside. During an interview on 10/3/2014 at 2:20 p.m., CRCA #3 indicated she received report from day shift and no one had indicated to her that Resident A was outside. She further indicated she went to check on her residents and found Resident A outside on the front porch. "Resident A was not acting like his usual self so I reported it to the nurse." During an interview on 10/3/2014 at 3:00 p.m., Resident A's wife indicated she was not at the facility on 8/25/2014 because it was to hot and humid outside and she believed her husband would remain inside that day. This Federal tag relates to Complaint IN 824. 3.1-45(a)(2)