Every finding on record at Parkview Care Center

Based on record review and interview, the facility failed to ensure the kitchen manager met required qualifications for 1 of 1 dietary manager qualifications reviewed. 80 of 82 residents in the facility received nutrition provided by facility dietary.Finding includes: During an interview on 12/8/25 8:45 A.M., the dietary manager indicated she did not have a dietary manager certification. On 12/11/25 at 8:25 A.M., the dietary manager's employee file was reviewed; the employee file indicated the dietary manager had been employed since 10/15/14 and had enrolled to take the dietary manager training 8/20/24, but had not yet taken it. During an interview on 12/8/25 at 8:45 A.M., the dietary manager indicated the dietician worked through a contract and was only not in the facility full time. On 12/11/25 at 1:50 P.M., the Administrator provided a policy titled Departmental Leadership Requirements, revised 4/16/24, that indicated If a qualified dietitian or other clinically qualified nutrition professional is not employed full-time, the facility must designate a person to serve as the director of food and nutrition services food service managers or dietary managers meets State requirements for food service managers or dietary managers. 3.1-20(e)

Based on observation, interview, and record review, the facility failed to ensure food was prepared to meet the individual needs of residents receiving puree diet for 1 of 3 observation of puree foods. Finding includes: During an interview on 12/10/25 at 11:02 A.M., the dietary manager indicated there were four residents who received puree diet, and one resident received double puree portions. During an observation on 12/10/25 at 11:04 A.M., dietary staff prepared puree zucchini, puree noodles, and puree beef. The beef was not of puree consistency and was dry, thick, with lumps. During an interview on 12/10/25 at 11:14 A.M., the dietary manager indicated puree consistency should be similar to applesauce. During an observation on 12/10/25 at 11:50 A.M., dietary was checking the temperature of the foods served on the steam table. The dietary manager indicated the puree beef was not the appropriate consistency; she added two cups of beef broth to the puree beef and placed in back in the serving dish. The beef was not of puree consistency and was thick with lumps. On 12/11/25 at 1:53 P.M., the Regional Nurse provided a document titled Diet Orders that indicated only two residents in the facility received puree altered foods. On 12/11/25 at 1:10 P.M., the Administrator provided a policy titled Puree Diet, revised 3/15/22, that indicated This diet consists of foods that are easy to swallow because they are blended, whipped, or mashed until they are a pudding-like texture. All foods on this diet should be smooth and free of lumps. 1.3-21(a)(3)

Based on observation, interview, and record review, the facility failed to ensure that residents who were self-administering medications were assessed for capability to self-administer medications for 1 of 1 residents with medications observed in their room. (Resident 2)Finding includes:On 12/9/25 at 9:31 A.M., Resident 2 was observed in bed with a bottle of Nystatin, dated 1/2/25, on her bedside table. At that time, Resident 2 indicated that she used the Nystatin as needed to treat thrush (a yeast infection) in her mouth. On 12/9/25 at 11:22 A.M., Resident 2's clinical record was reviewed. Diagnoses included, but were not limited to, dementia, schizophrenia, and diabetes mellitus. The most current Annual Minimum Data Set (MDS) Assessment, dated 11/20/25, indicated that Resident 2 had mild cognitive impairment, was independent in eating and transferring, required setup assistance of staff for toileting and bathing, and did not have any infections.Discontinued physician orders included, but were not limited to:Nystatin Mouth/Throat Suspension (a medication used to treat fungal infections) 100,000 units per milliliter (mL) - Give five milliliters by mouth four times a day for thrush for 14 Days. May keep at bedside, dated 1/3/25 and completed 1/17/25.The clinical record lacked a current order for Nystatin.The clinical record lacked documentation that Resident 2 had an active diagnosis of thrush.A care conference was completed on 10/14/25 with the resident and the resident's family member in attendance.The clinical record lacked a care plan for the self-administration of Nystatin.The clinical record lacked a self-administration of medication evaluation for Nystatin.During an interview on 12/10/25 at 11:37 A.M., the Director of Nursing (DON) indicated that there was not a self-administration of medication evaluation for the Nystatin, and the medication was from an old order, but the resident would not let the staff remove it from her room.On 12/11/25 at 12:50 P.M., the Administrator provided a current Self-Administration of Medication policy, last reviewed 9/15/25, that indicated The facility will ensure that each resident who requests to self-administer medications is assessed by the interdisciplinary team (IDT) to determine if the resident is safe to self-administer medications . The IDT in consultation with the primary physician for the resident will conduct an assessment of the resident's cognitive, physical, and visual ability to carry out this responsibility . The interdisciplinary assessment will be completed in the electronic medication record . After the IDT and primary physician review the assessment and determines the resident can safely self-administer, or self-administer and safely store medications at bedside, .the care plan for the resident will reflect the self-administration . If the resident demonstrates the ability to safely self-administer medications, a further assessment of the safety of bedside medication storage is conducted . The nurse is responsible for .removal of expired medications.3.1-11(a)

Based on observation, interview, and record review, the facility failed to ensure the development of a resident's comprehensive care plan for 1 of 1 residents reviewed for Respiratory Care and 1 of 5 residents reviewed for medications. (Resident 11, Resident 33)Findings include: 1. On 12/09/25 at 10:44 A, M., Resident 33's clinical record was reviewed. Diagnoses included, but were not limited to type 2 diabetes mellitus, unspecified, thoracic, thoracolumbar and lumbosacral intervertebral disc disorder, and atrial fibrillation. The current admission Minimum Data Set (MDS) Assessment indicated Resident 33 was cognitively intact. Resident 33 required partial to moderate assistance with toileting and dressing, and supervision with transferring. During the 7 day look back period the resident did not require oxygen therapy. Current physician orders included, but were not limited to:Oxygen at 2 liters/minute per nasal cannula as needed for SPO2 <90% as needed dated 10/31/25.Change oxygen tubing, humidifier bottle, and nebulizer circuit weekly every night shift every Sun Label when changed dated 12/04/25. The current record lacked a care plan for oxygen use. During an interview on 12/10/25 at 2:15 P.M., the Director of Nursing (DON) indicated there should be a care plan for oxygen. 2. On 12/9/25 at 1:57 P.M., Resident 11's clinical record was reviewed. Diagnoses included, but were not limited to, epilepsy. The most current Annual Minimum Data Set (MDS) Assessment, dated 11/4/25, indicated that Resident 11 had mild cognitive impairment, received an anticonvulsant during the 7-day lookback period, and had a diagnosis of epilepsy. Physician orders included, but were not limited to: Valproic Acid Oral Solution (an anticonvulsant medication) 250 milligrams (mg) per 5 milliliters (mL) - Give 750 mg via G-Tube two times a day related to idiopathic epilepsy, dated 10/3/25. A care conference was completed on 9/9/25 with the resident's family member in attendance. Care plans were reviewed. The clinical record lacked a care plan related to Resident 11's diagnosis of epilepsy or monitoring of the anticonvulsant medication. During an interview on 12/19/25 at 11:36 A.M., the Director of Nursing (DON) indicated that Resident 11 should have a care plan related to epilepsy and anticonvulsant medication. During an interview on 12/10/25 at 12:08 P.M., MDS Coordinator 15 indicated that Resident 11 did not have a care plan related to epilepsy and anticonvulsant medication, and it would be added. On 12/11/25 at 12:50 P.M., the Administrator provided a current Comprehensive Care Plans and Revisions policy, last reviewed 8/29/25, that indicated The facility will ensure the timeliness of each resident's person-centered, comprehensive care plan, and to ensure that the comprehensive care plan is reviewed and revised by an interdisciplinary team composed of individuals who have knowledge of the resident and his/her needs, and that each resident and resident representative, if applicable, is involved in developing the care plan and making decisions about his or her care. 3.1-35(a)3.1-35(b)(1)

Based on interview and record review, the facility failed to ensure physician orders were followed and obtained a residents daily weight for 1 of 1 residents reviewed for hospitalizations. (Resident 81) Finding includes: On 12/9/25 at 10:51 A.M., Resident 81's clinical record was reviewed. Resident 81 was admitted on [DATE]. Diagnoses included, but were not limited to, heart failure. The most recent admission Minimum Data Set (MDS) Assessment, dated 10/24/25, indicated Resident 81 was cognitively intact, required substantial assistance (staff do more than half of the work) for toileting, and received diuretic medication. Physician orders included, but were not limited to: Daily weight for 60 days: Notify MD/NP if greater than three pound gain in 24 hours or greater than five pound gain in seven days. Weight to be obtained is dry weight at 0700; Follow medication instructions for (as needed) Bumetanide 1 MG in the morning related to congestive heart failure for 60 days; Start date 11/12/25Bumetanide Oral Tablet 1 MG (a diuretic medication)Give 1 mg by mouth one time a day related to congestive heart failure; Start date 11/8/25 The clinical record, including electronic medication administration record, documents, progress notes, and vitals, indicated Resident 81's weight was not obtained on 11/15/25, and showed a nine pound weight gain on 11/16/25. On 12/11/25 at 1:50 P.M., the Administrator provided a policy titled Physician Orders, revised 2/26/24, that indicated A physician, physician assistant or nurse practitioner must provide orders for the resident's immediate care and ongoing care of the resident. The facility is obligated to follow and carry out the orders of the prescriber in accordance with all applicable state and federal guidelines. 3.1-35(g)(1)

Based on observation, interview, and record review, the facility failed to ensure proper oxygen services were provided according to physician orders for 1 of 1 residents reviewed for respiratory care. (Resident 33) Findings include: On 12/9/25 at 10:02 A.M., Resident 33 was observed sitting in a wheelchair wearing oxygen (O2) at 2 Liters/Nasal Cannula connected to a concentrator. The concentrator had a humidification bottle attached with no water present. On 12/10/25 at 9:40 A.M., Resident 33 was out of the room and the O2 concentrator was observed with the humidification with no water present. On 12/09/25 at 10:44 A, M., Resident 33's clinical record was reviewed. Diagnoses included, but were not limited to type 2 diabetes mellitus, unspecified, thoracic, thoracolumbar and lumbosacral intervertebral disc disorder, and atrial fibrillation. The current admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident 33 was cognitively intact. Resident 33 required partial to moderate assistance with toileting and dressing, and supervision with transferring. During the 7 day look back period the resident did not require oxygen therapy. Current physician orders included, but were not limited to:Oxygen at 2 liters/minute per nasal cannula as needed for SPO2 <90% as needed dated 10/31/25.Change oxygen tubing, humidifier bottle, and nebulizer circuit weekly every night shift every Sun Label when changed dated 12/04/25. The current record lacked a care plan for oxygen use. On 12/11/25 at 9:00 A.M., the Director of Nursing (DON) indicated the humidification bottle should be full of water and filled as needed. On 12/11/25 at 12:50 P.M., the Administrator provided a current Comprehensive Care Plans and Revisions policy, last reviewed 8/29/25, that indicated The facility will ensure the timeliness of each resident's person-centered, comprehensive care plan, and to ensure that the comprehensive care plan is reviewed and revised by an interdisciplinary team composed of individuals who have knowledge of the resident and his/her needs, and that each resident and resident representative, if applicable, is involved in developing the care plan and making decisions about his or her care. 3.1-47(a)(6)

Based on observation, interview, and record review, the facility failed to ensure it was free of a medication error rate of greater than 5 percent for 2 of 7 residents (Resident 28 and Resident 75) observed during the medication pass. There were 25 opportunities observed with 2 errors, resulting in an 8 percent medication error rate. Findings include:1. On 12/11/25 at 7:56 A.M., Registered Nurse (RN) 3 was observed preparing a Basaglar Kwikpen for insulin administration for Resident 28. RN 3 indicated that Resident 28 had a standing order for 40 units of insulin two times a day. RN 3 set the pen to 40 units, attached the needle, and administered the insulin to Resident 28 in her abdomen. RN 3 did not prime the insulin pen prior to administration. During an interview on 12/11/25 at 8:00 A.M., RN 3 indicated that the pen was supposed to be primed with one or two units of insulin prior to setting the dosage. On 12/11/25 at 9:15 A.M., Resident 28's clinical record was reviewed. Diagnoses included, but were not limited to, diabetes mellitus. The most current Annual Minimum Data Set (MDS) Assessment, dated 9/2/25, indicated Resident 28 was cognitively intact and received insulin 7 out of 7 days during the lookback period. Physician orders included, but were not limited to:Basaglar KwikPen Subcutaneous Solution Pen-injector 100 units per milliliter (mL) (insulin glargine - a long-acting insulin) - Inject 40 units subcutaneously two times a day for diabetes mellitus, dated 3/10/25 On 12/11/25 at 9:36 A.M., the instruction manual for Basaglar Kwikpen, revised November 2023, was reviewed. The instruction manual indicated Prime before each injection. Priming means removing the air from the needle and cartridge that may collect during normal use. It is important to prime your pen before each injection so that it will work correctly. If you do not prime before each injection, you may get too much or too little insulin. To prime your pen, turn the dose knob to select two units. On 12/11/25 at 12:50 P.M., the Administrator provided a current Insulin Use policy, dated 5/19/25, that indicated Remove the cap from the pen needle and prime the insulin pen by pointing it up in the air, dialing one or two units on the insulin pen, and then fully pressing the plunger or by following the manufacturer's instructions. A drop of insulin should appear at the needle tip. Repeat the priming procedure until a drop appears. 2. On 12/11/25 at 8:22 A.M., Licensed Practical Nurse (LPN) 11 was observed administering Advair (a dry powder inhaler) to Resident 75. After the dose was administered, LPN 11 did not offer or encourage the resident to rinse his mouth. On 12/11/25 at 9:27 A.M., Resident 75's clinical record was reviewed. Diagnoses included, but were not limited to, Chronic Obstructive Pulmonary Disease (COPD). The most current Quarterly Minimum Data Set (MDS) Assessment, dated 11/7/25, indicated Resident 75 was cognitively intact and required setup assistance for eating. Physician orders included, but were not limited to:Advair Diskus Aerosol Powder Breath Activated 250-50 micrograms per dose (Fluticasone-Salmeterol - an inhaled steroid medication used to improve symptoms of COPD) - One inhalation orally two times a day related to COPD. Rinse mouth after use, dated 7/28/25. On 12/11/25 at 9:45 A.M., the Advair Diskus instruction manual, revised June 2023, was reviewed. The instruction manual indicated After inhalation, the patient should rinse his/her mouth with water without swallowing to help reduce the risk of oropharyngeal candidiasis. On 12/11/25 at 10:01 A.M., the Director of Nursing (DON) indicated that the resident should rinse out their mouth after using a dry powder inhaler if the order said rinse mouth or if the inhalant was a steroid. On 12/11/25 at 12:50 P.M., the Administrator provided a current Dry Power Inhaler Use policy, revised 5/19/25, that indicated Have the patient rinse the mouth with water to remove medication from the mouth. Provide an emesis basin if necessary, because the patient should spit out the water, not swallow it. 3.1-48(c)(1)

Based on observation, interview, and record review, the facility failed to ensure infection control practices and standards were followed in 1 of 1 residents observed for catheter care. (Resident 6) Hand hygiene was not performed correctly.Finding includes: On 12/10/25 at 9:03 A.M., Certified Nurse Aide (CNA) 7 and CNA 9 were observed performing catheter care for Resident 6. Prior to donning gown and gloves, CNA 9 washed her hands for eight seconds. After performing the care and prior to emptying the catheter bag, CNA 9 washed her hands for 12 seconds. After all care was completed and prior to leaving the room, CNA 9 washed her hands for seven seconds and CNA 7 washed her hands for 13 seconds. During an interview on 12/11/25 at 7:35 A.M., the Infection Preventionist (IP) indicated that staff were trained to wash their hands for at least 40 seconds, but preferably 60 seconds. On 12/11/25 at 12:50 P.M., the Administrator provided a current Hand Hygiene policy, revised 10/28/25, that indicated This facility will utilize the Lippincott procedure: Hand Hygiene Procedure. On 12/11/25 at 1:14 P.M., the Administrator provided the [NAME] Hand Hygiene Procedure, revised 9/15/25. It indicated Work up a generous lather by vigorously rubbing your hands together .for at least 20 seconds. 3.1-18(l)

Based on record review and interview, the facility failed to ensure that the staff was adequately trained to use an external catheter device for 1 of 1 residents observed with external urinary catheter. (Resident 1) Findings include:On 12/9/25 at 11:33 A.M., Resident 1's clinical record was reviewed. Diagnoses included, but were not limited to, unspecified urinary incontinence, muscle weakness, and malignant neoplasm of the ascending colon The current admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident 1 was cognitively intact. Resident 1 required substantial maximum assistance for toileting, hygiene, and transferring and utilizing an external catheter appliance at night. Current Physician Orders included, but were not limited to:External catheter appliance urine collection system - Ensure system is level with the height of the bed when on every shift related to UNSPECIFIED URINARY INCONTINENCE dated 11/14/25.External catheter appliance to cannister drainage for diagnosis of Urinary Incontinence per manufacturer instructions. Connect the tubing to the eternal catheter appliance urine collection cannister; connect the canister to the unit; turn the unit on. Replace catheter every 8 hours dated 11/14/25.The current urinary incontinence care plan dated 11/14/25 included, but were not limited, to the following interventions:Resident and resident's family request the use of external catheter device dated 11/24/25.Will have no skin breakdown related to urinary incontinence and the use of external catheter appliance dated 11/14/25. During an interview on 12/09/25 at 8:37 A.M., Resident 1 was concerned that some of the staff did know how to use the external catheter appliance.During an interview on 12/10/25 at 9:14 A.M., Certified Nursing Assistant (CNA) 17 indicated she was not sure how to use the external catheter appliance. During an interview on 12/10/25 at 9:20, Licensed Practical Nurse (LPN) 19 indicated she had no formal education on the external catheter appliance. During an interview on 12/10/25 at 9:22 A.M., LPN 5 indicated there was no formal education on the external catheter device, but she would do individual training with a return demonstration, but would there was documentation of the education that was done. On 12/11/25 at 11:50 A.M., the Administrator provided a current policy Education and Training revised 10/1/25. The policy indicated .The facility will need to ensure staff are trained to be able to interact in a manner that enhances the resident's quality of life and quality of care and that they can demonstrate competency in the topic areas of the training program . 3.1-14(i)3.1-14(p)(6)

Based on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, on 3 of 3 units reviewed. The resident rooms had urine odors, damaged and unclean flooring. (Unit 100, Unit 200, Unit 300) Finding includes : The following was observed between 8:42 a.m. to 9:35 a.m. : room [ROOM NUMBER]- A strong urine odor in the bathroom. The same was observed at 1:17 p.m.room [ROOM NUMBER] - A strong urine odor in the bathroom. The same was observed at 1:19 p.m.Bathroom shared with room [ROOM NUMBER] and 207- Caulking around the wall was crumbling, and debris on the floor.Bathroom shared with room [ROOM NUMBER] and 210- Debris and cobwebs around wall edges, missing flooring. Bathroom shared with room [ROOM NUMBER] and 211- debris around wall edges, crumbling caulking.Bathroom shared with room [ROOM NUMBER] and 214 - debris around edges of wall and cobwebs.Bathroom shared with room [ROOM NUMBER] and 215- holes in linoleum flooring.room [ROOM NUMBER] shared with room [ROOM NUMBER]- A strong urine odor in the bathroom. The same was observed at 1:21 p.m. On 8/19/25 at 9:45 a.m., Housekeeper 2 indicated resident rooms were cleaned daily. Rooms were dusted, swept, mopped, high-touch surfaces cleaned, trash taken out, and bathroom toilets were cleaned. On 8/19/25 at 10:30 a.m. The resident council minutes for May 2025 were reviewed. The minutes included, but were not limited to : Housekeeping: Council would like a deep clean schedule. All in attendance state that the bathrooms are not being cleaned good enough. [name of resident ] stated, The floor in my bathroom is disgusting.On 8/19/25 at 9:15 a.m., the Administrator provided the current Housekeeping general policy with a revision date of 5/16/25. The policy included but was not limited to: . The facility must provide: Housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior .This citation relates to Complaint 2578016. 3.1-19(f)

Based on interview and record review, the facility failed to ensure a newly admitted resident had immediate orders for wound care for 2 of 3 residents reviewed for wounds. (Resident B, Resident C) Findings include: 1. On 3/6/25 at 9:44 a.m., Resident B's clinical record was reviewed. Diagnoses included, but were not limited to, displaced intertrochanter fracture of left femur, subsequent encounter for closed fracture with routine healing, other injury of unknown body region, subsequent encounter. An admission Minimum Data Set (MDS) assessment dated [DATE], indicated cognition was intact, 1 stage two pressure ulcer on admit. Resident B admitted to the facility on [DATE], discharged on [DATE]. Care plans included, but were not limited to: Enhanced barrier precautions r/t (related to) impaired skin integrity. Interventions included, but were not limited to: weekly skin checks, Tx (treatment) as ordered, date initiated 1/22/25, revision on 2/28/25. At risk for break in skin integrity. Resident refuses use of Prevalon boot, date initiated 1/21/25, revision on 2/28/25. Interventions included, but were not limited to: Prevalon boots to bilateral feet at all times, date initiated 2/6/25, revision on 2/28/25. Treatment as ordered, date initiated 1/21/25, revision on 2/28/25. Weekly skin checks, date initiated 1/21/25, revision on 2/28/25. Res admitted to facility with 3rd degree burn to right upper arm and non-healing surgical located to coccyx. Resident is at further risk for skin breakdown related to chronic pain, fibromyalgia, recent surgeries, and spondylosis. Resident further is incontinent of bowel and bladder, prefers to stay in bed, and slides down in bed often. Resident refuses use of Prevalon boot, date initiated 1/21/25, revision on 2/28/25. Interventions included, but were not limited to: Skin prep bil (bilateral) heels Q (every) shift for prevention, date initiated 1/23/25, revision on 2/28/25 Treatment as ordered, date initiated 1/21/25, revision 2/28/25. Weekly skin checks, date initiated 1/21/25, revision 2/28/25. The resident has potential/actual impairment to skin integrity, date initiated 1/29/25, revision on 2/6/25. Interventions included, but were not limited to: Clean and dry skin after each incontinent episode, date initiated 1/29/25, revision on 2/6/25. A wound observation tool with an effective date of 1/22/25, indicated present on admission 1/21/25. The document included but was not limited to: Observations: Location: right inner ankle Type: pressure Stage: 2 Measurements: Length (cm) 1.0 Width (cm) 1.0 Depth (cm) 0.1 NP( Nurse Practitioner) aware Additional comments: Res admitted to facility with 3rd degree burn to right upper arm and non-healing surgical located to coccyx and stage 2 pressure injury to right inner ankle . A wound observation tool with an effective date of 1/28/25, indicated present on admission 1/21/25. The document included but was not limited to: Observations: Location: right inner ankle Type: pressure Stage: 2 Measurements: Length (cm) 1.0 Width (cm) 1.0 Depth (cm) 0.8 Additional comments: Res admitted to facility with 3rd degree burn to right upper arm and non-healing surgical located to coccyx and stage 2 pressure injury to right inner ankle. Area is showing improvement, writer suggest resident utilize skin prep to area. Resident continues to be followed per IDT (Interdisciplinary Team) and wound nurse. A wound evaluation and management summary dated 1/30/25, indicated a non-pressure wound of the right ankle full thickness. Etiology: Trauma/injury Wound size (L x W x D) 1 x 0.8 x 0.1 cm Dressing treatment plan: skin prep apply once daily for 30 days Physician orders for January and February 2025 were reviewed and included, but were not limited to: Right inner ankle: apply skin prep to area, every day shift for healing, order date 1/31/25, discontinue date 2/10/25. 2. On 3/7/25 at 11:06 a.m., Resident C's clinical record was reviewed. Diagnoses included, but were not limited to, acquired absence of right leg above the knee, atherosclerosis of native arteries of extremities with intermittent claudation, bilateral legs, encounter for orthopedic aftercare following surgical amputation. An admission Minimum Date Set (MDS) assessment dated [DATE], indicated Resident C's cognition was intact, surgical wound on admit. Resident C admitted to the facility on [DATE], discharged on [DATE]. Care plans were reviewed and included, but were not limited to: Has break in skin integrity, date initiated 1/24/25, revision on 2/21/25. Interventions included, but were not limited to: Treatment as ordered, date initiated 1/24/25, revision on 2/21/25. Weekly skin checks. date initiated 1/24/25, revision on 2/21/25. A progress note dated 1/24/25 at 4:55 p.m., indicated Resident arrived at facility via wheelchair per hospital transport.Resident recently went to ER for eval for cool feeling in leg. Occluded right femoral artery found leading to right above knee amputation 1-16-25. Resident has been receiving betadine and kerlix on stump and stump protector stays on at all times except for skin care. No s/s to wound . (sic) January physician orders were reviewed and included, but were not limited to: [NAME] (sic) entire right above knee amputation wound site with betadine, allow to dry completely, cover with 4 x 4 gauze, wrap with Kerlix, secure with paper tape, change daily every day shift for AKA (above knee amputation), order date 1/26/25, start date 1/27/25. On 3/7/25 at 10:40 a.m., a resident concern and comment form dated 1/28/25 was reviewed for Resident C. The form included but was not limited to Resident C had a concern that his wound dressing had not been changed in the last two days after requests to do so. Follow up indicated according to the DON, the hospital did not send wound dressing orders, orders were received and Resident C was receiving tx's (treatments) . On 3/7/25 at 11:21 a.m., the Director Of Nursing (DON) indicated that during a mandatory staff meeting, it was reviewed it is the nurses responsibility to get orders if the resident admits with a wound and no wound orders. Don't wait on the wound Nurse Practitioner to assess the wound, if admitted on a Friday don't wait to get orders on the next business day. On 3/7/25 at 12:30 p.m., the DON indicated the nurse thought she put in orders for all bony prominences for Resident B, but only orders for heels were put in. The wound physician indicated the right inner ankle wound was non-pressure, it was from trauma, the nurse put it as a pressure wound. On 3/7/25 at 2:20 p.m., LPN 2 indicated wound orders most of the time come on the hospital discharge report, sometimes the hospital nurse gives wound care orders by phone on the resident admission report. LPN 2 indicated if a resident is admitted without wound orders the next step is to contact the facility the resident came from, or call the facility wound nurse if can't reach the physician to at least get wound orders in place until the wound nurse can do the assessment. On 3/7/25 at 2:28 p.m., the RN 3 provided the current treatment orders policy with a revised date of 7/9/24. The policy included, but was not limited to .quality of care is a fundamental principal that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices . On 3/7/25 at 2:28 p.m., the RN 3 provided the current skin integrity & pressure ulcer/injury prevention and management policy with a revision date of 7/9/2024. The policy included, but was not limited to, provide associates and licensed nurses with procedures to manage skin integrity, prevent pressure ulcer/injury, complete wound assessment/documentation, and provide treatment and care of skin and wounds utilizing professional standards of the NPIAP (National Pressure Injury Advisory Panel) and WOCN (Wound, Ostomy, Continent Nurse Society) . This citation relates to Complaint IN00454046. 3.1-30(a)

Based on interview and record review, the facility failed to develop care plans for 2 of 3 residents reviewed for Urinary Tract Infections (UTI), 1 of 1 residents reviewed for tube feedings, 2 of 5 residents reviewed for unnecessary medications, and 1 of 1 residents reviewed for hospice services. A care plan was not developed for residents receiving high risk medications, timeliness of tube feedings, for residents requiring assistance with transferring, and after residents received a new diagnosis and new medication orders. (Resident C, Resident N, Resident L, Resident Z, Resident J, Resident V) Findings include: 1. On 9/23/24 at 8:32 A.M., Resident C's clinical record was reviewed. Diagnoses included, but were not limited to, Urinary Tract Infection. The most current Quarterly Minimum Data Set (MDS) Assessment, dated 6/19/24, indicated Resident C was not assessed for cognitive impairment due to rarely or never being understood, required substantial to maximal assistance of staff (staff does more than half) for toileting, was always incontinent of bowel and bladder, and did not have a UTI. Current physician orders included, but were not limited to: Keflex (an antibiotic) 250 milligrams (mg) - Give one capsule by mouth three times a day for UTI, dated 9/19/24 with an end date of 9/25/24 The clinical record lacked a care plan related to the resident's urinary tract infection or antibiotic use. On 9/25/24 at 9:30 A.M., the Director of Nursing (DON) indicated that Resident C should have a care plan for a urinary tract infection and antibiotic use, but did not have one. 2. On 9/23/24 at 2:11 P.M., Resident N's clinical record was reviewed. Diagnoses included, but were not limited to, edema and hypertension. The most current Quarterly Minimum Data Set (MDS) Assessment, dated 8/28/24, indicated Resident N was cognitively intact, required substantial to maximal assistance of staff (staff does more than half) for toileting, and received a diuretic during the 7-day lookback period. Current physician orders included, but were not limited to: Furosemide (a diuretic) 40 milligrams (mg) - Give 40 mg by mouth one time a day for edema, dated 5/21/24. Spironolactone (a diuretic) 25 mg - Give 25 mg by mouth one time a day for edema, dated 5/21/24. The clinical record lacked a care plan related to the resident's edema, diuretic use, or potential side effects of the diuretic. On 9/25/24 at 12:56 P.M., the Director of Nursing (DON) indicated the facility did not initiate care plans for diuretic use or monitor for side effects of diuretics. 50827 3. On 9/23/24 at 12:20 P.M. Resident L's clinical record was reviewed and indicated the resident had diagnoses that included but was not limited to atrial fibrillation, benign prostatic hypertrophy, and diabetes mellitus. An MDS (Minimum Data Set) Assessment that was completed upon admission, 8/23/24, indicated that the resident was cognitively intact, used a walker and a wheelchair, required partial to moderate assistance with transfers and toileting. The clinical record also indicated that Resident L was being treated for a treatment resistent urinary tract infection caused by proteus mirabilis. Physician orders for Resident L included but were not limited to: Invanz (antibiotic) injection 1 gram, intramuscularly one time a day for 5 days dated 9/20/24. A current care plan, dated 8/23/24, in Resident L's chart indicated that the resident required ADL (activities of daily living) assistance and mobility as needed. Resident L's clinical record lacked a care plan related to their level of mobility and assistance required. The resident's clinical record also lacked a care plan to address their urinary tract infection and antibiotic use. 4. On 9/24/24 at 12:15 P.M. Resident Z's clinical record was reviewed and indicated the resident had diagnoses that included but were not limited to cerebral vascular accident (stroke), coronary artery disease, and peripheral vascular disease. An admission MDS dated [DATE] indicated that the resident was cognitively intact, used a walker and/or wheelchair, required partial or moderate assistance with transfers and toileting, and the resident was taking antiplatelet medications. Physician orders included but were not limited to: Aspirin (an antiplatelet medication) 81 milligrams by mouth once a day, dated 9/17/24. Ativan (an antianxiety medication) 0.5 milligrams by mouth twice a day, dated 9/8/24. Resident Z's clinical record lacked a care plan related to an antiplatelet medication and an antianxiety medication. 5. On 9/25/24 at 2:09 P.M. Resident J's clinical record was reviewed and indicated that resident had diagnoses that included but was not limited to heart failure and atrial fibrillation. A significant change MDS dated [DATE] indicated that the resident was cognitively intact and receiving hospice care. Physician Orders included but were not limited to: Bumex (a diuretic medication) 1 milligram once daily, dated 6/13/24. Resident J's clinical record lacked a care plan related to diuretic use. An interview with the DON (Director of Nursing) on 9/25/24 at 10:50 A.M. indicated that it was expected for a resident to have a care plan specifically for an antibiotic, a psychotropic medication such as ativan, but they would not have expected a care plan for 81 milligram aspirin. 6. During an interview and observation on 9/19/24 at 2:26 P.M., Resident V indicated staff are often late administering her enteral feeding. The enteral feed machine was turned off and no nutritional supplement or water was being delivered at this time. Resident V indicated she was unsure if she had lost weight; the facility had never weighed her because she felt like she couldn't breathe well while being in a mechanical lift. On 9/23/24 at 8:20 A.M., Resident V's clinical record was reviewed. Resident V was admitted on [DATE]. Diagnoses included, but were not limited to, spinal muscular atrophy and scoliosis. The most recent Quarterly MDS (Minimum Data Set) Assessment, dated 6/17/24, indicated Resident was cognitively intact, was completely dependant on staff (staff does all of the effort) for bathing, toileting, and mobility, and was receiving nutrition through tube feeding. Current physician orders included, but were not limited to: NPO (nothing by mouth) diet, NPO texture. Start date: 5/7/24 Change tubing and bag set for enteral feeding every 24 hours, everyday on day shift when turning pump on at 1300 (1:00 P.M.). Start date: 6/5/24 Vital AF 1.2cal (nutritional supplement) at 63 milliliters (mL) per hour for 15 hours via pump. Flush with 45 milliliters free water every hour. Turn pump off at 0400 (4:00 A.M.) and resume pump at 1300 (1 P.M.). Goal rate to be 63mL/hour as tolerated. Monitor for refeeding syndrome. Two times a day. Start date: 9/10/24 Current care plans included, but were not limited to: The resident has nutritional problem or potential nutritional problem related to NPO (nothing by mouth) with feeding tube for sole source of nutrition and hydration. Resident is allowed to have ice chips. Date Initiated: 5/16/24 The resident is totally dependent on one staff for eating via gastrostomy tube. Date Initiated: 9/17/24 The clinical record, including progress notes and order administration, lacked resident refusal or explanation for nutritional supplement to not being administered on 9/19/24. An admission progress note, dated 4/26/24, indicated Resident V weighed 85 pounds (height 56 inches). A weight recorded on 5/5/24, indicated Resident V weighed 70.2 pounds, a body mass index (BMI) of 15.7 (underweight). There was no alternative process to determine weight or body mass index for the resident. During an interview on 9/26/24 at 10:30 A.M., the DON (director of nursing) indicated Resident V had only been weighed on admission due to refusal of being weighed. On 9/26/24 at 10:45 A.M., the Administrator provided a policy titled Enteral Nutritional Therapy, revised 9/10/24, that indicated The facility will provide continuous enteral nutritional therapy in accordance with physician orders and professional standards of practice. Based on a resident's comprehensive assessment, the facility must ensure that a resident who is fed by enteral means receives the appropriate treatment and services. On 9/26/24 at 9:51 A.M., the Administrator provided a current Resident Assessment Instrument and Care Plan Development policy, revised 8/16/22, that indicated .develop an individualized person-centered care plan for each patient that includes the patient's voice, the patient's goals while residing in the facility and for discharge that assist the patient to attain and/or maintain their highest practicable level of well-being . other sources of information are to be included when developing an individualized person-centered care plan for each patient that is reviewed by the interdisciplinary team . On 9/26/24 at 9:51 A.M., the Administrator provided a current Changes in Resident's Condition or Status policy, dated 11/26/18, that indicated The care plan should address the resident's risk factors, allow for rapid identification of a change in status, and define baseline assessment findings. This citation related to complaint IN00443638. 3.1-35(a)

Based on interview, observation, and record review, the facility failed to ensure residents requiring assistance with Activities of Daily Living (ADLs) were bathed or assisted to bathe for 5 of 7 residents reviewed for ADL care. (Resident V, Resident P, Resident S, Resident T, Resident C) Findings include: 1. On 9/23/24 at 8:20 A.M., Resident V's clinical record was reviewed. Resident V was admitted on [DATE]. Diagnoses included, but were not limited to, spinal muscular atrophy and scoliosis. The most recent Quarterly MDS (Minimum Data Set) Assessment, dated 6/17/24, indicated Resident was cognitively intact and was completely dependant on staff (staff does all of the effort) for bathing, toileting, and mobility. Current care plans included, but were not limited to: Resident request a Complete Bed Bath one time a week and often refuses. Date Initiated: 4/27/24 During an interview on 9/24/24 at 2:40 P.M., Resident V indicated she would like to receive a complete bed bath more than once a week, but staff told her that is all they have time to provide a complete bed bath. On 9/26/24 at 8:45 A.M., the DON (Director of Nursing) provided Resident V's complete bed bath record from 8/1/24 to 9/26/24. A review of Resident V's documented showers indicated the resident did not receive a complete bath or shower during the following dates: 8/6, 7, 8, 9, 11 8/13, 14, 15, 16, 17, 18, 19 ,20, 21, 22, 23, 24 8/26, 27, 28, 29, 30, 31 9/2, 3, 4, 5, 6, 7, 8 9/10, 11, 12, 13, 14, 15 9/17, 18, 19, 20, 21, 22 There was no documentation of resident refusals. 50827 2. On 9/23/24 at 10:30 A.M. Resident P's clinical record was reviewed and indicated the resident had diagnoses that included but was not limited to diabetes mellitus and COPD (chronic obstructive pulmonary disease). A Quarterly MDS (Minimum Data Set) Assessment on 6/20/24 indicated Resident was cognitively intact, had no behaviors, and used a wheelchair. A state optional MDS dated [DATE], indicated Resident was independent in bed mobility and toileting, required supervision with transfers, and the resident was on a pain medication regimen with occasional pain that affected day to day activities. On 9/20/24 at 11:36 A.M. Resident P indicated they had not been getting showers on time, staff had a hard time finding her to give her showers even though she told them where she would be. On 9/23/24 at 10:17 A.M. a sign was observed on Resident P's closet door that indicated the resident is to have showers on day shift, on Tuesday and Thursdays. Resident P had a current care plan that indicated they have a self-care performance deficit, required physical assistance with one staff member for bathing and showering, and preferred to have a shower during the day twice a week. During clinical record review on 9/23/24 at 10:45 A.M., Resident P's clinical record had documentation of 3 showers in the last 30 days. Documented showers were dated 9/6/24, 9/13/24, and 9/20/24. All given on Friday. The clinical record lacked any documented showers or refusals of showers by the resident on the following days: 9/3/24, 9/5/24, 9/10/24, 9/12/24, 9/17/24, 9/19/24. 46758 3. During an interview on 9/20/24 at 9:21 A.M., Resident S indicated not getting bed baths on the days scheduled. On 9/24/24 at 9:32 A.M., Resident S's clinical record was reviewed. Diagnoses included, but were not limited to, COPD (Chronic Obstructive Pulmonary Disease), muscle weakness, and morbid obesity. On 9/16/24 at 10:30 A.M., Resident S was observed laying in bed with a clean gown and linen, hair was clean, face was somewhat stubbly. The current Quarterly MDS (Minimum Data Set) assessment dated [DATE] indicated Resident S was cognitively intact. The resident needed substantial assistance with hygiene, dressing, and transferring. Current physician orders included but were not limited to: Bilateral enablers to bed to aid in repositioning, ADL (Activities of Daily Living) functioning, and bed mobility. Side rail is not considered a restraint dated 9/23/24. Keep head of bed elevated d/t (Due To) shortness of breath while lying flat r/t (Related To) diagnosis of COPD every shift related dated 9/18/24. The current ADL care plan revised on 1/29/24 indicated the resident has a self-care deficit related to The resident has an ADL self-care performance deficit r/t morbid obesity and dyspnea with exertion. Interventions included, but were not limited to, prefers bed bath instead of a shower 2 to 3 times/week revised on 1/29/24 and praise all efforts of self-care initiated on 5/22/23. The Point of Care (POC) (a Certified Nurse Aide documentation system) Tasks for showering and bathing indicated the Resident received bed baths Monday, Thursday and Saturday. A record review from 4/1/24 through 9/26/24 indicated Resident S lacked documented bed baths or refusals on the following Monday April 15 Thursday May 24 Monday June 3 Monday June 10 Monday August 19 Monday August 29 During an interview on 9/20/24 at 9:21 A.M., Resident S indicated not getting bed baths on the days scheduled. 48147 4. On 9/19/24 at 1:14 P.M., Resident T indicated she didn't feel clean all the time and wanted her hair washed more frequently. The last time she had her hair washed was more than a week ago. She indicated that staff did not usually wash her hair if she received a bed bath. At that time, her hair was observed to be oily. On 9/23/24 at 1:50 P.M., Resident T's clinical record was reviewed. Resident T was admitted to the facility on [DATE]. Diagnoses included, but were not limited to, Chronic Obstructive Pulmonary Disease (COPD) and generalized muscle weakness. The most current Quarterly Minimum Data Set (MDS) Assessment, dated 8/31/24, indicated Resident T was mildly cognitively impaired, required substantial to maximal assistance of staff (staff does more than half) for bathing, and had no rejection of care. An Activities of Daily Living (ADL) Assistance care plan, dated 5/16/24, indicated staff was to assist with mobility and ADLs as needed. A current shower schedule indicated Resident T was scheduled to receive showers on Mondays and Thursdays during the day. On 9/24/24 at 2:01 P.M., the Administrator provided bathing performed from 5/20/24 to 9/23/24. Resident T did not receive a shower or bed bath with a hair wash on: 5/23/24 5/27/24 5/30/24 6/3/24 6/6/24 6/13/24 6/17/24 6/20/24 6/24/24 6/27/24 7/18/24 7/22/24 7/25/24 7/29/24 8/1/24 8/5/24 8/12/24 8/15/24 8/19/24 8/22/24 8/26/24 8/29/24 9/2/24 9/5/24 9/9/24 9/12/24 9/16/24 9/19/24 On 9/23/24 at 1:25 P.M., Licensed Practical Nurse (LPN) 7 indicated Resident T did not get showers because she was difficult to get up. 5. In a confidential interview on 9/19/24 at 9:48 P.M., it was indicated that Resident C preferred to have a shower twice a week due to eczema, but the facility wanted to compromise and give the resident one shower and one bed bath every week and sometimes the resident got two bed baths instead of a shower during the week. They also indicated that the resident did not like facial hair and preferred to be clean shaven. On 9/23/24 at 10:12 A.M., Resident C was observed in bed with his eyes closed. He had hair stubble on his chin and upper lip. On 9/24/24 at 8:31 A.M., Resident C was observed in the restorative dining room. He had hair stubble on his chin and upper lip. On 9/23/24 at 8:32 A.M., Resident C's clinical record was reviewed. Resident C was admitted to the facility on [DATE]. Diagnoses included, but were not limited to, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, aphasia following cerebral infarction, and atopic dermatitis. The most current Quarterly Minimum Data Set (MDS) Assessment, dated 6/19/24, indicated Resident C was not assessed for cognitive ability due to being rarely or never understood, was dependent on staff for bathing, and had no rejection of care. An Activities of Daily Living (ADL) Assistance care plan, dated 5/24/24, indicated staff was to assist with mobility and ADLs as needed. An ADL self care performance deficit care plan, dated 6/12/24, indicated the resident was to be shaved daily in the morning. Current physician orders included, but were not limited to: Ensure resident is shaved daily every day shift, dated 9/18/24. A current shower schedule indicated Resident C was scheduled to receive showers on Tuesdays during the day and a complete bed bath on Saturdays during the day. On 9/24/24 at 2:01 P.M., the Administrator provided bathing performed from 5/24/24 to 9/23/24. Resident C did not receive a shower on the following Tuesdays: 5/28/24 6/4/24 6/11/24 6/18/24 7/23/24 8/13/24 8/27/24 9/3/24 9/10/24 9/17/24 Resident C did not receive a bed bath on the following Saturdays: 7/13/24 8/10/24 On 9/24/24 at 2:42 P.M., Certified Nurse Aide (CNA) 10 indicated that residents got showers twice a week, and if they preferred a shower, they would be given a shower. On 9/26/24 at 10:53 A.M., the Director of Nursing (DON) indicated that staff filled out shower sheets, but they were not a part of the clinical record. All showers should be documented in Point of Care (POC) Tasks (a documentation program for CNAs). On 9/26/24 at 10:31 A.M., the Administrator provided an Activities of Daily Living (ADLs) policy, revised 2/12/24, that indicated A resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. This citation related to complaint IN00443638 and complaint IN00440635. 3.1-38(a)(2)(A) 3.1-38(a)(3)(B) 3.1-38(a)(3)(D) 3.1-38(b)(2) 3.1-38(b)(3)

Based on observation, record review, and interview, the facility failed to ensure proper storage of medications for 4 of 6 medication carts. Loose pills were observed in the medication cart drawers. (Cherry Lane Medication Cart, Dogwood Lane Cart 1, [NAME] Lane Cart 1, [NAME] Lane Cart 2) Findings include: On 9/19/24 at 9:00 A.M., the Cherry Lane Medication Cart was observed with the following loose pills and materials: 1 small, oblong, white, pill Broken pieces of peach pill 1 small, round, white, pill 1 bottle of water in lower drawer On 9/19/24 at 9:05 A.M., the Dog [NAME] 1 Medication Cart was observed with the following loose pills: 1 small round pink pill with # 50 1 white capsule with #IP 101 1 long, oblong, white pill TGL #341 1/2 small, round, white pill 1 small, round, white pills 1/2 small, oblong, pink pill On 9/19/24 at 9:18 A.M., the [NAME] Lane 1 Medication Cart was observed with the following loose pills: 2 1/2 small, round, white pills 1/2 small, round, brown pill On 9/19/24 at 9:25 A.M., the [NAME] Lane 2 Medication Care was observed with the following loose pills: 1 small, round, red pill 1/2 small, oblong, white pill 1 small, round, pink pill During an interview on 9/19/24 at 9:12 A.M., RN (Registered Nurse) 3 indicated water in bottom should not be there. During an interview on 9/19/24 at 9:15 A.M., RN (Registered Nurse) 5 indicated that there should be no loose pills in the carts and that if there were the pills are placed in drug buster. On 9/26/24 at 10:40 A.M., the Administrator provided a current policy Storage and Expirations Dating of Medication, Biologicals revised 8/7/23. The policy indicated .the facility should ensure that all medications . are securely locked in a cabinet/cart that is inaccessible by residents and visitors. 3.1-25(j)

Based on interview and record review, the facility failed to notify the physician and resident representative of changes in a resident's medical status for 1 of 1 residents reviewed for skin conditions and urinary tract infections. The physician was not notified of a new wound, and the resident's representative was not notified of a new wound, new diagnosis, and new medication order. (Resident C) Finding includes: On 9/20/24 at 10:20 A.M., a family member indicated that on 9/18/24 they found a dressing covering a wound on Resident C's foot. Upon further inspection, sores were found on his buttocks, on the back of his thigh, on his scrotum, and on his perineum. They requested a skin assessment be completed that day with the wound nurse to show her Resident C's skin injuries. They indicated they believed that Resident C had a UTI, but lab work had not returned and the resident had not been started on antibiotics yet. In a confidential interview on 9/20/24 at 12:38 P.M., it was indicated that a staff member had put bandages on Resident C's foot without letting anyone know he had sores. It was indicated that the bandages were the wrong type of bandages because when they were pulled away, the sore broke open and the scab was removed. On 9/23/24 at 8:32 A.M., Resident C's clinical record was reviewed. Diagnoses included, but were not limited to, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, aphasia following cerebral infarction, atopic dermatitis, and urinary tract infection. The most current Quarter Minimum Data Set (MDS) Assessment, dated 6/19/24, indicated Resident C was not assessed for cognitive impairment due to the resident being rarely or never understood, was dependent on staff for bathing, was at risk for pressure injuries, had no skin injuries, required substantial to maximal assistance of staff (staff does more than half) for toileting, and did not have a urinary tract infection (UTI). A skin integrity care plan, dated 5/24/24, indicated staff should provide treatment as ordered and complete weekly skin checks. A pressure injury care plan, dated 9/19/24, indicated Resident C had a pressure injury on his right great toe. Interventions included, but was not limited to, treatment as ordered. The clinical record lacked a care plan for urinary tract infection. Current physician orders included, but was not limited to: Right great toe: Cleanse with wound cleaner and pat dry. Paint Betadine and allow to dry. Cover with foam for protection. Every day shift for protection and as needed for dislodgment, dated 9/20/24. Shearing right back thigh: Cleanse with wound cleaner and pat dry. Apply skin prep to periwound. Apply medical grade honey to shearing and cover with foam. Every day shift every other day for healing and as needed for dislodgment, dated 9/20/24. Left 2nd toe: Paint with Betadine and leave open to air. Every shift, dated 9/20/24. Venelex External Ointment ([NAME]-[NAME] Oil) - Apply to buttocks/scrotum topically every shift for healing and apply to buttocks/scrotum topically as needed for incontinence, dated 9/18/24. Keflex (an antibiotic) 250 mg - Give 1 capsule by mouth three times a day for UTI until 9/25/24, dated 9/19/24. Weekly skin assessments from 8/16/24 to 9/14/24 indicated the following skin impairments were identified: 8/16/24 Weekly - blanchable redness on bilateral buttocks 8/24/24 Weekly - blanchable redness on bilateral buttocks 8/26/24 Update - Nodule on anterior testicle 8/31/24 Update - Nodule on anterior testicle 8/31/24 Weekly - friction/shearing on scrotum 9/7/24 Weekly - friction/shearing on scrotum 9/14/24 Weekly - friction/shearing on scrotum The clinical record lacked documentation to indicate the physician and resident representative had been notified of the skin impairments. Nurse Practitioner (NP) progress notes from 8/19/24 to 9/17/24 did not include documentation to show that identified skin impairments were assessed or treatment was ordered and provided. On 9/17/24 at 10:30 A.M., a psychosocial progress note indicated family were informed that a urinalysis was done on 9/16/24 but had not yet resulted. Lab results, collected on 9/16/24 and resulted on 9/18/24, indicated Resident C had proteus mirabilis bacteria in his urine indicating a UTI. The clinical record lacked documentation to indicate the resident's representative had been informed of the urinalysis results or the new antibiotic medication order. A care management progress note, dated 9/18/24 at 4:17 P.M., indicated a head to toe skin assessment had been completed with the family at the bedside. Upon assessment the resident was noted to have an open area to right great toe, shearing to posterior right thigh, and skin loss to buttocks and scrotum. A wound observation tool progress note, dated 9/19/24, identified the open area to the right great toe was a stage 2 pressure ulcer measuring 0.4 centimeters (cm) in length, 0.3 cm in width, and 0.2 cm in depth. On 9/24/24 9:16 A.M., the Director of Nursing (DON) indicated documentation of notification to the physician and family would be found in the progress notes and was not documented anywhere else in the clinical record. On 9/25/24 at 9:30 A.M., the Director of Nursing (DON) indicated staff should have notified the physician and family of the nodule, shearing, and friction on Resident C's scrotum when it was identified. She indicated that the nurse who applied the dressing to Resident C's toe did not feel it was a concern and did not notify the physician or family. She indicated family should be notified if a resident received a new diagnosis or new medication order. On 9/26/24 at 9:51 A.M., the Administrator provided a current Changes in Resident's Condition or Status policy, dated 11/26/2018, that indicated Communicate the change in resident's status to the appropriate practitioner. Notify the resident's family about the change in the resident's status and the subsequent treatment plan . Document the procedure . Documentation associated with identifying and communication a change in a resident's status includes: communication with other health care team members . communication with resident's family. On 9/26/24 at 9:51 A.M., the Administrator provided a current Nursing Documentation policy, dated 8/20/2019, that indicated Nursing notes will reflect any significant nursing observations of the resident. On 9/26/24 at 10:31 A.M., the DON provided a current Area of Focus: Basic Skin Management policy, dated 11/29/2023, that indicated If any new skin alteration/wound is identified, it is the responsibility of the nurse to perform and document the assessment/observation, obtain treatment orders, and notify MD (medical doctor) and responsible party. This citation related to complaint IN00443638. 3.1-5(a)(3)

Based on interview, record review, and observation, the facility failed to ensure residents with limited range of motion received restorative nursing services to further prevent decrease in range of motion for 2 of 4 residents reviewed for ADL (activities of daily living) care who receive restorative nursing. (Resident V, Resident 35) Findings include: 1. During an interview on 9/19/24 at 2:14 Resident V indicated she had not received restorative nursing any days that week. Resident V had contractures of all extremities. On 9/23/24 at 8:20 A.M., Resident V's clinical record was reviewed. Resident V was admitted on [DATE]. Diagnoses included, but were not limited to, spinal muscular atrophy and scoliosis. The most recent Quarterly MDS (Minimum Data Set) Assessment, dated 6/17/24, indicated Resident was cognitively intact and was completely dependant on staff (staff does all of the effort) for bathing, toileting, and mobility. Current care plans included, but were not limited to: Resident has impaired mobility due to the diagnosis of spinal muscular atrophy and is on a restorative passive ROM (range of motion) program. Date Initiated: 7/4/24 Resident will tolerate 2 sets of 20 reps of gentle stretching to bilateral upper extremities through target date. Date Initiated: 7/4/24 Assist resident in performing bilateral lower passive ROM. 10-15 reps. Stop activity if resident complains of pain. Date Initiated: 8/24/24 Assist resident in performing upper extremity passive ROM. 10-15 reps. Stop activity if resident complains of pain. Date Initiated: 8/24/24 On 9/24/24 at 1:40 P.M., the Administrator provided documents titled Restorative Program for Resident V: 9/13/24 blank 9/14/24 documented not applicable 9/15/24 documented not applicable and resident refused 9/16/24 documented not applicable 9/17/24 documented 10 minutes completed and marked resident refused 9/18/24 documented 5 minutes completed and marked resident refused 9/19/24 documented 5 minutes completed and marked resident refused 9/20/24 documented not applicable 9/21/24 documented resident refused 9/22/24 documented resident refused The clinical record, including progress notes and administration records, lacked further documentation relating to days restorative nursing was not provided to Resident V. 2. On 9/23/24 at 10:49 A.M., Resident 35's clinical record was reviewed. Resident 35 was admitted on [DATE]. Diagnoses included, but were not limited to, muscle weakness and dementia. The most recent Quarterly MDS Assessment, dated 6/17/24, indicated Resident 35 was cognitively intact and required partial assistance from staff for bathing, toileting, and transfers. Current care plans included, but were not limited to: Resident has impaired mobility due to the diagnosis of dementia and muscle weakness. Resident is on a restorative program. Date Initiated: 7/9/24 Provide Active range of motion to bilateral upper extremities using #1 free weights or cycle on level 1 or 0 for 15 to 20 minutes. Stop Activity if resident complains of pain. Revision on: 9/5/24 On 9/24/24 at 1:40 P.M., the Administrator provided documents titled Restorative Program for Resident 35. The following days included active range of motion marked not available or was left undocumented/blank: 9/13/24 9/18/24 9/19/24 9/21/24 9/22/24 9/23/24 The clinical record, including progress notes and administration records, lacked further documentation relating to days restorative nursing was not provided to Resident 35. During an interview on 9/26/24 at 8:53 A.M., the Administrator indicated that every resident care planned for restorative nursing services should be receiving restorative nursing services seven days a week unless the care plan specifies only certain days. On 9/26/24 at 10:45 A.M., the Administrator provided a policy titled Restorative Nursing, dated 11/20/23, that indicated Measurable objectives and interventions must be documented in the care plan and in the medical record. The trained CNA will document provided techniques per the restorative care plan in the medical record. The licensed nurse will conduct an evaluation on a routine basis, to include the progress towards goal and response to the program. 3.1-42(a)(1)

Based on observation, record review, and interview the facility failed to ensure an oxygen concentrator filter was being cleaned for 1 of 1 resident reviewed for respiratory care (Resident P). Finding includes: On 9/23/24 at 10:17 A.M., Resident P's oxygen concentrator was observed to have moderate dust on the filter cover. On 9/23/24 at 10:30 A.M. Resident P's clinical record was reviewed and indicated the resident had diagnoses that included but was not limited to COPD (chronic obstructive pulmonary disease). A Quarterly MDS (Minimum Data Set) Assessment on 9/23/24 indicated Resident was cognitively intact and required the use of oxygen. Resident P had a current physician order for oxygen at three liters, continuously per nasal cannula, dated 5/4/24. On 9/25/24 at 10:41 A.M. DON (Director of Nursing) indicated that nurses were responsible for cleaning filters on oxygen concentrators every Sunday and it was expected to be a task in a resident's Treatment Administration Record. Resident P's clinical record lacked an order for the Treatment Administration Record to clean the filter for their oxygen concentrator. On 9/25/24 at 02:00 P.M., Resident P's oxygen concentrator observed to still have moderate dust on filter cover. A policy for oxygen administration provided by the Administrator on 9/26/24 at 11:30 A.M. indicated external filters should be checked daily and all dust should be removed. Filters should be washed with soap and water, then dried and reinserted once weekly and as needed. 3.1-47(a)(6)

Based on record review and interview, the facility failed to ensure the documentation was completed and accurate for 2 of 2 residents reviewed for accuracy of falls documentation. (Resident P and Resident 12) Findings include: 1. On 9/23/24 at 10:30 A.M. Resident P's clinical record was reviewed and indicated the resident had diagnoses that included but was not limited to diabetes mellitus and COPD (chronic obstructive pulmonary disease). A Quarterly MDS (Minimum Data Set) Assessment on 9/23/24 indicated Resident was cognitively intact, had no behaviors, and used a wheelchair. A state optional MDS dated [DATE], indicated Resident was independent in bed mobility and toileting, required supervision with transfers, and the resident was on a pain medication regimen with occasional pain that affected day to day activities. A progress note in Resident P's clinical record, dated 9/18/24 at 3:54 A.M., indicated the resident was found laying on the floor, face down, in her room. Indicated that it was believed Resident P rolled out of bed. Resident was found by CNA doing routine checks. Did not have any complaints of pain at that time. The progress note also indicated that the resident sleeps on the edge of their bed, and no injury was noted. A fall risk assessment dated [DATE] was completed for Resident P. A neurological check list was started on 9/18/24 at 2:15 A.M. Within the neurological check list, the 1st, 4 hour check time slot on 9/18/24 at 5 P.M. was skipped (blank) and indicated the resident was sleeping. The 4th, 8 hour time slot with no date added, was blank with no documentation for reason. The 24 hour after last 8 hour, check with no added date, was blank with no documentation for reason. The clinical record lacked a completed neurological assessment after Resident P's fall on 9/18/24. An interview with the DON (Director of Nursing) on 9/25/24 at 11:37 A.M. indicated there should be a risk assessment and neurological check list completed after each fall event. Indicated that neurological check lists should have been completed fully, regardless if a resident were sleeping during the neurological check. 46758 2. On 9/09/23/24 at 6:29 A.M., Resident 12's clinical record was reviewed. Diagnoses included, but were not limited to, dementia disorder, schizoaffective disorder, muscle weakness, and intellectual disabilities. The current quarterly MDS (Minimum Data Set) assessment dated [DATE] indicated that Resident 12 was severely cognitively impaired. Resident 12 needs partial help for transferring, dressing, and hygiene. Current physician orders included, but were not limited to: Up in wheelchair with ant-tippers and anti-rollback dated 8/31/24 Scoop mattress to define bed perimeter dated 8/6/24 Bed against the wall dated 8/6/24 The current falls care plan indicates that the resident is a fall risk due to impaired mobility with and will not sustain serious injury requiring hospitalization through the next review date. Interventions included but not limited to, 2 staff members for toileting, initiated 08/22/2024, anti-tippers to wheelchair initiated 8/28/2024, and anti-rollback initiated 8/28/24. On 9/25/26 at 10:00 A.M., the DON (Director of Nursing) provided copies of Neurological Check List for Resident 12 as follow: Fall #1 7/20/24 at 8:30 P.M. lacked first 15-minute vital signs 7/20/24 at 8:45 P.M. lacked second 15-minute vital signs 7/20/24 at 9:30 P.M., lacked first 30-minute vital signs 7/20/24 at 10:00 P.M. lacked second 30-minute vital signs 7/20/24 at 10:30 P.M. lacked third 30-minute no vital signs and neuro checks 7/20/24 at 11:00 P.M. lacked fourth 40 minute no vital signs and neuro check time slot marked skipped (blank) reason sleeping 7/21/24 at 1:00 A.M. lacked first 2-hour vital signs and neuro checks time slot was marked skipped (blank) reason sleeping 7/21/24 at 3:00 A.M. lacked second vital signs 7/21/24 at 11:00 A.M. lacked first 4-hour vital signs no vital signs 7/21/24 at 3:00 P.M. lacked second 4-hour vital signs 7/21/21 7:00 no vital signs for 3rd 4 hours 7/22/24 at 7:00 A.M. new fall so the neuro checks are started at beginning of that fall Fall #4 8/21/24 12:00 new fall and neuro assessment started again 8/21/24 at 2:45 P.M. lacked fourth 15-minute vital sign check resident was listed as combative but was still able to the neuro check 8/21/24 at 10:45 P.M. lacked fourth 2-hour vital signs resident was combative and refused- this was documented in the nurses notes also Fall #5 8/22/24 at 6:4. resident fell again restarted neuro assessment 8/22/24 at 7:15 A.M. lacked second 15-minute vital signs time slot skipped (blank) indicated resident refused 8/22/24 at 3:30 P.M. lacked third 2-hour vital signs and neuro checks not done because resident was listed as sleeping 8/23/24 at 9:30 A.M. lacked fourth 4-hour vital signs and neuro check reason missed indicated was on a second form there was no other form on a second neuro form 8/24/24 at 1:30 A.M. lacked first 8-hour vital signs and neuro assessments missing because indicated resident was sleeping Fall #6 8/28/24 at 7:15 A.M. started new assessment 8/31/24 at 6:00 PM lacked 24 hours after last 8 hour not completed vital signs or neuro assessment new fall Fall #7 8/31/24 11:50 AM restart neuro assessment During an interview on 9/25/24 at 10:30 A.M., the DON (Director of Nursing) indicated that all of the boxes should be completed on the Neurological Check List. On 9/26/24 at 9:50 A.M., the DON provided a current Fall Management policy reviewed on 9/22/2023. The policy indicated . the facility will assess the resident .with any fall event .documentation will include .vitals signs . 3.1-50(a)(1) 3.1-50(a)(2)

Based on interview and record review, the facility failed to ensure a communication process with hospice personnel was developed and implemented, including how the communication will be documented between the LTC (long term care) facility and the hospice provider, and to ensure that the needs of the resident were addressed. The clinical record lacked documentation of ongoing communication between facility staff and hospice staff for 1 of 1 residents reviewed for hospice. (Resident J) Finding includes: On 9/25/24 at 2:09 P.M. Resident J's clinical record was reviewed and indicated that Resident had diagnoses that included but was not limited to heart failure and atrial fibrillation. A significant change MDS (Minimum Data Set) assessment dated [DATE] indicated that the resident was cognitively intact and receiving hospice care. Physician Orders included but were not limited to: Admit to (Name of Hospice Company), dated 6/15/24. Resident J's clinical record lacked a care plan related to hospice services. Resident J's clinical record lacked any documentation of communication between hospice staff and facility staff. There was no hospice medical record within Resident's clinical record. On 9/25/24 at 2:27 P.M. LPN (Licensed Practical Nurse) 11 indicated that (Name of Hospice Company) did not utilize physical hospice binders any longer, an online portal was utilized. On 9/26/24 at 9:41 A.M. LPN 9 indicated that they believed the DON (Director of Nursing) is the one who had access to the hospice portal for Resident J. On 9/26/24 at 9:55 A.M. the DON indicated that unit managers and the infection prevention nurse have her username and password to log into the portal for hospice. Also indicated that the hospice staff was very good at communicating with their nurses during the visits, nurses had to sign tablet of hospice staff during visit. All hospice progress notes, vitals, and visit notes were only accessible through the hospice portal. QMA (Qualified Medication Aide) 8 indicated, on 9/26/24 at 10:06 A.M., they were not aware that (Name of Hospice Company) had switched to an online portal. At 10:07 A.M. on 9/26/24, LPN 9 indicated that if the DON was not present in the facility when they needed to access Resident J's hospice records, they would text her to get the log in information or call hospice directly. The Administrator provided a hospice policy on 9/25/24 at 10:00 A.M. The policy indicated that the facility provides hospice care under a written agreement and must ensure that each residents' plan of care includes both the most recent hospice plan of care and a description of the services furnished by the LTC facility to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. The policy indicated a Communication Protocol: Prior to the admission of any Facility resident to Hospice, Hospice and Facility shall work together to develop a written communication protocol governing how they will communicate all information needed for the Hospice Patients' care (such as physician orders and medication information), including how such communication will be documented to ensure that the needs of Hospice Patients are addressed and met twenty-four (24) hours a day. The communication protocol shall include, among other things, a procedure that clearly outline the chair of communication between the parties in the event a crises of emergency develops, a change of condition occurs, and/or changes to the Hospice Plan of Care are indicated, and it must also address how Hospice Physician orders will be communicated to Facility staff. Such protocol shall be distributed to all Hospice and Facility staff involved in the Hospice Patients' care. 3.1-13(m)

Based on observation, interview, and record review, the facility failed to post accurate actual hours worked for licensed and unlicensed nursing staff directly responsible for resident care per shift daily for 5 of 6 days during the annual survey period. Finding includes: During an observation on 9/23/24 at 2:59 P.M., a posted nurse staffing data sheet, dated 9/23/24, was observed on the nurses station desk inside the main entrance. The sheet included, but was not limited to, the following information: Census, total number of staff for each shift and total hours of each shift for CNA (Certified Nurse Aide), LPN (Licensed Practical Nurse), QMA (Qualified Medication Aide) and RN (Registered Nurse). The sheet indicated that 2 LPNs worked 20 hours between 7:00 A.M. and 7:00 P.M. but did not specify the actual hours that the staff worked. The sheet indicated that 1 QMA worked 8 hours between 7:00 A.M. and 7:00 P.M. but did not specify the actual hours that the staff worked. The sheet indicated that 1 QMA worked 4 hours between 7:00 P.M. and 7:00 A.M. but did not specify the actual hours that the staff worked. During an observation on 9/24/24 at 8:37 A.M., a posted nurse staffing data sheet, dated 9/24/24, was observed on the nurses station desk inside the main entrance. The sheet included, but was not limited to, the following information: Census, total number of staff for each shift and total hours of each shift for CNA, LPN, QMA, and RN. The sheet indicated that 2 QMAs worked 20 hours between 7:00 A.M. and 7:00 P.M. but did not specify the actual hours that the staff worked. The sheet indicated that 14 CNAs worked 60 hours between 3:00 P.M. and 11:00 P.M. but did not specify the actual hours that the staff worked. On 9/25/24 at 9:30 A.M., the Administrator provided a copy of posted nurse staffing sheets for dates 9/19/24, 9/20/24, 9/23/24, 9/24/24, and 9/25/24. Each of these dates did not reflect actual hours worked. On 9/25/24 at 10:15 A.M., the Director of Nursing indicated she was unable to tell by looking at the posted nurse staffing sheet which hours staff worked during shifts where hours worked did not equal the specified shift length. On 9/26/24 at 9:09 A.M., the Administrator provided a Posted Nurse Staffing Data and Retention Requirements policy, revised 7/2023, that indicated The facility must post the following information at the beginning of each shift . total number and actual hours worked by the following categories of licensed and unlicensed nursing staff .

Based on observation, record review, and interview, the facility failed to monitor, thoroughly assess and implement interventions for 1 of 4 residents reviewed for falls. Resident K fell twice in a 2 hour period, the second fall resulted in multiple fractures requiring surgical intervention; failed to monitor Resident G for behavior for elopement and exit seeking for 1 of 1 residents who left the building unattended. (Resident K, Resident G) Findings include: 1. On 7/22/2020 at 10:34 a.m., the record for Resident K was reviewed. [DIAGNOSES REDACTED]. other part of head. The MDS (Minimum Data Set) had an entry tracking record, dated 4/10/2020. The resident was admitted [DATE], discharged to hospital on [DATE], and readmitted to the facility on [DATE]. The Admission MDS (Minimum Data Set), dated 4/25/2020, indicated, but was not limited to, extensive assist of 2 or more staff members for bed mobility and transfer, dependent for toileting with assist of 2 staff, and extensive assist of 1 for eating. Baseline care plan, dated 4/10/2020 at 6:00 p.m., indicated at risk for falls. Interventions included assist with adls (activities of daily living), call light in reach, complete fall risk assessment, and orient resident to room. Additional risks included urinary incontinence, respiratory infection, and at risk for alteration in psychosocial well-being due to visitation restrictions. Care plans included, but were not limited to: Resident K was risk of falls related to personal history of falls, [DIAGNOSES REDACTED]. Goal: Resident K will not sustain serious injury requiring hospitalization through the review date, date initiated 4/18/2020. Interventions included, but were not limited to,anticipate and meet the resident's needs, date initiated 4/12/2020. Assist with ADLs (Activities of Daily Living) as needed, date initiated 4/11/2020. Call light within reach, date initiated 4/11/2020. Complete fall risk assessment, date initiated 4/11/2020. Orient resident to room, date initiated 4/11/2020. Provide appropriate footwear non-skid socks when ambulating or mobilizing in w/c, date initiated 4/12/2020. Pt (sic) (Physical Therapy) evaluate and treat as ordered or PRN (as needed), date initiated 4/12/2020. Resident has had an actual fall with serious injury related to Poor Balance, Poor communication/comprehension, Psychoactive drug use, unsteady gait, date initiated 4/12/2020. Goal: Resident K orbital fx (fracture), left wrist fx, left hip fx will show signs of healing by review date, date initiated 4/12/2020. The resident has a left [MEDICAL CONDITION] and a left wrist fracture and is at risk for complications, date initiated 5/4/2020. Resident K expresses discomfort r/t (related to) history of [MEDICAL CONDITION] and [DIAGNOSES REDACTED]. Progress notes indicated on 4/11/2020 at 20:20 (8:20 p.m.) Event Note Text: RN observed resident lying on her back in her room when she was walking down hallway area. W/C was approximately a (sic) 1 foot away from her RN had observed resident sitting in her W/C 10-12 minutes prior to incident. Moderated (sic) amount of blood noted on the floor next to resident. Resident had approximately 2-3 cm (centimeter) laceration on left eyebrow area. Left eye slight discolored and swollen shut. Residents right eye open but not verbally responsive. Ice pack applied to laceration. (Hospital name) Nursing Triage notified of event and current status. Triage notifying MD on Call. 8:35 p.m. (family name) residents son notified of status and waiting for return call from MD. 8:40 p.m. Triage called with orders from (MD name) to send to (hospital name) . B/P (blood pressure) 179/105, P (pulse) 84, R (respirations) 18. The MDS tracking record, Entry, was dated 4/18/2020. Progress note dated 4/19/2020 at 10:13 a.m., .fractured left hip, left wrist and left orbital, from previous fall here at (facility name) .pneumonia . On 7/22/2020 at 11:22 a.m., Resident K was observed lying in bed with eyes closed, oxygen per nasal cannula in place, a fall mat at bedside, and Broda chair at foot of bed. On 7/23/2020 at 8:02 a.m., Resident K was observed lying in bed with head of bed elevated, oxygen per nasal cannula in place, eyes closed with breakfast set up in front of her untouched, and opened her eyes briefly when addressed, remained non verbal. On 7/23/2020 at 8:25 a.m., LPN 1 indicated she was working the shift when Resident K had fallen and went to the hospital. She had history of falling at home and had fell 2 times in the facility, the second time with injuries. She would get up by herself, had dementia, and needed reminders. She didn't use the call light. On 7/23/2020 at 10:23 a.m., the Director of Nursing was interviewed while she was providing information from her computer, the surveyor did not have access to the risk management category in the computer system. It was a glitch and the surveyors should have access. She indicated Resident K had fallen on 4/11/2020 at 6 p.m. and at 8:20 p.m. On 7/23/2020 at 10:27 a.m., the Director of Nursing indicated there were no nurses notes regarding the fall at 6 p.m. in the progress notes or assessments in the medical record. The information was in the Risk Management area. The Risk Management information was not part of the medical record. On 7/23/2020 at 1:28 p.m., the Director of Nursing provided the Risk Management report dated 4/11/2020 at 6:00 p.m., for Resident K. The Risk Management notes indicated, but was not limited to, Nursing Description: Resident K was found on buttocks side of wheel chair, stated I fell backwards, Resident Description: I fell backwards down on the floor, was going outside. Immediate Action Taken - Description: no signs of injuries, assist of two back in wheel chair for her supper . Mental Status: oriented to person .Mobility: Wheelchair bound .Predisposing Environmental Factors: other .Predisposing Physiological Factors: confused, current UTI (urinary tract infection), impaired memory .Predisposing Situation Factors: admitted within last 72 hrs .family notified 4/11/2020 at 8:07 p.m., physician notified at 8:03 p.m. The Risk Management report was stamped at the bottom of each page: Privileged and Confidential - Not part of the Medical Record - Do not Copy. The Risk Management report for Resident K, dated 4/11/2020 at 8:20 p.m., indicated, but was not limited to, Incident Description - Nursing Description: RN observed resident lying on her back in her room when she was walking down the hall. W/C was approximately 1 foot away from resident. RN had observed resident sitting in her W/C 10-12 min (minutes) prior to incident. Moderate amount of blood noted on floor next to resident. Resident left eye swollen shut. Right eye open but no (sic) verbally responsive. Immediate Action Taken: Resident assessed for injury. Resident had approximately 2-3 laceration on left eyebrow area. Ice pack applied. Left eye discolored and swollen shut. (Hospital name) Nursing Triage notified. Received orders to send resident to (hospital name) ER (emergency room ) for evaluation. Resident taken to Hospital? marked N. Injuries Observed at Time of Incident: Bruise face, Bruise left wrist, Laceration top of scalp. Level of Consciousness: (blank) .Injuries Report Post Incident: no injuries observed post incident .Predisposing Physiological Factors: confused, incontinent, current UTI, impaired memory .Predisposing Situational Factors: admitted within last 72 hours, ambulating without assist .Other info (information): resident has a history of Alzheimer's, dementia, depression, anxiety, bilateral pneumonia, and UTI. Resident also has a history of osteopenia .Witnesses: no witnesses found .DON (Director of Nursing) notified 4/11/2020 at 8:20 p.m., physical notification 8:30 p.m., and family member notification 8:35 p.m. The Risk Management report was stamped at the bottom of each page: Privileged and Confidential - Not part of the Medical Record - Do not Copy. On 7/21/2020 at 2:18 p.m., the Director of Nursing indicated they assess the resident from head to toe, obtain vital signs, do neuro (neurological) checks if unwitnessed, notify the physician, family, Director of Nursing, do a risk management section, complete a pain assessment, fall assessment, and put on pertinent charting for 72 hours when a fall occurs. The resident's permanent clinical record lacked neurological checks beginning with unwitnessed fall date 4/11/2020 at 6 p.m., documentation of fall which occurred at 6 p.m., and interventions to prevent further falls. On 7/23/2020 at 3:03 p.m., the Director of Nursing provided the current facility policy, Fall Management, issues 6/4/2020. The Policy indicated, but was not limited to, Purpose - to promote patient safety and reduce patient falls by proactively identifying, care planning, and monitoring of patients' fall indicators. The facility will assess the resident upon admission/readmission, quarterly, and with change in condition, and with any fall event for any fall risks and will identify appropriate interventions to minimize the risk of injury related to falls .Residents will be assessed for fall indicators upon admission, readmission, quarterly, change in condition and with any fall utilizing the Fall Risk Assessment UDA (User Defined Assessments). 2. On 7/21/2020 at 9:40 a.m., the record for Resident G was reviewed. [DIAGNOSES REDACTED]. The Admission MDS (Minimum Data Set), dated 1/7/2020, indicated moderate cognitive impairment. The Significant Change MDS, dated [DATE], indicated severe cognitive impairment. Resident G needed extensive assistance with bed mobility, transfer, and dressing, and supervision for mobility and eating. Baseline care plan dated 12/27/2019 indicated, but was not limited to, exit seeking at times, occasionally lost in directions, 15 minute checks, redirection for elopement. Goal: resident will not leave facility unattended through the review date. Interventions: complete elopement risk assessment, encourage to participate in activities to divert from exit seeking behavior, provide for safe wandering - resident is an elopement risk. Care plans included, but were not limited to, Resident G is at risk for elopement related to disorientation to place, history of attempts to leave facility unattended, impaired safety awareness. Resident wanders aimlessly, date initiated 12/29/19, revised on 6/25/2020. Interventions included, but were not limited to, add resident to the Elopement Book, date initiated 1/19/2020. Complete elopement risk assessment, date initiated 12/29/19. Document wandering behavior and attempted diversional interventions in Point Click Care, date initiated 1/19/2020. Encourage Resident G to participate in activities to divert from exit seeking behavior, date initiated 12/29/19 . Psychology Diagnostic assessment dated [DATE] indicated, but was not limited to, Review of Symptoms: exit seeking, suspicious/paranoid, distractibility . note dated 3/11/2020 indicated anxiety, delusions, distractibility, exit seeking, impulsivity, intrusiveness, sundowning, wandering, pacing .note dated 5/26/2020 indicated exit seeking. Psychiatry progress note dated 6/1/2020 indicated, but was not limited to, exit seeking. Elopement Risk Evaluation dated 3/27/2020 indicated, but was not limited to, does the resident have a history of Elopement while at home .exhibits exit seeking behavior (checking doors, windows, setting off alarms etc.), history of leaving facility without supervision, or history of leaving facility without informing staff? Answer: No. Does the resident become agitated when diverted from exits, agitated to being contained within the boundaries of the facility (ie verbal expressions of I'm leaving, let me out, I'm calling the police etc.), or has the resident been heard or observed asking others how to get out of here? Answer: Yes. Resident is at risk for elopement at this time? Answer: Yes. Wandering/Elopement interventions: .Add resident to the Elopement Book .frequent monitoring. Progress note dated 5/30/2020 at 7:27 p.m., 15 minute checks continue .no complaints of discomfort from previous fall. Up and down hallway continually. Confusion, restlessness. Anxious and asking for a ride home. At front door and wanting to go home repeatedly. Close observation until episode passes . Progress note dated 6/1/2020 at 7:18 p.m., Continually walking up and down hallway. Around exits stating she has a court date and needs to leave. Difficulty redirecting . Progress note dated 6/3/2020 9:00 p.m., resident went out the front door at 18:49 (6:49 p.m.). She returned at 19:32 (7:32 p.m.) (Name) resident's daughter notified at 20:34 (8:34 p.m.). Physician notified at 2058 (8:58 p.m.). Resident immediately placed (sic) one on one monitoring. Head to toe assessment. No signs or symptoms of injuries noted. Will continue to (sic) one on one monitoring. Progress note effective date 6/3/2020 at 9:09 p.m., created date 6/4/2020, indicated Resident G's care plan updated and psychosocial support provided immediately for resident. Referrals for more appropriate placement have been made. Due to COVID other facilities can not keep Resident G in isolation and would not assume care. Will have social services follow up in the morning. Weekly Skin Integrity Data Collection report dated 6/4/2020 indicated skin intact. On 7/21/2020 at 2:23 p.m., the Director of Nursing indicated CNA 1 had reported seeing Resident G while driving down the street, stopped and got the resident, and gave her a ride to the facility. She was down the road near (Name of fast food restaurant) On 7/21/2020 at 2:35 p.m., CNA 1 indicated she had returned to work to get her purse, had left thru the traffic light on ST Joseph, had recognized her on the left side of the road, at the corner of (Name of fast food restaurant's) intersection (mileage was 1.4 miles south of the facility). She turned her car around, called her over to the car, and offered to take her back to the facility. She called the facility supervisor and she and the Director of Nursing met her at the car when she pulled in the facility parking lot, and escorted Resident G into the facility. She had not noticed Resident G attempting to exit while she was working her day shift. Risk Management Report, Elopement, provided on 7/23/2020 at 8:00 a.m., was dated 6/3/2020 6:49 p.m., revised on 6/4/2020 10:52 a.m., and indicated Resident G was let out front door exit per (hospice nurse name) . (hospice nurse name) reported Resident G was standing at the front door. He reported she had her purse and mask on. He believed she was a visitor. Resident returned to the facility at 7:32 p.m. The Report was stamped privileged and Confidential - Not a part of the Medical Record - Do not Copy on each page. On 7/23/2020 at 11:34 a.m., the Director of Nursing indicated Resident G was being monitored every 2 hours for side effects of fall. If they were a new resident, behavior monitoring would be on paper, if they had been there a while, the behavior monitoring was in the MAR. She verified continuous pacing was the only behavior monitoring in the medical record. On 7/23/2020 at 3:03 p.m., the Director of Nursing provided the current facility policy, Behavioral Health Management, last revised date 10/3/2017. The Policy indicated, but was not limited to, promote resident safety, attain highest practicable mental/psychosocial well-being and reduce behavior related events .facility must provide necessary behavioral health care and services which include: ensuring that the necessary care and services are person-centered and reflect the resident's goal of care, while maximizing the resident's dignity, autonomy, privacy, socialization, independence, choice, and safety. This Federal tag relates to Complaint IN 520, IN 880, IN 297, & IN 331. 3.1-45(a)(2)

Based on observation, interview, and record review, the facility failed to ensure residents were free from accidents for 2 of 3 residents reviewed for falls. Supervision and effective fall interventions were not in place for a resident, which resulted in a resident receiving a femur fracture and surgical intervention and a resident who obtained a hematoma from a fall. Resident 1 did not receive care by 2 assistance resulting in the resident falling out of bed. (Resident 1, Resident 83) Findings include: 1. On 3/2/20 at 9:52 a.m., Resident 1 indicated she had fell out of bed approximately three weeks ago and sustained a fracture of her right femur. She indicated she had surgery on the leg, a rod was placed in it, and she still had her staples in. The clinical record for Resident 1 was reviewed on 3/3/2020 at 10:51 a.m. [DIAGNOSES REDACTED]. A quarterly MDS (Minimum Data Set) assessment, dated 11/11/19, indicated the resident had no cognitive impairment. The MDS indicated the resident required extensive assist of 2 persons for bed mobility. A care plan, start date 9/3/19, indicated the resident had an ADL (Activity of Daily Living) self-care performance deficit related to disease process, end stage kidney disease, fatigue, and limited mobility. A bed mobility intervention included, but was not limited to, resident requires extensive assist by 2 (two) and use of 1/4 bilateral side rails to turn and reposition in bed routinely and as necessary, start date 7/15/19, revision date 11/24/19. A progress note, dated 2/10/2020 at 7:00 a.m., indicated the resident fell from her bed during a bed check/change at 5:40 a.m. According to the CNA and resident, the CNA was attempting to roll the resident over using the side rail while the CNA was removing the pad under the resident. The resident placed her right leg over her left leg and this caused the resident to fall to the floor. The resident complained of severe left leg pain in her thigh. The resident was assisted into bed by 8 persons and a Hoyer lift (a mechanical lift), and a portable x-ray was ordered. A progress note, dated 2/10/2020 at 11:41 a.m., indicated the resident had her left leg and knee x-rayed and the resident had a broken leg. A progress note, dated 2/10/2020 at 4:06 p.m., indicated the resident had fell out of bed this a.m. Reported that an x-ray of left leg had been ordered. Resident had a left distal femur fracture. The x-ray technician did not want to move the resident's leg for any other x-rays at that time. Findings were called and the report sent to the physician's triage service. Order was received to transfer the resident to the emergency room for evaluation and treatment. The resident was notified of the physician's orders [REDACTED]. The resident's family was notified An IDT (Intradepartmental Team) note, dated 2/15/2020, included, but was not limited to, Resident 1 had a fall resulting in a left femur fracture. She was sent to the hospital and had a rod placed on 2/12/2020. She returned to the facility on [DATE]. Root cause analysis performed and staff was interviewed. CNA involved in incident did not follow plan of care. Resident 1 was a bed assist of 2 persons and CNA was only staff in room turning resident. The bed the resident was on was inspected and in proper working order. A new bed was placed in the resident's room that was wider and more conducive to the resident habitus and moisture state. An x-ray report, dated 2/10/2020, of the left femur included, but was not limited to, the following: Findings: Comminuted [MEDICAL CONDITION] femoral diaphysis extending into the distal metaphysis. There is dorsal displacement of the distal fragment, as well as overriding and anterior angulation. Proximal femur is intact. Normal alignment of the left hip joint. Diffuse loss of bone mineral density. A Fall Risk Evaluation, dated 2/10/2020 at 8:01 a.m., indicated the resident had a score of 14, which indicated the resident was a high risk for falls. A Fall Risk Evaluation, dated 2/4/2020 at 6:00 p.m., indicated the resident had a score of 14, which indicated the resident was a high risks for falls On 3/4/2020 at 10:21 a.m., LPN 2 indicated the resident had fallen out of bed when pericare was being provided. She had turned herself to side causing her leg to slip off and she rolled out of bed. She indicated the resident required surgery and had several staples in her leg which will be removed next week. On 3/4/2020 at 2:00 p.m., the DON (Director of Nursing) indicated the resident was a 2 person assist for bed mobility and had only 1 CNA assisting her to turn when she rolled out of bed, fracturing her left femur. She indicated the staff had been educated regarding following the care plans of the residents. 2. On 3/2/2020 at 11:13 a.m., Resident 83 was observed to be lying in a broda chair (a chair that offers tilt-in-space positioning). Resident 83 had a bruise to the right eye. The clinical record for Resident 89 was reviewed on 3/3/2020 at 2:14 p.m., [DIAGNOSES REDACTED]. A quarterly MDS (Minimum Data Set) assessment, dated 2/7/2020, indicated the resident had severe cognitive impairment. The MDS assessment indicated the resident required extensive assist of 2 persons for transfers. An ADL (Activity of Daily Living) care plan, start date 1/6/2020, included, but was not limited to, the following intervention: resident required assist of 2 staff and mechanical lift for transfers, start date 1/6/2020. A history of falls care plan, start date 12/24/19, included, but was not limited to, the following intervention: Call light within reach, start date 12/24/29, revision date 1/6/2020. Assist with ADLs as needed, start date 12/24/19, revision date 1/6/2020. Resident was not to be left in common areas without staff near as the resident would attempt to get up before she will ask for help, start date 2/21/2020. A Fall Risk Evaluation, dated 2/21/2020 at 2:41 p.m., indicated the resident had a score of 22 which indicated the resident was a high risk for falls. A progress note, dated 2/21/2020 at 1:54 p.m., indicated Resident was noted to have laceration to bridge of nose and hematoma to R (right) eyebrow, resident also stated that R shoulder hurt but was able to move without issues. MD (Physician) notified and ordered facial x-ray and x-ray to R shoulder, neuro checks performed per policy. Residents pupils are 3 and react brisk. A facial bones x-ray report, dated 2/21/2020 at 11:08 p.m., included, but was not limited to the following conclusions: No obvious or acutely displaced fracture. A right shoulder x-ray report, dated 2/21/2020 at 11:08 p.m., included, but was not limited to the following conclusion:Mild shoulder arthrosis without radiographic evidence of an acute bony abnormality. On 3/4/2020 at 1:30 p.m., CNA 1 indicated the resident had fallen out of her broda chair in the restorative dining room. She indicated no staff was present in the room when the resident fell . On 3/5/2020 at 9:25 a.m., the Director of Nursing (DON) indicated she had not entered an IDT note regarding the resident's fall. The resident was left unattended in the restorative dining room and fell out of her chair. The staff had been educated no one should be left alone if they were a fall risk. A Root Cause Analysis dated 2/21/2020, provided by the Director of Nursing on 3/5/2020 at 9:37 a.m., indicated At risk for falls no CNA in restorative-spoke with CNAs and nurses regarding no resident who is at risk for falls should be left unattended. The current facility policy, Fall Management, revision date 4/15/19, provided by the DON on 3/5/2020 at 1:47 p.m., included, but was not limited to, the facility must ensure that the resident's environment remained as free of accident hazards as is possible and each resident received adequate supervision and assistance devices to prevent accidents. 3.1-45(a)

Based on interview and record review, the facility failed to ensure a resident was transferred with a mechanical lift and/or gait belt, resulting in the resident being lowered to the floor and obtaining a left humeral fracture; and failed to document the incident in the clinical record or notify the family and responsible party, for 1 of 3 residents reviewed for falls, in a sample of 5. (Resident B) Findings include: The clinical record of Resident B was reviewed on 8/22/18 at 11:00 A.M. [DIAGNOSES REDACTED]. A Care Plan, dated 1/20/17 with a goal target date of 10/31/18, indicated, At risk for fall related injury due to [MEDICAL CONDITION] and impaired mobility. The Approaches included: Report falls to physician and responsible party. Provide/observe use of adaptive devices. 3/19/18 Changed to 2 person transfer with gait belt. A Therapy note, dated 5/16/18, indicated, Transfer bed to and from w/c (wheelchair) (with) dependent lift using yellow sling. Transfer to and from toilet (with) mechanical sit to stand lift using black sling. A quarterly Minimum Data Set (MDS) assessment, dated 6/15/18, indicated Resident B had no memory impairment, and required extensive assistance of two+ staff for bed mobility and transfer. The resident did not ambulate. A test for balance indicated Not steady, only able to stabilize with staff assistance for surface-to-surface transfers. Resident B had fallen once since the previous assessment. Resident's weight was recorded as 252 pounds. A Care Directive, date not written, indicated, Transfers: Assist 2, Mechanical Lift, Sit/Stand .Dependent Leift (sic) use yellow sling to go from bed to/from wheelchair. Transfers to toilet with sit to stand using a black sling. Nurses Progress Notes included the following notations: 8/3/18 at 7:51 A.M.: On 8/2/18 at 11:30 pm, resident complained of left arm pain again. She had also complained of it hurting earlier in the shift at 9pm in which she was given her PRN (as needed) [MEDICATION NAME] (pain medication) as ordered. She has been complaining of left arm pain more often than usual .had been on [MEDICATION NAME] 150 mg twice a day for diabetic [MEDICAL CONDITION] prior to a hospital stay in which she returned on 6/8/12 and the order had been discontinued upon readmission .Did get order to xray her left arm to rule out any kind of injury 8/3/18 at 10:27 A.M.: .Received call that resident may resume her [MEDICATION NAME] 150 BID (twice daily) DX (diagnosis): [MEDICAL CONDITION] pain in left arm 8/3/18 at 8:17 P.M.: Continues to complain of left arm pain. PRN pain medication given as ordered. X-ray results received and faxed to (name of physician). No fractures noted A radiology report, dated 8/3/18, indicated, Mild [MEDICAL CONDITION] joint disease of the left shoulder; otherwise, no fracture or dislocation seen. Humerus (shoulder). No fracture or dislocation is seen. The shoulder joint is grossly intact. Normal left humerus. Nurses Progress Notes continued: 8/4/18 at 6:46 A.M.: .No c/o (complaints of) pain or discomfort voiced this shift 8/6/18 at 9:46 A.M.: Resident continues to complain of pain in left arm - xray completed to show no acute trauma or fracture. Request therapy referral at this time Documentation of the resident falling or being lowered to the ground on 8/6/18 was not found in the clinical record. A Fall Risk Evaluation, dated 8/6/18, indicated the resident had 1-2 falls in the previous 90 days, required assistance with elimination, and was not able to attempt a balance evaluation without physical help. The evaluation indicated the resident had a score of 20, and included A resident who scores a 10 or higher is at risk for falls. A written note indicated, Sit to stand or dependent lift for transfers. Nurses Progress Notes continued: 8/7/18 at 3:07 A.M.: Res (resident) requested PRN pain medication r/t (related to) pain in left arm 8/7/18 at 6:00 A.M.: CNA doing bed check at this time res c/o pain with any movement. PRN pain medication given at this time. 8/8/18 at 6:23 A.M.: .Complaint of pain with movement 8/10/18 at 11:35 A.M.: Resident continues to cry out in pain with her left arm when it is moved. She continues to receive her PRN pain medication every 4 hours Plus she on (sic) her [MEDICATION NAME] twice a day. She continues to see OT (occupational therapy) services 8/12/18 at 7:16 A.M.: Resident complaining of left arm and shoulder pain with movement, new order per (name of physician) for view x-ray of shoulder and arm 8/12/18 at 9:56 A.M.: Radiology Report received and results: there is a (sic) acute minimally displaced [MEDICAL CONDITION] humeral (shoulder) shaft. No dislocation, [MEDICAL CONDITION] changes or destructive [MEDICAL CONDITION] .AMR (ambulance service) notified of transfer to (name of hospital) An ambulance report, dated 8/12/18 at 10:12 A.M., indicated: Dispatched for a PA (patient) fall .Patient stated she was being lifted out of a chair and into her wheel chair. Patient stated, 'They did not use the lift and dropped me on my arm.' Nurse stated 'She never fell . Patient was lowered to the ground. We did an BRay (sic) and it did not show a fracture. We did another one today and she has a fractured proximal humerus.' (The resident indicated) - 'My left arm hurts really bad where they dropped me.' (History) .Patient stated she was 'dropped' on Thursday An emergency room note, dated 8/12/18 at 11:06 A.M., indicated, .Pt (patient) reports that this AM she was being transferred into her wheelchair. She states that she is supposed to be transferred using a lift, but the staff at (name of facility) was attempting to transfer her without the lift .Pt states that she was 'dropped and fell .' Pt reports that she began to have left upper arm pain immediately A Nurses Progress Note, dated 8/13/18 at 6:41 A.M., indicated: Late Entry for 8-12-18. Resident started screaming while CNA's (sic) were providing care at 6:30 AM. I went in to check on situation et (and) resident was screaming et crying from pain in her left upper arm. Upon further examination resident's left arm had increased [MEDICAL CONDITION] (swelling), was warmer to touch than right arm et was slightly red. Resident stated that her arm hurt between her shoulder et her elbow at 10 on a scale of 1-10. I contacted (name of physician) .order was given to obtain x-ray of left shoulder et left humerus On 8/22/18 at 2:05 P.M., LPN 2 was interviewed. She indicated the night shift nurse had reported to her on 8/12/18 that Resident B had screamed all night, and got an order for [REDACTED]. She indicated the resident was dead weight, and there would be no way that even 2 staff members could get her off the floor by themselves. She indicated the resident was normally transferred with a mechanical lift and 2 persons, and was very heavy. On 8/22/18 at 2:15 P.M., CNA 4 was interviewed. She indicated she usually worked with Resident B. She indicated she was transferred with a hoyer (mechanical) lift. She indicated she had not heard that Resident B had fallen, but that her arm had been hurting for a couple of weeks. On 8/22/18 at 2:25 P.M., QMA 1 was interviewed. QMA 1 indicated it was very rare for Resident B to complaint of pain, but that she had asked for a pain pill for her left arm a couple of weeks prior. She indicated the resident was paralyzed on her left arm, and would frequently lay on that side. She indicated she was not 100% clear on her stories all the time. On 8/22/18 at 2:45 P.M., CNA 5 was interviewed. She indicated, It was hearsay. I heard her and her roommate talking about it; how she was dropped. She indicated the resident was in a lot of pain. She indicated she thought the resident's story would change, and the resident would get mixed up regarding which day she fell . She indicated she heard the staff involved were CNA 1 and CNA 2, and that they got written up. CNA 5 indicated she thought it happened on a Monday, a week before she actually went to the hospital. CNA 5 indicated CNA 2 stated they were trying to transfer the resident themselves instead of using a lift. On 8/22/18 at 3:25 P.M., RN 2 was interviewed. RN 2 indicated she heard Resident B was lowered to the floor, but never saw her on the floor, and did not know any details. She indicated Resident B, didn't complain of pain unless we moved her. She indicated she heard CNA 1 and CNA 2 were the staff involved. On 8/22/18 at 3:50 P.M., during an interview with LPN 1, she indicated she heard through the grapevine that Resident B was lowered to the floor, but that she did not know the details. She indicated she heard CNA 1 and CNA 2 were the staff involved, and that it occurred on evening or night shift. On 8/22/18 at 3:55 P.M., RN 1 was interviewed. RN 1 indicated, About 2 or 3 weeks ago .around 8-9ish in the evening, one of the aides (CNA 1) told me they had to lower (Resident B) to the floor. RN 1 indicated she entered the room, and Resident B was on the floor. CNA 2 was with the resident. She indicated they obtained the lift, and lifted the resident back to her bed. She indicated the CNAs were attempting to stand the resident, and were not using a lift. She indicated she did not chart the incident in the nurses notes, or fill out an incident report. She indicated, They swore they just lowered her to the floor, and they didn't drop her. She indicated she thought she probably reported it to the next shift. On 8/22/18 at 4:10 P.M., CNA 3 was interviewed. She indicated she was working on 8/6/18, but left at 7:00 P.M. She indicated Resident B was to have a shower that day, but liked to have her showers later in the evening. She indicated she informed CNA 1 to transfer Resident B with the sit to stand lift. She indicated Resident B informed her when she returned a couple of days later that she had fallen. CNA 3 indicated she did not think CNA 1 was familiar with Resident B, because she usually worked on a different hall, but that CNA 2 would be familiar with Resident B's care. On 8/23/18 at 9:10 A.M., CNA 1 was interviewed. CNA 1 indicated her and CNA 2 were attempting to transfer Resident B into a shower chair. She indicated, She wasn't able to stand, and the other aide (CNA 2) said let's ease her down. We went and got the nurse. She indicated they were not using a gait belt, and did not use a mechanical lift. She indicated she had never cared for her before. CNA 1 indicated Resident B was a big lady, but didn't feel like they dropped her hard to the floor. She indicated they were attempting to hold onto her under her arms and around her waist. On 8/23/18 at 8:50 A.M., the Director of Nursing (DON) provided an In-Service Training Report, dated 8/13/18. The report included: All staff are to follow gait belt policy. All staff are to follow care directives guides. All changes in plane must be reported to the director of nursing, a head to toe assessment completed, and an IDA (incident report) completed. The DON indicated CNA 1 and CNA 2 also received disciplinary action. On 8/23/18 at 11:30 A.M., during an interview with the DON and Administrator, the Administrator indicated she began her investigation on 8/13/18 after she heard the resident say she was dropped. On 8/23/18 at 8:55 A.M., the DON provided the current facility policy, Incident Management, revised 2/2007. The policy included: Each resident receives adequate assistance and oversight as defined in an individualized plan of care that reduces the risks for incidents. If a resident has had an accident or fall the facility investigates and provides focused review to minimize the potential for recurrence. Procedure .Define an 'accident' as an unexpected, unintended event that can result in bodily injury .Identify residents who are at risk for incidents and implement care-planned procedures designed to reduce the risk of incidents. Respond promptly to immediate medical needs when an incident occurs .Notify those who need to know .Provide timely investigation of accidents/falls .The unit nurse completes the Incident Report at the time of the occurrence. Each Incident Report must include the date and time of the incident, a description of the incident, witnesses, parties involved, vital signs, the date and time the family and physician were notified, who was notified, and the signature of the person completing the Incident Report This Federal tag relates to Complaint IN 902. 3.1-45(a)(2)