Every finding on record at Prairie Village Nursing and Rehabilitation

Based on observation, interview, and record review, the facility failed to ensure residents were treated with dignity, respect, and per their preference for 1 of 3 residents reviewed for resident rights. A resident was touched and tickled by a staff member while in the dining room without consent. (Resident B)Finding includes: An observation and interview on 8/30/26 at 1:25 P.M., Resident B was lying in bed in her room. She was dressed and a walker was near the bed. Resident B indicated she was able to utilize her walker by herself and mostly helped herself and provided her own care. Resident B indicated she did not care for one of the staff members, CNA 4. CNA 4 had tickled her and hit her on the head in the dining room. Resident B indicated she did not like when the CNA tickled her and her friends. A review of facility reported incidents on 8/30/26 at 1:35 P.M. included an incident, dated 8/16/26, with a description that indicated CNA 4 had tickled Resident B. Resident B told the CNA to stop and the CNA then touched the resident's head, stopped tickling her, and apologized. Resident B notified a family member of the incident and the local police responded to the facility. A follow up added 8/21/26 indicated Resident B preferred not to be tickled or patted. A review of the facility's investigation of the incident included two witness statements. A statement dated 8/16/26 included, Yesterday during supper time CNA [4] was at [Resident B's] table talking to the girls. [CNA 4] was joking around with the residents and was tickling [Resident B] on neck [and] top of head. Another witness statement dated 8/16/26 included, This nurse was with CNA as she was giving her report to the police officer. CNA reported that she had tickled resident on her sides, resident asked her to stop. CNA reports that she did as requested, rubbed her on the head [and] walked away.A review of Resident B's record on 8/30/26 at 1:45 P.M. indicated the residents diagnoses included, but was not limited to, anxiety and mild intellectual disabilities. Resident B's most recent Annual Minimum Data Set (MDS) assessment, dated 6/17/26, indicated the resident had moderate cognitive impairment. Resident B's plan of care included no documentation that the resident preferred or enjoyed to be tickled. During an interview on 8/30/26 at 3:00 P.M., CNA 8 indicated that it was not appropriate to for staff to tickle residents. Some of the resident do enjoy joking around with the staff members, however, Resident B is not really like that. On 8/30/26 at 3:59 P.M., the Facility Administrator supplied a facility policy dated 3/2018, titled Resident Rights. The policy included, .Respect and Dignity .The resident has the right to be treated with respect and dignity, including the right to: .reside and receive services in the facility with reasonable accommodation of resident needs and preferences .This citation relates to intake 3170488.410 IAC (Indiana Administrative Code) 16.2-3.1-3(t)410 IAC 16.2-3.1-3(v)(1)

Based on interview and record review, the facility failed to ensure the resident's right to participate in the development and implementation of the resident's plan of care for 5 of 5 residents reviewed for care plan conferences. Care plan conferences were not completed quarterly. (Resident 24, Resident 8, Resident 41, Resident 1, Resident 14) Findings include: 1. On 5/7/25 at 1:34 P.M., Resident 24's clinical record was reviewed. Diagnoses included, but were not limited to, anxiety, depression, and Bipolar disorder. The most recent Quarterly Minimum Data Set (MDS) assessment, dated 2/25/25, indicated a moderate cognitive impairment. Care plan conferences for the previous 12 months took place on the following dates: 5/31/24 8/28/24 1/23/25 Resident 24 lacked a care plan conference from 1/23/25 to current. 2. On 5/7/25 at 2:22 P.M., Resident 8's clinical record was reviewed. Diagnoses included, but were not limited to, seizure disorder, anxiety, and depression. Resident 8 was admitted [DATE]. The most recent Quarterly MDS assessment, dated 2/18/25, indicated a moderate cognitive impairment. Care plan conferences since admission took place on the following dates: 11/25/24 Resident 8 lacked a care plan conference from 11/25/24 to current. 45933 3. On 5/7/25 at 11:30 A.M., Resident 1's clinical record was reviewed. Diagnoses included, but was not limited to, hypertension, anxiety disorder, and schizophrenia. The most recent Annual MDS assessment, dated 2/25/25 indicated Resident 1 had severe cognitive impairment. The clinical record indicated Resident 1 lacked a care plan conference between 6/13/24 and 1/16/25 and after 1/16/25. 4. On 5/7/25 at 9:28 A.M., Resident 41's clinical record was reviewed. Diagnoses included, but was not limited to, type 2 diabetes mellitus, heart failure, and depression. The most recent Quarterly MDS, dated [DATE] indicated Resident 41 had moderate cognitive impairment. The clinical record indicated Resident 41 lacked a care plan conference after 12/9/24. 46416 5. On 5/7/25 at 1:17 P.M., Resident 14's clinical record was reviewed. Diagnoses included, but were not limited to, hemiplegia affecting left side, schizophrenia, vascular dementia with anxiety, depression, and diabetes mellitus type II. Resident 14 was admitted on [DATE]. The most recent Quarterly MDS assessment, dated 3/23/25, indicated Resident 14's cognition was moderately impaired, she was dependent on staff assistance for showering, and substantial/maximum assistance of staff (staff performed over half the effort) for toileting, bed mobility, and transfers. The clinical record lacked a care plan conference between 9/25/24 and 3/21/25. During an interview on 5/12/25 at 12:25 P.M., the Director of Nursing (DON) indicated they should do the care plan conferences at least quarterly, along with the MDS assessments, and as needed. On 5/12/25 at 11:17 A.M., a current Comprehensive Care Plan Policy, last revised August 2023, was provided by the DON and indicated . Care plan review will be interdisciplinary . Resident, resident's representative, or others as designated by resident will be invited to care plan review . Care plan problems, goals, and interventions must be reviewed and revised by the interdisciplinary team periodically and following completion of each MDS assessment . Review the Comprehensive Care Plan and complete the IDT Care Plan Summary Observation . 3.1-3(n)(3) 3.1-35(d)

Based on observation, interview, and record review, the facility failed to provide a safe environment for 1 of 2 halls reviewed for hot water. The water temperature in resident areas exceeded 120 degrees Fahrenheit. (100 hall, 200 hall) Finding includes: On 5/6/25 between 1:35 P.M. and 1:50 P.M., the following water temperatures were obtained: room [ROOM NUMBER] (shared bathroom with room [ROOM NUMBER]) 122 degrees Fahrenheit room [ROOM NUMBER] (private bathroom) 126 degrees Fahrenheit room [ROOM NUMBER] (shared bathroom with room [ROOM NUMBER]) 126 degrees Fahrenheit On 5/6/25 between 2:02 P.M. and 2:06 P.M., the following water temperatures were obtained by the Maintenance Supervisor: room [ROOM NUMBER]-- 123 degrees Fahrenheit room [ROOM NUMBER]-- 127.6 degrees Fahrenheit room [ROOM NUMBER]-- 127.6 degrees Fahrenheit During an interview at that time, the Maintenance Supervisor indicated water temperatures are checked every morning and should be between 100 and 120 degrees Fahrenheit. During an interview on 5/6/25 at 2:19 P.M., the Maintenance Supervisor indicated he went to check the boiler room and had accidentally turned the temperature up instead of down when he adjusted the temperatures that morning. On 5/12/25 at 11:17 A.M., the Director of Nursing provided an undated Test and Log the Hot Water Temperatures Form as their policy that indicated, .For burn prevention, federal guidelines advise that you keep domestic water temperatures below 120 degrees Fahrenheit . 3.1-19(e)

Based on observation, interview, and record review, the facility failed to ensure resident centered care and services were provided to meet resident needs for 1 of 1 resident reviewed for elopement. Wandering and exit seeking behaviors were not monitored, elopement risk assessments were inaccurately completed, leading to a lack of an elopement risk care plan with interventions to prevent elopement. (Resident 40) Finding includes: On 5/7/25 at 10:22 A.M., Resident 40's clinical record was reviewed. Diagnoses included, but were not limited to, dementia, anxiety, and depression. The most recent Annual Minimum Data Set (MDS) assessment, dated 3/5/25, indicated a moderate cognitive impairment and no behaviors including wandering. Resident 40 required supervision or touching assistance with wheelchair mobility. Current physician orders included, but were not limited to: Activity Level: Up ad lib (allowed to move around freely by oneself) with walker/wheelchair, dated 4/6/24. A current Behavior Care Plan, dated 1/30/23 and last revised 3/26/25, indicated Resident 40 had episodes of delusions/hallucinations, hears and sees things that were not there, and utilized antipsychotic medication. Resident 40's clinical record lacked a current care plan related to wandering or exit seeking. A Certified Nurse Aide (CNA) form, dated 5/5/25, indicated Resident 40 was up ad lib with walker/wheelchair. The form lacked behaviors or interventions related to wandering. A psychiatric exam note, dated 5/15/24, indicated since the last visit, Resident 40 continued to have increased delusions. Resident 40 was observed coming out of her room demanding to leave, and appeared very confused and upset. At the time of the exam, the resident indicated, I've got to get to work. You can't keep me locked up here forever. The note indicated short term and long term memory impairment. A Quarterly MDS assessment, dated 6/20/24, indicated Resident 40 required supervision or touching assistance with wheelchair mobility. An elopement risk assessment, dated 6/21/24, indicated, but was not limited to, the following questions: #1 Resident has the ability to move about freely and easily which would allow the resident the capability of leaving the facility unassisted. #4 Resident is often seen wandering aimlessly/without purpose. #7 Resident exhibits significant cognitive impairment that impacts elopement risk (ie consider and assess disorientation to surroundings, poor decision making abilities, etc). If question #1 and any of questions #2-7 are answered yes, the resident is at risk for elopement. If question #1 is yes and all of questions #2-7 are no, the resident is not at risk to elope. If question #1 is no, the resident is not at risk to elope. The form was marked no for question #1, and yes for question #7. A Social Services note, dated 6/25/24, indicated Resident 40 had been looking for her dog, that someone had taken it form her room and she could not find it. The dog in question had not been in the facility since March of 2023 and was removed due to the resident's declining condition. A psychiatric exam note, dated 6/25/24, indicated facility staff reported continued increased anxiety and paranoia. Resident thought someone had stolen her dog, and believed at times, her daughter was in danger and had been kidnapped. A Nurse Practitioner (NP) exam note, dated 7/1/24, indicated Resident 40 was alert and oriented with intermittent confusion and forgetfulness. A monthly behavior review, completed by the Social Services Director (SSD) and dated 7/13/24, indicated resident had delusions and hallucinations, but lacked behaviors of wandering or exit seeking. A monthly behavior review, completed by the SSD and dated 8/2/24, indicated resident had delusions and hallucinations, but lacked behaviors of wandering or exit seeking. A psychiatric exam note, dated 8/6/24, indicated resident continued to have increased delusions. Staff reported that resident was often wandering up and down the halls looking for her dog, refusing care, and became agitated when redirected. An elopement risk assessment, dated 9/13/24, was marked no for all questions. A monthly behavior review, completed by the SSD and dated 10/15/24, indicated resident had delusions and hallucinations, but lacked behaviors of wandering or exit seeking. A monthly behavior review, completed by the SSD and dated 11/13/24, indicated resident had delusions and hallucinations, but lacked behaviors of wandering or exit seeking. A monthly behavior review, completed by the SSD and dated 12/5/24, did not list any behaviors. A Quarterly MDS assessment, dated 12/9/24, indicated Resident 40 required supervision or touching assistance with wheelchair mobility. An elopement risk assessment, dated 1/15/25, was marked yes for question #1, and no to all others. A monthly behavior review, completed by the SSD and dated 1/29/25, indicated no behaviors were noted at that time. An elopement risk assessment, dated 2/17/25, was marked yes for question #1, and no to all others. Resident 40's clinical record lacked another elopement risk assessment after 2/17/25. A monthly behavior review, completed by the SSD and dated 3/4/25, did not list any behaviors. Resident 40's clinical record lacked another monthly behavior review after 3/4/25. A psychiatric exam note, dated 3/25/25, indicated the facility staff had informed them that Resident 40 had been exit seeking and argumentative with increased behaviors. A nursing note, dated 5/4/25, indicated Resident 40 was very confused with exit seeking behavior. Resident 40 took belongings from her room, was asking how to get outside and how to get out the door, and rolled to the door trying to push on it indicating I'm just gonna go out that door. A nursing note, dated 5/6/25, indicated Resident 40 was observed wandering up and down the 200 Hall the previous night. A nursing note, dated 5/7/25, indicated Resident was observed wandering around the building and nurses station the previous night. On 5/7/25 at 11:32 A.M., Resident 40 was observed wheeling down the hall in a wheelchair, propelling herself with her feet. The resident turned the corner by the nurses station, and wheeled into the dining room. Resident 40 wandered around the dining room and back into the hall before turning around and going back into the dining room. On 5/9/25 at 1:46 P.M., Registered Nurse (RN) 3 indicated Resident 40 had always wandered, and that was a normal behavior for her. She indicated the resident used to wander with purpose, knowing where she was going, but had slowly increased in confusion, and now wandered aimlessly. She indicated the wandering was not documented, and that staff just knew that was what she did. She indicated Resident 40 had poor decision making abilities for the last few years. She indicated sometime around November of 2024, Resident 40 indicated she was going to the bar, and since then had went back and forth saying things like she was leaving and going somewhere, but had not attempted to exit until recently. On 5/9/25 at 1:55 P.M., CNA 5 indicated Resident 40 had always wheeled herself in the wheelchair, and her mobility had not changed in the last year. She indicated the resident had always wandered, and every now and then talked about leaving. On 5/9/25 at 2:01 P.M., the Director of Nursing (DON) indicated when a resident had exit seeking behavior, he was notified via text or phone call, and the staff would start a new or worsening behavior event in the clinical record. He indicated any wandering or exit seeking behavior would be discussed at the following morning meeting, and a care plan implemented immediately by the Interdisciplinary Team (IDT). On 5/12/25 at 11:17 A.M., the DON provided a current Resident Change of Condition policy, last revised 11/2018, that indicated It is the policy of this facility that all changes in resident condition will be communicated to the physician and family/responsible party, and that appropriate, timely, and effective intervention takes place On 5/12/25 at 11:17 A.M., the DON provided a current Behavior Management policy, last revised 8/2022, that indicated It is the policy of [company name] to provide behavior interventions for residents with problematic or distressing behaviors. Interventions provided are both individualized and non pharmacological and part of a supportive physical and psychosocial environment that is directed toward preventing, relieving and/or accommodating a resident's behavioral expressions . Care plans should be initiated . Residents with documented behaviors will have a Behavioral Health Monthly Review. This review includes evaluation of behaviors which have occurred that month and that interventions for behavioral expressions are current and effective . Direct care staff will be educated as to the interventions for residents reviewed by the IDT On 5/12/25 at 11:17 A.M., the DON provided a current Elopement Prevention and Response Program policy, last revised 10/2020, that indicated The facility will utilize an ELOPEMENT RISK ASSESSMENT to identify residents at risk for elopement . Care plans will be developed and individualized for residents who are at risk for elopement 3.1-37(a)

Based on observation, interview, and record review, the facility failed to ensure residents that were self administering medications were assessed for capability to self administer medications for 1 of 1 random observation. (Resident 24) Finding includes: During the Resident Council meeting on 5/8/25 at 2:26 P.M., Resident 24 administered 2 puffs of an albuterol inhaler (respiratory medication) to herself. She asked another resident how many doses were left in the inhaler and proceeded to administer another puff (total of three puffs) to herself. Resident 24 did not rinse her mouth after use. There was no staff present during this time. On 5/9/25 at 9:53 A.M., Resident 24's clinical record was reviewed. Diagnoses included, but were not limited to, chronic obstructive pulmonary disease (COPD), hypertension, and diabetes mellitus. The most recent Quarterly Minimum Data Set (MDS) assessment, dated 2/25/25, indicated Resident 24 had moderate cognitive impairment. Physician's Orders included, but were not limited to, Ventolin (albuterol sulfate) inhaler, 90 micrograms (mcg), administer two puffs as needed every six hours. Rinse mouth after use, rinse and spit, do not swallow, start date 12/12/24. Resident 24's clinical record lacked a self administration of medication care plan and a physician order to self administer medications. Resident 24's clinical record lacked a self administration of medication assessment related to inhalers. During an interview on 5/9/25 at 10:59 A.M., Registered Nurse (RN) 3 indicated Resident 24 does not self administer any medications. During an interview on 5/9/25 at 1:37 P.M., RN 3 indicated Resident 24 had two inhalers in the medication cart, but she should not have any in her possession. On 5/12/25 at 11:17 A.M., the Director of Nursing (DON) provided a current Self Administration of Medications Policy, revised 1/2015, indicated, .A physician order will be obtained specifying the resident's ability to self-administer medications . During an interview on 5/12/25 at 11:55 A.M., the DON indicated it was their policy to store the inhalers in the medication cart if the resident did not have an order to self administer the inhaler. 3.1-11(a)

Based on observation, interview, and record review, the facility failed to ensure infection control practices were followed for 1 of 3 residents during an observation of perineal care. Staff put hand sanitizer on soiled gloves, gloves were not changed between dirty and clean tasks during perineal care, and staff failed to sanitize hands between dirty and clean tasks. (Resident 2) Finding includes: On 5/8/25 at 10:11 A.M., Certified Nurse Aide (CNA) 7 and CNA 9 performed perineal care on Resident 2. CNA 7 used her gloved hand to wipe resident 2's perineal area with a wet wash cloth, placed that washcloth in a bag, grabbed another wash cloth, and wiped Resident 2's scrotum. At that time, she walked over to the hand sanitizer machine on the wall and dispensed hand sanitizer onto her soiled gloves, then she grabbed a dry towel from a bag and patted Resident 2 dry. Resident 2 was turned on his right side and CNA 7 wiped his buttocks with the same gloves and dried with a towel. CNA 7 failed to change gloves and perform hand hygiene before she placed the clean incontinence pad under Resident 2. Resident 2 rolled back on his back and CNA 7 fastened the incontinence pad with her soiled gloves. During an interview on 5/12/25 at 10:49 A.M., the Director of Nursing (DON) indicated staff should not put hand sanitizer on soiled gloves, and gloves should be changed from dirty to clean tasks. At that time, the Infection Preventionist (IP) indicated staff should also sanitize and change gloves when going from the residents front side to back side during perineal care. On 5/12/25 at 11:17 A.M., the DON provided a current Perineal Care skills competency as their policy, reviewed 3/2023 that indicated, .28. Doff gloves. 29. Perform hand hygiene . 3.1-18(b) 3.1-18(l)

Based on interview and record review, the facility failed to ensure each resident was free from unnecessary medications for 1 of 5 residents reviewed for unnecessary medications. A Gradual Dose Reduction (GDR) was not attempted as required for a hypnotic medication. (Resident 24) Finding includes: On 5/7/25 at 1:34 P.M., Resident 24's clinical record was reviewed. Diagnoses included, but were not limited to, anxiety, depression, insomnia, and Bipolar disorder. The most recent Quarterly Minimum Data Set (MDS) assessment, dated 2/25/25, indicated a moderate cognitive impairment. Resident 24 had received a hypnotic medication. Current physician orders included, but were not limited to: Ambien (zolpidem) (a hypnotic) 5 mg (milligrams) at bedtime, dated 12/12/24. The order had originally been dated 10/13/23 - 12/12/24. A current risk for adverse side effects related to use of psychotropic medication care plan, dated 2/20/19 and last revised 5/6/25, indicated use of a hypnotic for a diagnosis of insomnia. Interventions included, but were not limited to, Interdisciplinary Team (IDT) to review routinely to attempt gradual dose reductions, unless contraindicated, dated 12/12/24. A pharmacy consultation report, dated 6/4/24, indicated Resident 24 had received Ambien for insomnia since 11/11/22 and was reduced at that time. The recommendation at that time was for a GDR of a different medication and to Continue with other medications as currently ordered as it is not recommended to attempt reduction on more than one psychotropic at a time. The Nurse Practitioner (NP) indicated a clinical contraindication to the GDR attempt (for the other medication recommended), dated 6/11/24. A pharmacy consultation report, dated 10/1/24, indicated Resident 24 was taking Ambien for insomnia and the recommendation at that time was for a GDR of a different medication. A pharmacy consultation report, dated 2/4/25, indicated Resident 24 was taking Ambien and the recommendation at that time was for a GDR of a different medication. On 5/9/25 at 2:46 P.M., the Regional Consultant provided a current Gradual Dose Reduction Tracking Report that indicated the following for Resident 24's Ambien: Therapy start: 7/2/20 Last GDR attempt: 11/11/22 Next GDR evaluation: 6/4/25 Date clinical contraindication documented: 6/11/24 Resident 24's clinical record lacked a clinical contraindication for a GDR of Ambien in the last 12 months. On 5/9/25 at 2:46 P.M., the Regional Consultant indicated the only information related to a GDR of Ambien had already been provided, and was unable to provide a contraindication to a GDR at that time. She indicated a GDR may not have been completed for the Ambien due to the resident being on so many different psychotropic medications. On 5/12/25 at 11:17 A.M., a current Pyschotropic Management Policy, last revised September 2024, was provided by the Director of Nursing (DON) and indicated, . Periodic re-evaluation of the medication regimen is necessary to determine whether continued use of a medication is indicated. Prescribers will evaluate the efficacy and risks for psychotropic medications and document their assessment in the medical record The pharmacist will evaluate psychotropic medication as part of the monthly medication regimen review. Psychotropic medications may be considered regularly for potential GDR including during monthly pharmacy reviews, during behavioral health services visits, and when the IDT is evaluating behavioral expressions. The frequency and schedule of GDRs will meet current standards of practice and be based on person centered risk factors and underlying conditions . all rationale must be documented in the medical record . 3.1-48(b)(2)

Based on observation, interview, and record review, the facility failed to ensure residents received necessary respiratory care and services in accordance with professional standards of practice for 1 of 1 residents reviewed for respiratory care. A resident's oxygen concentration indicator was on the wrong setting. (Resident 19) Finding includes: During an observation on 5/5/25 at 10:58 A.M., Resident 19 was observed in her wheelchair with oxygen on via nasal cannula at 1.5 Liters Per Minute (LPM), and the back of the machine had dust particles on it. At that time, Resident 19 indicated she should be on 2.5 Liters (L) of oxygen. On 5/8/25 at 10:10 A.M., Resident 19's clinical record was reviewed. Diagnoses included, but were not limited to, acute respiratory failure, hypertension, and diabetes mellitus. The most recent Quarterly Minimum Data Set (MDS) assessment, dated 4/23/25, indicated Resident 19 was cognitively intact and utilized oxygen. Physician's Orders included, but were not limited to, oxygen at 2 L via nasal cannula, dated 1/21/25. A current care plan for impaired gas exchange related to acute respiratory failure included an intervention to administer oxygen as ordered, dated 1/21/25. During an observation on 5/9/25 at 11:03 A.M., Resident 19 was observed in her wheelchair with oxygen on via nasal cannula at 1.5 Liters Per Minute (LPM), and the back of the machine had dust particles on it. During an interview on 5/9/25 at 11:05 A.M., Registered Nurse (RN) 3 indicated Resident 19 did not change her oxygen concentrator settings and her current order was for 2 LPM. At that time, RN 3 observed the oxygen concentrator machine indicator and indicated if you looked at the oxygen concentration machine indicator standing up, it was set at 2 LPM but if you bent down to see the indicator on the oxygen concentration machine, it was set at 1.5 LPM. She observed the back of the machine had dust on it. RN 3 indicated the machines were cleaned on Wednesdays by night shift staff (two days ago). On 5/12/25 at 11:17 A.M., the Director of Nursing (DON) provided a current, undated Oxygen Concentrator policy that indicated, .1) Verify and understand the physician's order . 3.1-47(a)(6)

Based on interview and record review, the facility failed to ensure services of an RN (Registered Nurse) were available at least 8 consecutive hours a day, seven days a week for one of seven days reviewed. (Facility) Findings include: On 5/1/24 at 3:30 P.M., the review of nurse staffing from 4/20/24 through 4/26/24 indicated there was no RN coverage for 8 consecutive hours on 4/21/24. During an interview on 5/2/24 at 9:03 A.M., the DON (Director of Nursing) indicated he had an RN scheduled for 4/21/24 but she called in sick and was replaced with an LPN (Licensed Practical Nurse). He indicated there should be an RN in the building at least 8 hours a day, seven days a week. During an interview on 5/2/24 at 12:41 P.M., the DON indicated they did not have a policy for RN coverage but it was their policy to follow the state regulations. 3.1-17(b)(3)

Based on observation, interview, and record review the facility failed to ensure proper storage of medications in 1 of 2 medication carts and 1 of 1 medication storage rooms. The narcotic box was not locked in a medication cart, unlabeled and expired medications where in the treatment cart. (100/400 Hall medication cart, treatment cart in E wing medication storage room) Finding includes: On 5/1/24 at 2:27 P.M., the narcotic box of the 100/400 Hall medication cart was observed unlocked. On 5/1/24 at 2:38 P.M., the following was found in the treatment cart in the medication storage room on the E Hall: -two unlabeled 15 gram (g) bottles of nystatin topical powder (anti-fungal) with expiration dates of 11/30/23 -two bottles of ammonium lactate lotion (lotion for dry skin) 12%, opened but not dated when opened -three 45 g tubes of clotrim betameth cream (anti-fungal) 1-0.5% with expiration dates of 5/30/23, 11/30/23, and 12/30/23 -one 1.5 fluid ounce (fl oz) tube of medihoney (medicated honey for wound care) gel from a resident that passed away 3/24/24 -one 1.5 fl oz tube of medihoney gel from a resident that passed away 4/10/24 During an interview on 5/1/24 at 2:30 P.M., Registered Nurse (RN) 26 observed the narcotic cart unlocked and indicated it should be locked when nurse wasn't using it. On 5/1/24 at 2:43 P.M., Licensed Practical Nurse (LPN) 5 indicated when residents pass away or medications expire, the nurses take the medications out of the carts and the Director of Nursing (DON) would contact the pharmacy to take the medications back or dispose of them. The carts should be checked by the night shift nurses periodically for expired medications or medications of residents that have passed away. The medications should be labeled properly and dated when opened. On 5/1/24 at 6:00 A.M., a current Medication Storage Policy, revised 8/7/23, was provided by the DON and indicated . Facility should store Schedule II-V Controlled Substances in a separate compartment within the locked medication carts . Facility should ensure that medications and biologicals that 1) have an expired date on the label; 2) have been retained longer than recommended by manufacturer or supplier guidelines; or 3) have been contaminated or deteriorated, are stored separate from other medications until destroyed or returned to the pharmacy or supplier . Facility staff should record the date opened on the primary medication container . 3.1-25(m) 3.1-25(r)

Based on interview and record review, the facility failed to ensure quarterly care plan conferences were completed for 3 of 5 residents reviewed for unnecessary medications and 1 of 3 residents reviewed for falls. (Resident 22, Resident 2, Resident 13, Resident 1) Findings include: 1. On 5/2/24 at 6:22 A.M., Resident 22's clinical record was reviewed. Diagnosis included, but was not limited to, epilepsy. The most recent Quarterly MDS (Minimum Data Set) Assessment, dated 2/28/24, indicated Resident 22 was cognitively intact. The most recent care plan conference was completed 9/6/23. 2. On 5/1/24 at 9:06 A.M., Resident 2's clinical record was reviewed. Diagnosis included, but was not limited to, blindness. The most recent Annual MDS Assessment, dated 2/21/24, indicated Resident 2's cognition status could not be assessed. The most recent care plan conference was completed 9/20/23. 3. On 4/30/24 at 12:05 P.M., Resident 13's clinical record was reviewed. Diagnosis included, but was not limited to, schizophrenia. The most recent Annual MDS Assessment, dated 4/24/24, indicated Resident 13 was cognitively intact. The most recent care plan conference was completed 8/28/23. During an interview on 4/29/24 at 10:50 A.M., Resident 13 indicated he was unsure if he was having care plan confrences. On 5/1/24 at 3:01 P.M., the SSD (Social Services Director) indicated she was responsible for completing care plan conferences, but had been out and unable to complete them. She indicated care plan conferences should be done at least quarterly. 45933 4. On 4/30/24 at 11:09 A.M., Resident 1's clinical record was reviewed. Diagnoses included, but were not limited to, anemia, thyroid disorder, and schizophrenia. The most recent Significant Change MDS, dated [DATE], indicated a moderate cognitive impairment. The clinical record lacked any care plans before or after 9/20/23. During an interview on 5/1/24 at 1:54 P.M., the Social Services Director (SSD) indicated care plan conferences should be completed quarterly. On 5/3/24 at 8:58 A.M., the Director of Nursing (DON) provided a IDT (Inter Disciplinary Team) Comprehensive Care Plan Policy, revised 8/2023, that indicated, It is the policy of this facility that each resident will have an interdisciplinary comprehensive person-center care plan developed and implemented based on Resident Assessment Instrument (RAI) process . 3.1-35(c)(2)(C)

Based on observation, interview, and record review, the facility failed to ensure a safe and sanitary environment to help prevent the development and transmission of diseases and infections for 3 random observations and 1 of 2 residents reviewed for pressure ulcers. Staff did not don personal protective equipment (PPE) before care was performed. Wash basins, urinals, and a plunger were uncovered. A urinal hung on a used trashcan. Linens were uncovered in a bathroom. (Resident 1, Resident 34, Resident 41, Resident 45, room [ROOM NUMBER]) Findings include: 1. During an observation on 4/29/24 at 11:40 A.M., an uncovered easy shampoo wash basin with an uncovered urinal was placed on the floor in Resident 34's bathroom. During an observation on 5/2/24 at 11:22 A.M., an uncovered eash shampoo wash basin continued to be on the floor in the bathroom. 2. During an observation on 4/29/24 at 11:43 A.M., an uncovered gray wash basin was on the floor in Resident 41's bathroom and a urinal was hung on the side of the trashcan. During an observation on 5/2/24 at 1:27 P.M., an uncovered gray wash basin with an uncovered urinal was on the floor in the bathroom. 3. During a random observation on 5/03/24 9:21 A.M., Certified Nurse Aide (CNA) 3 placed a urinal on Resident 1's trashcan by his bed that had used gloves and used white tissues in it. At that time, she indicated that his urinal should always be placed on his trashcan. During an interview on 5/2/24 at 1:55 P.M., the Housekeeping Supervisor indicated she was unsure how the easy shampoo wash basins should be stored, but the gray wash basins and urinals should both be covered with a bag and not placed directly on the ground. 46416 4. On 5/1/24 at 10:16 A.M. Resident 45's clinical record was reviewed. Diagnoses included, but were not limited to, congestive heart failure, diabetes mellitus type II with bilateral foot ulcers, and pressure ulcers on left foot. The most recent Quarterly MDS (Minimum Data Set) Assessment, dated 4/9/24, indicated Resident 45's cognition was severely impaired, an extensive assist of 2 staff for bed mobility, totally dependent on 2 staff for transfers and toileting, had diabetic foot ulcer, and did not have pressure ulcers at that time. Current Physician's Orders included, but were not limited to, the following: Cleanse right and left foot wounds with normal saline, pat dry, apply/paint with Betadine, cover with 2 Abdominal Gauze (ABD) pads, wrap with Kerlix gauze and secure with tape. Change daily, ordered 5/1/24 A current EBP Care Plan, dated 4/6/24, included the following interventions: Identify resident as needing EBP through signage and medical record, initiated 4/6/24 Use standard precautions including hand hygiene in addition to EBP, initiated 4/6/24 Enhanced Barrier Precautions, initiated 4/6/24 On 4/29/24 at 9:55 A.M., a current, daily Certified Nurse Aide (CNA) Assignment Sheet was provided by LPN 34 and indicated Wear gown and gloves prior to high contact resident care activities and Enhanced Barrier Precautions as interventions for Resident 45. On 5/2/24 from 8:56 A.M. to 9:30 A.M., Licensed Practical Nurse (LPN) 9 was observed changing Resident 45's wound dressings with Certified Nurse Aide (CNA) 7 assisting. Neither staff wore gowns as the wound dressings were changed. An Enhanced Barrier Precautions (EBP) sign was hanging above his bed indicating a gown and gloves should be worn for high contact resident care which included wound care. During an interview on 5/2/24 at 9:25 A.M., LPN 9 indicated she was not sure if EBP should be used when doing wound care on Resident 45. On 5/3/24 at 8:58 A.M., a current Standard and Transmission-Based Precautions (Isolation) Policy was provided by the Director of Nursing (DON) and indicated . An intervention designed to reduce the transmission of resistant organisms that employs targeted use of gown and glove use during high contact resident care activities . it refers to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of Multidrug-Resistant Organisms (MDROs) to staff hands and clothing . used for residents with chronic wounds . examples of chronic wounds include, but are not limited to, pressure ulcers, diabetic foot ulcers . 5. During an observation on 4/29/24 at 11:12 A.M. of room [ROOM NUMBER], the following was observed: A female urinal uncovered, with brown stains on the inside and a strong urine odor was hanging from the bedside cabinet and in the bathroom, the call light cord was stained brown, an uncovered plunger was on the right side of the toilet, the was a hole on the inside of the bathroom door, and a wheelchair cushion on the shower floor with 3 uncovered bunches of bed linens on it. During an observation on 5/1/24 at 10:19 A.M., the same uncovered, brown stained female urinal with a strong urine odor was hanging on the trash can and in the bathroom, two uncovered bunches of bed linens were stuck between the wall and the hand rail in the shower, and the hole on the inside of the bathroom door and call light cord were the same. During an interview on 5/2/24 at 10:12 A.M., CNA 7 indicated urinals were replaced for residents. she was not sure how often but it should be changed out if soiled, stained, or it had an odor. At that time, CNA 7 replaced the urinal with a new one. During an interview on 5/2/24 at 11:02 A.M., the Infection Preventionist (IP) indicated linens were supposed to be covered if they were kept in resident rooms in the top of the closet and should be placed straight on the bed. Usually clean linens were stored in a covered cart. At that time, she indicated Resident 45 was on EBP and staff should follow it for any prolonged resident contact as the signage indicated. On 5/3/24 at 8:58 A.M., a current Laundry/Linen Policy, revised 12/2021, was provided by the DON and indicated . to ensure the proper care and handling of linen and laundry to prevent the spread of infection . clean linen should not be stored in resident rooms, drawers, or shower rooms . During an interview on 5/3/24 9:33 A.M., the Infection Preventionist (IP) indicated urinals should never be stored on a trashcan and the facility's policy is to store urinals on the bed rail or uncovered in the bathroom. 3.1-18(b)(1)

Based on observation, interview, and record review, the facility failed to ensure residents that were self administering medications were assessed for capability to self administer medications for 1 of 1 residents observed with medications in their room. (Resident 13) Finding includes: On 4/29/24 at 10:50 A.M., Resident 13 was observed sitting on his bed and indicated he had a Ventolin inhaler on the nightstand that he kept with him at all times. A Ventolin inhaler was observed on the nightstand, not dated. An albuterol inhaler was also observed sitting on the nightstand that was empty. At that time, Resident 13 indicated staff had given him the blue one (Ventolin) when the other ran out. On 4/30/24 at 12:05 P.M., Resident 13's clinical record was reviewed. Diagnosis included, but were not limited to, chronic obstructive pulmonary disease. The most recent Annual MDS (Minimum Data Set) Assessment, dated 4/24/24, indicated Resident 13 was cognitively intact, a limited assistance of 1 staff for bed mobility and transfers, and extensive assistance of 1 staff for toileting. Current Physician's Orders included, but were not limited to: Ventolin (respiratory inhaler) 90 mcg/actuation HFA (hydrofluoroalkane) aerosol inhaler, 2 puffs every 4 hours as needed, dated 4/19/24. Resident 13 lacked a current order to self administer medications. Resident 13 lacked a care plan related to self administration of medications. Resident 13 lacked a self administration of medications assessment. On 5/2/24 at 7:37 A.M., Resident 13 was observed lying in bed asleep. The two inhalers were observed on the nightstand. On 5/2/24 at 10:00 A.M., Licensed Practical Nurse (LPN) 5 indicated Resident 13 had a current order for as needed Ventolin, but the order did not say it could be kept at the bedside. She also indicated Resident 13 did not have a self administration assessment for that medication and should not have it at the bedside. At that time, LPN 5 observed 2 inhalers on the resident's nightstand and Resident 13 indicated he used the inhaler twice a day around the same time each day. On 5/3/24 at 8:58 A.M., a current Self Administration of Medications policy, dated 1/2015, was provided by the Director of Nursing and indicated If a resident desires to participate in self-administration, the Interdisciplinary Team will assess the competence of the resident to participate by completing the Self-Administration of Medication Assessment observation . A physician order will be obtained specifying the resident's ability to self-administer medications and, if necessary, listing which medications will be included in the self-administration plan . Storage of self-administered medications will comply with state and federal regulations. All bedside medications will be maintained in a secured location in the resident's room 3.1-11(a)

Based on observation, interview, and record review, the facility failed to develop and implement comprehensive person-centered care plans for 2 of 5 residents reviewed for unnecessary medications and 1 of 3 residents reviewed for falls. Antiplatelet care plans were not developed for 2 residents on antiplatelet medications. An oxygen concentrator filter was not cleaned and oxygen tubing was not changed as ordered. A resident was not wearing non skid socks. (Resident 13, Resident 2, Resident 16) Findings include: 1. On 4/29/24 at 11:00 A.M., Resident 13 was observed sitting bedside in his room wearing oxygen per nasal cannula at 4 LPM (liters per minute). The oxygen tubing and empty humidifier bottle were dated 3/21 and the concentrator filter was gray instead of black from the accumulated dust. On 4/30/24 at 11:18 A.M., Resident 13 indicated staff changed his humidifier bottle yesterday but it was observed with a date of 4/24/24 but the oxygen tubing was observed dated 3/21 and the filter was observed gray instead of black from the accumulated dust. On 4/30/24 at 12:05 P.M., Resident 13's clinical record was reviewed. Diagnoses included, but were not limited to, chronic obstructive pulmonary disease and atherosclerotic heart disease The most recent Annual MDS (Minimum Data Set) Assessment, dated 4/24/24, indicated Resident 13 was cognitively intact, a limited assist of 1 staff for bed mobility and transfers, and an extensive assist of 1 staff for toileting. Resident 13 was on oxygen and administered an AP, AA, and antiplatelet during the 7 day look back period. Current Physician's Orders included, but were not limited to, the following: aspirin (antiplatelet) 81 milligram (mg) tablet,delayed release, give 1 by mouth daily, ordered 4/19/24 Change oxygen tubing, humidifier bottle,clean concentrator, and filter once a day on Wednesdays, ordered 04/19/2024 A current Respiratory Care Plan, dated 9/19/18 included, but was not limited to, the following interventions: resident uses oxygen, 9/19/18 The clinical record lacked a care plan for an antiplatelet medication. The Medication Administration Record (MAR) for April 20-30, 2024 was reviewed and indicated Resident 13 was administered the antiplatelet aspirin. The Treatment Administration Record (TAR) for April 2024 was reviewed and indicated the tubing and humidifier bottle was changed and the concentrator filter was cleaned on 4/24/24 and 4/30/24. During an interview on 5/1/24 at 3:10 P.M., Licensed Practical Nurse (LPN) 29 indicated she was responsible for developing nursing care plans. At that time, she indicated there was not an antiplatelet care plan in Resident 13's clinical record but there should have been. During an interview on 5/2/24 at 9:58 A.M., LPN 5 indicated night shift was responsible for changing the oxygen tubing and humidifier bottle and cleaning the oxygen concentrator filter every Wednesday night and otherwise it was changed as needed by whoever would observe it being dirty or empty. At that time, she indicated it was recorded in the TAR when it was completed and the date on the humidifier bottle and tubing was the date it was changed. She indicated the filter would not have been that dirty if it was changed 1 week or 1 day ago. 2. On 4/29/24 at 10:16 A.M., Resident 2 was observed sitting in his room in a recliner and was barefooted. On 4/30/24 at 11:16 A.M., Resident 2 was observed sitting in his room in a recliner, barefooted and asleep On 5/1/24 at 11:09 A.M., Resident 2 was sitting in his room. He was observed to stand up without the assistance of staff. On 5/1/24 at 9:06 A.M., Resident 2's clinical record was reviewed. Diagnoses included, but were not limited to, cerebral palsy, diabetes mellitus type II, and blindness. The most recent Annual MDS Assessment, dated 2/21/24, indicated Resident 2's cognition was unable to be assessed and he was an extensive assist of 2 staff for bed mobility, transfers, and toileting. A current Falls Care Plan, dated 3/18/85, included, but was not limited to, the following intervention: Non skid footwear, initiated 3/18/85 On 4/29/24 at 9:55 A.M., a current, daily Certified Nurse Aide (CNA) Assignment Sheet was provided by LPN 34 and indicated non skid footwear as an intervention for Resident 2. During an interview on 5/1/24 at 11:09 A.M., LPN 15 indicated that she was shocked the resident had non skid socks on but it was probably because state was in the building. At that time, she indicated Resident 2 was constantly standing up without staff's assistance and needed to wear them, but usually wouldn't let them on. 46882 3. On 4/30/24 at 2:34 P.M., Resident 16's clinical records were reviewed. Diagnosis included, but was not limited to chronic diastolic (congestive) heart failure, atrial fibrillation, atherosclerotic heart disease of native coronary artery without angina pectoris, dementia, anxiety disorder, and bipolar disorder. The most current Significant Change in Condition MDS (Minimum Data Set) Assessment, dated 3/11/24, indicated Resident 16 had severe cognitive impairment and needed extensive assistance of two for bed mobility, extensive assistance of one for eating, and total dependence of two for transfers and toilet use. Physician orders included, but were not limited to the following: aspirin 81 mg tablet,chewable Once a day Indication: Heart Health, Atherosclerotic heart disease of native coronary artery without angina pectoris, dated 3/5/2024 The clinical record lacked a care plan for anti-platelet use. On 5/2/24 at 10:13 A.M., the MAR (Medication Administration Record) was reviewed from 3/5/24 through 3/11/24. Resident 16 was in the hospital from 3/2/24 through 3/5/24. Aspirin 81 mg (milligram) one daily was given for heart health from 3/6/24 through 3/11/24. During an interview on 5/2/24 at 12:41 P.M., the DON (Director of Nursing) indicated they didn't have a policy for following the care plan interventions or provider orders, but it was their policy to follow the interventions and orders. On 5/2/24 at 12:41 P.M., a Comprehensive Care Plan Policy, revised 8/23, was provided by the DON which indicated, It is the policy of this facility that each resident will have an interdisciplinary comprehensive person-centered care plan developed and implemented based on Resident Assessment Instrument (RAI) process . 3.1-35(b)(1)

Based on observation, interview, and record review, the facility failed to ensure each resident was treated with respect and dignity and care was performed for each resident in a manner that protected and promoted the rights of the resident for 2 of 2 residents reviewed for dignity. Two female residents could not get their legs shaved on their shower day. (Resident 14, Resident 31) Findings include: 1. On 4/29/24 at 2:03 P.M., during the Resident Council Meeting, Resident 14 indicated staff won't shave her legs in the shower. She indicated she had asked several times, and she can't wear shorts because they won't shave her legs. During an interview on 4/30/24 at 10:01 A.M., Resident 14 indicated she had asked CNAs (Certified Nursing Assistant) to shave her legs when she got a shower and they told her they would be back but never show up. On 5/1/24 at 11:12 A.M., Resident 14's clinical record was reviewed. Diagnosis included but was not limited to chronic obstructive pulmonary disease, hemiplegia, unspecified affecting left nondominant side, and major depressive disorder. The most recent Admission MDS (Minimum Data Set) Assessment, dated 2/5/24, indicated Resident 14 was cognitively intact and required extensive assistance of two for bed mobility, transfers, and toilet use. Care Plan: Resident requires assistance with ADLs (activities of daily living) including bed mobility, transfers, eating and toileting related to: COPD (chronic obstructive pulmonary disease), DM 2 (diabetes mellitus Type II), hemiplegia on left nondominant side, dysphagia following cerebral infarct, vascular dementia, paranoid schizophrenia, major depressive disorder, hypertension, anemia, hypothyroidism, hyperlipidemia, convulsions, GERD (gastroesophageal reflux disease), rheumatoid arthritis, muscle weakness, pain in right shoulder, constipation. Start Date 1/29/2024 Interventions included, but were not limited to the following: Assist with bathing as needed per resident preference. Offer showers two times per week, partial bath in between. Start Date 1/29/2024 Assist with dressing/grooming/hygiene as needed. Encourage resident to do as much for self as possible. Start Date 1/29/2024 2. On 4/29/24 at 2:03 P.M., during the Resident Council Meeting, Resident 31 indicated staff didn't have time to shave her legs while they were standing at the desk talking. During an interview on 4/30/24 at 9:49 A.M., Resident 31 indicated she wanted her legs shaved, but staff told her they didn't have time on shower days. She indicated it didn't have to be done every time. On 4/30/24 at 11:09 A.M., Resident 31 clinical record's were reviewed. Diagnosis included, but were not limited to chronic obstructive pulmonary disease, asthma, diabetes mellitus with diabetic neuropathy, epilepsy, major depressive disorder, and generalized anxiety disorder. The most current Quarterly MDS (Minimum Data Set) Assessment, dated 4/8/24, indicated Resident 31 was cognitively intact and required supervision of one for bed mobility, and transfers and extensive assistance of two for toilet use. Care Plan: Resident requires assistance with ADLs including bed mobility, transfers, eating and toileting related to: COPD (chronic obstructive pulmonary disease), asthma, DM 2, epilepsy, atherosclerotic heart disease, hypertension, GERD, anemia, hyperlipidemia, major depressive disorder, obesity, poly osteoarthritis, chronic kidney disease, constipation, chronic embolism and thrombosis, chronic pain, allergic rhinitis, arthropy, chronic ischemic heart disease, chronic pain, ESBL (extended-spectrum beta-lactamase). Start Date 2/01/2024 Interventions included, but were not limited to the following: Assist with bathing as needed per resident preference. Offer showers two times per week, partial bath in between. Start Date 2/01/2024 Assist with dressing/grooming/hygiene as needed. Encourage resident to do as much for self as possible. Start Date 2/01/2024 During an interview on 5/1/24 at 10:51 A.M., with QMA (Qualified Medication Aide) 31 and CNA (Certified Nursing Assistant) 23, both indicated they helped with showers and would shave residents if needed. They indicated they shave men and women who looked like they need shaved and would shave women's legs if they were asked. They indicated not all women wanted their legs shaved. On 5/3/24 at 8:58 A.M., a current Resident Rights Policy, revised on 1/06, provided by the DON (Director of Nursing), indicated .All Staff members recognize the rights of residents at all times and residents assure their responsibilities to enable personal dignity, well being, and proper delivery of care. 3.1-3(a)

Based on observation, interview, and record review the facility failed to ensure that a resident received an accurate and thorough testing of blood glucose. Glucometer controls were not ran on a new glucometer before use as specified in the manufacturer's package insert for 1 of 1 residents observed for glucometer testing. The facility lacked a policy related to glucometer controls. (Resident 25) Finding includes: On 10/17/22 at 12:00 P.M., RN (Registered Nurse) 15 was observed to open a box containing a new glucometer. RN 15 took the new glucometer, test strip, and a lancet into Resident 25's room and proceeded to wipe the resident's right middle finger with an alcohol pad. RN 15 obtained a blood sample which was placed on the test strip in the new glucometer. The blood sugar reading was 209. Documentation in the clinical record after reading was obtained read as 230. On 10/18/22 at 2:00 P.M., Resident 25's clinical record was reviewed. Resident 25's diagnosis included, but was not limited to, diabetes mellitus type II. The most recent admission MDS (Minimum Data Set) Assessment, dated 8/25/22, indicated the resident's cognition status was unable to be assessed. On 10/18/22 at 2:11 P.M., the manufacturer's package insert for the glucometer used was provided and indicated the purpose of the control solution testing was to validate that the glucometer was working properly with the test strips. It further indicated controls should have been performed when using the meter for the first time. During an interview on 10/18/22 at 2:00 P.M., the DON (Director of Nursing) indicated controls should be ran before a new glucometer was used to check the resident's blood sugar. During an interview on 10/19/22 at 2:44 P.M., the DON indicated there was not a policy for running controls on a new glucometer, but it was the facility policy to run them when opening a new glucometer. 3.1-25(e)(1)

Based on observation, interview, and record review, the facility failed to maintain privacy for 4 of 4 random observations. A resident was administered an insulin injection with the door open, and staff did not knock before entering rooms. (Resident 8, Resident 25, Resident 3) Findings include: 1. On 10/17/22 at 11:30 A.M., LPN (Licensed Practical Nurse) 3 was observed to enter Resident 8's room and administered an insulin injection in the resident's abdomen without closing the door or pulling a privacy curtain. 2. On 10/17/22 from 11:40 A.M. to 11:58 A.M., RN (Registered Nurse) 15 was observed walking into Resident 25's room [ROOM NUMBER] (four) times to perform a glucometer check without knocking before entering. Resident 25 was observed lying in bed. 3. On 10/17/22 at 12:07 P.M., RN 15 was observed to enter Resident 31's room to wash her hands without knocking on the door. Resident 31 was observed lying in bed. 4. On 10/19/22 at 10:49 A.M., LPN 3 was observed entering Resident 25's room without knocking and walked into the resident's bathroom. Resident 25 was observed lying in bed. During an interview on 10/20/22 at 2:15 P.M., CNA (Certified Nurse Aide) 7 indicated staff should knock on resident's doors before entering On 10/20/22 at 1:50 P.M., a current medication administration policy, revised 1/1/22, was provided and indicated Observe each resident's privacy and rights in accordance with Applicable Law (e.g., knocking before entering the room, pulling privacy curtains, informing resident what is to occur before administration) On 10/20/22 at 1:50 P.M., a current resident rights policy, revised 11/16 was provided and indicated You have a right to personal privacy . 3.1-3(p)(2) 3.1-3(p)(4)

Based on observation, interview, and record review, the facility failed to ensure ADL (activities of daily living) care was provided for dependent residents for 2 of 2 residents reviewed for ADLs. Residents were not provided grooming and personal care in a timely manner, and a resident was observed sitting in a soiled chair for 3 (three) of 4 (four) days during the survey. (Resident B, Resident C) Findings include: 1. During an observation on 10/17/22 at 10:39 A.M., Resident B had greasy and messy hair, long fingernails with debris caked under nails and the room had a urine odor. During an observation on 10/18/22 at 11:13 A.M., Resident B was being pushed down Hall 300 in a high back wheelchair by CNA (Certified Nurses Aide) 21. Resident B had a urine odor with visibly wet pants and food debris was observed on his shirt. Resident B had greasy and messy hair, long fingernails with debris caked under nails, and was not shaved. From 11:19 A.M. until 11:30 A.M. the following was observed: LPN (Licensed Practical Nurse) 24 stopped resident in the hall to administer medication, then LPN 28 pushed Resident B up the hall to get a haircut. After leaving the area, a yellow puddle was observed on the floor under his wheelchair. Neither LPN addressed the resident's wet clothes prior to taking to the barber. On 10/19/22 at 10:48 A.M., Resident B's clinical record was reviewed. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The most recent Quarterly MDS (Minimum Data Set) assessment, dated 7/21/22, indicated Resident B's cognitive status could not be assessed and required extensive assist of 2 (two) for bed mobility, transfers and toileting. Resident B also required total dependence of 2 for bathing. A current ADLs care plan, revised 8/8/22, indicated but was not limited to the following interventions: Assist with toileting/incontinence care as needed. During an interview on 10/20/22 at 12:45 P.M., CNA 7 indicated staff was supposed to check dependent residents for incontinence every 2 (two) to 3 (three) hours, and change them as needed after meals when resident's were assisted to bed. She further indicated if residents were visibly wet, they were supposed to be changed right away. CNA 7 then indicated the urine odor in Resident B's room was from the chair that he continuously sat in, as the urine seeped from his incontinence brief into the chair. 2. On 10/17/22 at 10:37 A.M., Resident C was heard yelling for help from the hall with the door closed. Upon entering Resident C's room, Resident C was observed sitting a wheelchair with food debris in between his legs, and on the left footrest of the wheelchair. No call light was observed to be in reach. At that time, Resident C indicated he didn't have a way to call the nurse and was having pain and needed someone. On 10/17/22 at 02:05 P.M., Resident C was observed sitting in a wheelchair in the middle of his room. Resident C's call light was observed behind the bed and out of reach of the resident. On 10/19/22 at 9:40 A.M. Resident C's clinical record was reviewed. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The most current Quarterly MDS assessment dated [DATE], indicated Resident C had a severe cognitive impairment and required extensive assistance of 2 (two) with bed mobility and total dependence of 2 (two) with transfers, toileting and bathing. Current physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A current risk for falls care plan, dated 6/14/21, indicated but was not limited to the following interventions: Keep call light within reach. During an interview on 10/20/22 at 2:27 P.M. the Administrator indicated there was not a written policy that call lights should be within reach of all residents, but it was the facility's policy that call lights should be within reach of all residents. On 10/20/22 at 1:50 P.M., a current bowel and bladder policy, revised 5/2019, was provided and indicated If a resident is totally incontinent and unable to be placed on a toilet or bedpan, resident should be checked and changed every two hours. A current ADL policy was requested and not provided. This Federal tag relates to Complaint IN 313. 3.1-38(a)(2)(C) 3.1-38(a)(3)(E)

Based on interviews and record reviews, the facility failed to properly prevent and/or contain COVID-19, failed to follow CDC/CMS guidelines by failing to ensure 100% of the 65 staff were vaccinated, ensuring the completion of 2 of 2 staff with medical exemptions and had 1 resident who was COVID-19 positive in the past 4 weeks. (Resident H, Staff 1, Staff 2) Findings include: 1. On 3/9/22 at 11:55 A.M., the Director of Nursing (DON) provided a spreadsheet of current employees. The spreadsheet indicated the following: 65 staff members. 3 were documented as partially vaccinated. 57 were completely vaccinated, and 5 had exemptions. Four (4) of those were medical exemptions (Staff 1, 2, 3, 4). 96.9% staff were vaccinated and had approved exemptions 2. The clinical record of Resident H was reviewed on 3/9/22 at 3:15 P.M. The resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Nurses notes indicated the resident had frequent behaviors of wandering and being resistive to care. A nurses note, dated 2/22/22 at 6:50 P.M., indicated, resident transferred to [hospital behavior unit] at this time via Ambulance Service. A hospital history and physical note, dated 2/22/22, indicated, The patient was seen and examined. The patient is medically doing well. He did fail behavioral health clearance, as he is positive for COVID. Patient will need to return to nursing home. The resident returned to the facility on [DATE] at 3:30 P.M. He was to be on transmission based precautions through 3/4/22. The resident was transferred to the hospital on 3/4/22, to be admitted to the behavior unit, due to continued behaviors. He was treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . 3. On 3/9/22 at 2:15 P.M., the Administrator provided the Medical Exemption form for Staff 1. The form indicated, My patient [Staff 1] may be exempt from receiving the COVID vaccine due to anxiety associated with getting it. The form did not specify which vaccine was contraindicated. The reason for the exemption did not follow CDC guidelines. 4. On 3/9/22 at 2:15 P.M., the Administrator provided the Medical Exemption form for Staff 2. The form indicated, [Staff 2] should not to [sic] receive COVID vaccine d/t [due to] auto-immune disorder. The form did not specify which vaccine was contraindicated. On 3/9/22 at 11:55 A.M., the DON provided the current facility policy, COVID-19 Employee Vaccination Requirement, dated 2/11/22. The policy included, All Current Employees, unless granted an exemption must, receive vaccines as per the below: 1st dose or the one dose vaccine by February 14, 2022 .Please note that employees who are unvaccinated and whom do not have an approved vaccination exemptions based on these deadlines will be removed from the schedule .Medical Exemptions: .medical exemption requests must include documentation from a licensed healthcare provider that confirms, in detail, the existence of a medical condition, disability or allergy that contradicts COVID-19 Vaccination. The CDC has recognized specific clinical contraindications .Healthcare provider documentation must specifically confirm a recognized clinical reason why the employee should not receive a COVID 19 Vaccination 3.1-18(b)

Based on observation, interview, and record review, the facility failed to assess, treat, develop and implement a plan of care for a resident with recurring [MEDICAL CONDITION] of his feet, resulting in more than 1 hospitalization for [MEDICAL CONDITION]; and failed to assess and document the appearance of the resident's toes and feet; for 1 of 4 residents reviewed for skin impairments (Resident K). Findings include: On 7/31/20 at 10:15 A.M., the Director of Nursing Services (DNS) indicated Resident K had been admitted with an area of impaired skin to the buttocks. The DNS did not indicate the resident had any altered skin on the feet and/or toes. The clinical record of Resident K was reviewed on 8/3/20 at 10:50 A.M. [DIAGNOSES REDACTED]. A quarterly Minimum Data Set (MDS) assessment, dated 3/12/20, indicated the resident had a slight memory problem, required supervision of set up help for personal hygiene, and physical help of set up help for bathing. The resident had no venous or arterial ulcers, and no foot problems. Nurses Notes included the following notations: 5/10/20 at 7:54 A.M.: Resident very lethargic, shaking uncontrollably, weak and just a general change in condition, MD aware and new order to send to (name of hospital) ER for eval and tx (evaluation and treatment) 5/10/20 at 3:07 P.M.: (Name of hospital) called and admitted res (resident) [MEDICAL CONDITIONS] (skin infection) A hospital discharge summary, dated 5/13/20, indicated, Discharge Diagnosis: [REDACTED].Hospital course: May 11: .The patient does also report have (sic) [MEDICAL CONDITION] to his toes .Bilateral extremities were discolored and suggestive of chronic venous stasis .[MEDICAL CONDITION] of the left foot .Patient was given [MEDICATION NAME] (an antibiotic) and [MEDICATION NAME] (an antibiotic) in the ER and I will continue [MEDICATION NAME] The resident returned to the facility on [DATE] at 3:45 P.M. An Admission Observation form, dated 5/13/20 at 3:52 P.M., indicated Resident K had a skin impairment on his coccyx. Documentation of the appearance of his feet/toes at this time was not found. A plan of care to monitor the resident's feet was not found. Nurses Notes continued: 5/14/20 at 2:43 A.M.: .BLE (bilateral lower extremity) [MEDICAL CONDITION] (swelling) noted, [MEDICAL CONDITION] continues 5/16/20 at 11:44 P.M.: .(Name of antibiotic) continues for treatment of [REDACTED]. A Physician's note, Date of Service: 05/14/2020, indicated, .The patient was recently hospitalized . The patient was noted to be [MEDICAL CONDITION] .for [MEDICAL CONDITION] of right (sic) great toe Nurses Notes continued: 6/4/20 at 2:47 A.M.: .res transferring with assist of 2 at this time, Res is unable to move right foot while transferring with staff 6/11/20 at 3:45 A.M.: .Res is unable to move right foot while transferring with staff 6/12/20 at 4:41 P.M.: Res not feeling well, lethargic, cant (sic) sit up at this time .99.1 T (temperature). Calling (name of physician). 6/12/20 at 9:41 P.M.: Res continues to be lethargic, skin is pale. T 99.3 .Notified (name of physician) order to send to (name of hospital) ER 6/13/20 at 12:13 A.M.: Resident admitted .with DX (diagnosis) of Metabolic [MEDICAL CONDITION] A hospital discharge summary, dated 6/14/20, indicated, Discharge Diagnosis: [REDACTED]. Suspect dementia .Chronic bilateral lower extremity wounds The resident returned to the facility on [DATE] at 6:19 P.M. An Admission Observation, dated 6/14/20 at 6:37 P.M., indicated the resident had no alterations in skin. A plan of care in regards to monitoring the resident's feet was not found. A quarterly MDS assessment, dated 6/30/20, indicated Resident K had a moderately impaired memory, required extensive assistance of one staff for personal hygiene, and total dependence of one staff for bathing. The resident had no venous or arterial ulcers, and no foot problems. A Nurses Note, dated 7/9/20 at 7:57 P.M., indicated, Resident very lethargic with slight elevated temp. This nurse notified MD et (and) N/O (new order) noted to send resident to (name of hospital) ER for eval et treatment A hospital history and physical, dated 7/9/20, indicated, Patient was recently admitted on ,[DATE] for .[MEDICAL CONDITION] of Left foot then admitted in 6/2020 for toxic/metabolic [MEDICAL CONDITION] with concern for [MEDICAL CONDITION] of Left foot .Physical Exam: 1+ [MEDICAL CONDITION] (swelling) of bilateral feet .Patient has [DIAGNOSES REDACTED] (redness) with dry flaking skin on left foot .Assessment/Plan: Toxic/Metabolic [MEDICAL CONDITION], suspected to be an acute infection .unknown source of infection but possibly related to his wounds .Multiple chronic wounds The resident returned to the facility on [DATE] at 1:04 P.M. A Nurses Note, dated 7/17/20 at 1:04 P.M., indicated, Resident returned to facility .extreme difficulty standing with walker, unable to straighten legs to standing position, per assist x 3 nursing staff to pivot to WC (wheelchair). Resident going to be hoyer lift until therapies can eval et tx as indicated .ATB (antibiotic) continues for [MEDICAL CONDITION] of L (left) great toe An Admission Observation, dated 7/17/20 at 2:12 P.M., did not indicate there was any impairment to the feet and/or toes. A plan of care regarding the resident's [MEDICAL CONDITION] and appearance of toe was not found in the clinical record. A wound assessment of the resident's left great toe was not found in the clinical record. A Physician's note, Date of service: 07/18/2020, indicated, .[MEDICAL CONDITION] to left great toe - [MEDICATION NAME] swab daily to affected area; p.o. (oral) antibiotics to continue course of treatment A physician's orders [REDACTED]. Nurses Notes included the following notations: 7/19/20 at 8:33 A.M.: .Skin issues noted on toe 7/22/20 at 7:11 A.M.: .Skin issues noted on toe A dietary note, dated 7/24/20, did not address the resident's toe. A Physician's note, Date of service: 07/24/2020, indicated, .[MEDICAL CONDITION] to left great toe - [MEDICATION NAME] swab daily to affected area; p.o. antibiotics to continue course of treatment Nurses Notes continued: 8/1/20 at 8:30 A.M.: .skin issues noted on L toe area A wound assessment of the resident's toes was not found in the clinical record. A care plan regarding the resident's toes was not found in the clinical record. On 8/3/20 at 2:15 P.M., a skin assessment was requested. LPN 2 indicated she did not work very much and was unfamiliar with the resident's skin. The resident was observed to be wearing protective shoes on each foot. LPN 2 was unsure which foot had wounds, and the resident pointed to his left foot. The resident was observed to be wearing socks, which appeared to be very snug, as LPN 2 had some difficulty removing them. Gauze dressings were observed on the resident's left great toe and left 2nd toe. The date on the dressings was illegible, but LPN 2 indicated she thought the date written was 8/7. LPN 2 indicated the date was probably the date that the dressings needed to be removed. The left great toe was reddened, with an open area on the outside of the toe. A scant amount of bloody drainage was observed on the dressing. The 2nd toe was also reddened, with an open area observed. A scant amount of bloody drainage was observed on that dressing. The resident's right foot had no open areas, but appeared discolored. On 8/3/20 at 2:25 P.M., LPN 1 was interviewed. LPN 1 indicated she performed the facility's wound assessments, and assessed the residents' wounds. When questioned regarding Resident K's wounds on his feet, LPN 1 indicated those areas were self-inflicted. Upon further interview, LPN 1 indicated she was unaware of any wounds on the resident's feet or toes, and was unaware of a treatment order to the toes. LPN 1 checked the resident's physician orders, and indicated there was an order for [REDACTED]. LPN 1 indicated there was no documentation for Resident K's areas, because she was unaware of the areas. The clinical record of Resident K was reviewed again on 8/4/20 at 9:30 A.M. A Nurses Note, dated 8/3/20 at 3:55 P.M., indicated, This nurse and DNS (Director of Nursing Services) assessed residents (sic) bilateral feet at this time, noted on right foot resident has discoloration on top of right foot near base of toes and on other right great toe, noted on left foot an area of impairment on top of left foot, red in appearance and superficial, also noted area of impairment on outer left great toe and on outer second toe of left foot both areas dark red in appearance and superficial, (name of physician) notified at this time and order given to [MEDICATION NAME] areas on left foot until he assesses bilateral feet on 8/4/2020. Wound Management documentation included the following: Wound location: Left big toe. Date/Time Identified: 08/03/2020 04:04 PM .Length 2.6 (centimeters), Width 1.5 (centimeters), Wound healing status: Stable. MD to assess .Tx of [MEDICATION NAME] obtained for every shift. Wound location: Left top of foot. Date/Time Identified: 08/03/2020 04:02 PM .Length 3(centimeters), Width 3.2 (centimeters), Wound healing status: Stable. On 8/3/20 at 3:25 P.M., the DNS and LPN 1 provided the current facility policy, Skin Management Program, dated 4/2018. The policy included: Procedure for Alterations in Skin Integrity - Pressure and Non-Pressure 1. Alterations in skin integrity will be reported to the MD/NP, the resident and/or resident representative as well as to the direct care staff. 2. Treatment order will be obtained from the MD/NP. 3. All alterations in skin integrity will be documented on the admission observation in the medical record .4. All newly identified areas after admission will be documented on the New Skin Event. 5. The wound nurse will be notified of alterations in skin integrity. a) The wound nurse is responsible for communicating to IDT (interdisciplinary team) on a weekly basis .b) The wound nurse will complete the appropriate skin evaluation on the next business day. i) Wound Management for ulcers (arterial, diabetic, pressure or venous) will be updated until resolved .6. A plan of care will be initiated to include resident specific risk factors and contributing factors with appropriate interventions implemented This Federal tag relates to Complaint IN 655. 3.1-37(a)

Based on interview, observation, and record review, the facility failed to notify the physician of a resident's complaints of odor and drainage of a [MEDICAL CONDITION] wound, resulting in maggots being found in the wound; and then failed to immediately notify the physician of the appearance of the maggots, resulting in psychosocial harm, for 1 of 3 residents reviewed for wound care, in a sample of 5. (Resident B) Findings include: On 8/27/18 at 1:00 P.M., during the initial tour, the Director of Nursing (DON) indicated Resident B had open areas on her left stump area and on the back of her thigh. The DON did not indicate the resident had an open area on her right heel. The resident was observed sitting on her bed at that time, with a disposable shoe cover on her right foot. Her right leg was wrapped with a dressing. The clinical record of Resident B was reviewed on 8/27/18 at 1:50 P.M. [DIAGNOSES REDACTED]. A quarterly Minimum Data Set (MDS) assessment, dated 6/15/18, indicated Resident B had no memory impairment, no behavior symptoms in the previous 7 days, and required extensive assist of two+ staff for bed mobility and transfer. The resident did not ambulate. Resident B had 1 unhealed pressure ulcer, and no [MEDICAL CONDITION]. A Wound Assessment from the Wound Care Clinic, dated (Monday) 8/6/18 at 9:19 A.M., indicated: Wound # 1 Right Heel, Length: (cm) 7, Width: (cm) 4.2, Depth: (cm) 0.1, Exudate (drainage) Amount: Copious (large) .Odor: None . The Wound Orders included: Primary dressing - puraply am # 3 applied to rt (right) heel and secured with steri strips, wound veil and borderless foam and optilock to lower leg .and then 2 press compression applied to rt leg. DO NOT GET WET. Nursing home to take off compression and borderless foam and optilock and reapply borderless foam, optilock, 2- 4.5 kerlix and coban on Saturday (8/11/18). Toes and between toes with [MEDICATION NAME] violet daily A Wound Management tool, dated 8/6/18 at 12:41 P.M., included: Length (centimeters): 7, Width (centimeters): 4.2 .Exudate Amount: Moderate .Wound odor present? No .Area stable this week; will continue to see (name of facility) for Wound Healing. No other facility documentation regarding the right heel wound/dressing was found in the clinical record until 8/8/18. A Nurses Note, dated 8/8/18 at 4:11 A.M., indicated: .DX (sic) to RLE (right lower extremity) d/i (dry/intact) .Will continue to monitor. Nurses Notes continued: 8/8/18 at 8:16 A.M.: Resident alert and sitting on side of bed, extensive assist of staff with all ADLs (activities of daily living) .Treatments continue a/o (as ordered) to right heel, resident to see wound care center at (name) weekly. Resident nonadherent with elevating right leg and wearing off loading boot on right foot .makes all wants and needs known well .right leg hanging down and putting pressure on foot and heel 8/9/18 at 8:16 A.M.: Resident alert and sitting on side of bed, extensive assist of staff with all ADLs (activities of daily living) .Treatments continue a/o (as ordered) to right heel, resident to see wound care center at (name) weekly. Resident nonadherent with elevating right leg and wearing off loading boot on right foot .makes all wants and needs known well .right leg hanging down and putting pressure on foot and heel A Weekly Wound Review, dated 8/10/18, indicated: Diabetic ulcer on right heel .presents 50% granulated tissue and 50% clean nongranulated tissue .Does the resident exhibit signs or symptoms of infection? No. Has the condition of the wound(s) improved, worsened, or remained stable? Worsened. Resident is nonadherent with elevating right foot and is very nonadherent with all wound care orders . Resident will continue to see (name) for wound healing on a weekly basis .Will continue all orders per wound care center Nurses Notes continued: 8/11/18 at 12:56 A.M.: Resident trying to elevate her RT (right) leg, dressing to RT leg non removed, noted some leakage and wetness to outer bandage, she states it leaks down her leg from her thigh. Will use a towel to aleviate (sic) the wetness, will cont. to monitor. Documentation that the physician was notified of the increased drainage, or that the dressing was changed at that time, was not found in the record. Nurses Notes continued: 8/11/18 at 8:36 P.M.: DX (sic) to R (right) foot changed per MD order by this nurse et (and) tolerated well. 8/12/18 at 2:22 A.M.: During dressing change to right heel, the night shift nurse noted a copious amount of freely moving maggots on wound bed, MD made aware and stated to send to (name of hospital) for eval and tx (evaluate and treat) 8/12/18 at 2:31 A.M.: (Name of ambulance service) arrives and transports resident to (name of hospital) at this time A hospital emergency room note, dated 8/12/18 at 5:05 A.M., included: Chief Complaint: maggots in wound .Evidently the nursing home noted that she had maggots in her wound and so they sent her to the emergency room for evaluation .She has had drainage coming from the wound but otherwise no other new complaints .Physical Exam .Skin: Warm. Some [DIAGNOSES REDACTED] (redness) is noted on the wound and there is quite a bit of eschar (dead tissue) on the wound also. There are some live maggots on the wound also .Final Impression: 1. Chronic venous stasis [MEDICAL CONDITION] (skin inflammation) of right lower extremity. 2. Wound drainage. On 8/27/18 at 2:30 P.M., LPN 1 and the DON were interviewed. LPN 1 indicated she was working 2:00 A.M. to 2:00 P.M. on 8/12/18. She indicated when she came in to work, LPN 2 had already changed Resident B's dressing on her right foot the prior evening. She indicated LPN 2 initially saw the maggots in the wound, and saved them for her. She indicated LPN 2 cleaned the wound, and redressed it, and saved the dressing with the larva on it. LPN 1 indicated after she saw the maggots, she then phoned the physician, and the resident was transported to the emergency room . LPN 1 indicated she was the staff member who usually took care of the wounds. She indicated that the resident went to the Wound Care Clinic on a Monday, and the facility was not to change the dressing until Saturday 8/11/18. The DON and LPN 1 indicated they had not noted any odor. The DON indicated the resident's toes were open to air, and it is possible a fly could have entered the wound that way. The DON and LPN 1 indicated LPN 2 probably was just mentally stressed, and so she did not immediately call a physician. On 8/27/18 at 3:35 P.M., Resident B was interviewed. She indicated she went to the Wound Care Clinic on a Monday. She noticed a bad odor on Wednesday or Thursday, and could tell it was draining because she could see the drainage on the dressing. She indicated she kept telling the staff about it, but the staff could not take the dressing off until Saturday. She indicated the staff told her they could wrap more on, but could not take anything off. She indicated the nurse finally changed the dressing Saturday evening, and kept saying, Oh my, Oh my, because the smell was so bad. Resident B indicated the nurse then started Screaming, and said there were maggots in the wound. She indicated the nurse stated she would wait until LPN 1 got there to find out what to do. Resident B stated, I was freaking out. They sent me to the ER, and got it cleaned up. She added the physician at the hospital told her to keep the flies off of herself. Resident B indicated she still is having nightmares about bugs crawling on her. On 8/28/18 at 1:30 P.M., during an interview with the DON, she indicated she was unaware that the resident was having nightmares about the maggots. She indicated the staff was just following the Wound Care Clinic orders regarding the dressing change. She indicated the Weekly Wound Review, completed on 8/10/18, was a summary of the wound, and that the staff did not look at the wound that date. She indicated staff does wound rounds on a Monday, and then fill out the Weekly Wound Review on a Friday. She indicated the wound had not been observed by facility staff, due to the resident going to the Wound Care Clinic. The DON indicated the resident is very non-compliant with bathing and hoards items in her room, which would contribute to flies. On 8/28/18 at 11:35 A.M., the DON provided the current facility policy, Resident Change of Condition, revised 1/2015. The policy included: It is the policy of this facility that all changes in resident condition will be communicated to the physician and family/responsible party, and that appropriate, timely, and effective intervention takes place .Any sudden or serious change in a resident's condition .will be communicated to the physician. If unable to contact the attending physician or alternate physician in a timely manner, notify the Medical Director for medical intervention This Federal tag relates to Complaint IN 721. 3.1-5(a)(3)

Based on interview, observation, and record review, the facility failed to manage the wound care of a diabetic foot wound, by failing to assess the drainage and odor of the wound; notify the physician of a resident's complaints of odor and drainage of the wound, resulting in maggots being found in the wound; and then failed to immediately notify the physician of the appearance of the maggots, resulting in psychosocial harm, for 1 of 3 residents reviewed for wound care, in a sample of 5. (Resident B) Findings include: On 8/27/18 at 1:00 P.M., during the initial tour, the Director of Nursing (DON) indicated Resident B had open areas on her left stump area and on the back of her thigh. The DON did not indicate the resident had an open area on her right heel. The resident was observed sitting on her bed at that time, with a disposable shoe cover on her right foot. Her right leg was wrapped with a dressing. The clinical record of Resident B was reviewed on 8/27/18 at 1:50 P.M. [DIAGNOSES REDACTED]. A Care Plan, dated 5/2/18, indicated, Resident has impaired skin integrity: right heel .diabetic ulcer . The Approaches included: Notify MD or worsening or no change in wound or for signs of infection. Observe for signs of infection: redness, pain, drainage, malodorous drainage A quarterly Minimum Data Set (MDS) assessment, dated 6/15/18, indicated Resident B had no memory impairment, no behavior symptoms in the previous 7 days, and required extensive assist of two+ staff for bed mobility and transfer. The resident did not ambulate. Resident B had 1 unhealed pressure ulcer, and no [MEDICAL CONDITION]. A Wound Assessment from the Wound Care Clinic, dated (Monday) 8/6/18 at 9:19 A.M., indicated: Wound # 1 Right Heel, Length: (cm) 7, Width: (cm) 4.2, Depth: (cm) 0.1, Exudate (drainage) Amount: Copious (large) .Odor: None . The Wound Orders included: Primary dressing - puraply am # 3 applied to rt (right) heel and secured with steri strips, wound veil and borderless foam and optilock to lower leg .and then 2 press compression applied to rt leg. DO NOT GET WET. Nursing home to take off compression and borderless foam and optilock and reapply borderless foam, optilock, 2- 4.5 kerlix and coban on Saturday (8/11/18). Toes and between toes with [MEDICATION NAME] violet daily A Wound Management tool, dated 8/6/18 at 12:41 P.M., included: Length (centimeters): 7, Width (centimeters): 4.2 .Exudate Amount: Moderate .Wound odor present? No .Area stable this week; will continue to see (name of facility) for Wound Healing. No other facility documentation regarding the right heel wound/dressing was found in the clinical record until 8/8/18. A Nurses Note, dated 8/8/18 at 4:11 A.M., indicated: .DX (sic) to RLE (right lower extremity) d/i (dry/intact) .Will continue to monitor. Nurses Notes continued: 8/8/18 at 8:16 A.M.: Resident alert and sitting on side of bed, extensive assist of staff with all ADLs (activities of daily living) .Treatments continue a/o (as ordered) to right heel, resident to see wound care center at (name) weekly. Resident nonadherent with elevating right leg and wearing off loading boot on right foot .makes all wants and needs known well .right leg hanging down and putting pressure on foot and heel 8/9/18 at 8:16 A.M.: Resident alert and sitting on side of bed, extensive assist of staff with all ADLs (activities of daily living) .Treatments continue a/o (as ordered) to right heel, resident to see wound care center at (name) weekly. Resident nonadherent with elevating right leg and wearing off loading boot on right foot .makes all wants and needs known well .right leg hanging down and putting pressure on foot and heel A Weekly Wound Review, dated 8/10/18, indicated: Diabetic ulcer on right heel .presents 50% granulated tissue and 50% clean nongranulated tissue .Does the resident exhibit signs or symptoms of infection? No. Has the condition of the wound(s) improved, worsened, or remained stable? Worsened. Resident is nonadherent with elevating right foot and is very nonadherent with all wound care orders . Resident will continue to see (name) for wound healing on a weekly basis .Will continue all orders per wound care center Nurses Notes continued: 8/11/18 at 12:56 A.M.: Resident trying to elevate her RT (right) leg, dressing to RT leg non removed, noted some leakage and wetness to outer bandage, she states it leaks down her leg from her thigh. Will use a towel to aleviate (sic) the wetness, will cont. to monitor. Documentation that the physician was notified of the increased drainage, or that the dressing was changed at that time, was not found in the record. Nurses Notes continued: 8/11/18 at 8:36 P.M.: DX (sic) to R (right) foot changed per MD order by this nurse et (and) tolerated well. 8/12/18 at 2:22 A.M.: During dressing change to right heel, the night shift nurse noted a copious amount of freely moving maggots on wound bed, MD made aware and stated to send to (name of hospital) for eval and tx (evaluate and treat) 8/12/18 at 2:31 A.M.: (Name of ambulance service) arrives and transports resident to (name of hospital) at this time A hospital emergency room note, dated 8/12/18 at 5:05 A.M., included: Chief Complaint: maggots in wound .Evidently the nursing home noted that she had maggots in her wound and so they sent her to the emergency room for evaluation .She has had drainage coming from the wound but otherwise no other new complaints .Physical Exam .Skin: Warm. Some [DIAGNOSES REDACTED] (redness) is noted on the wound and there is quite a bit of eschar (dead tissue) on the wound also. There are some live maggots on the wound also .Final Impression: 1. Chronic venous stasis [MEDICAL CONDITION] (skin inflammation) of right lower extremity. 2. Wound drainage. Documentation of assessments of the right foot dressing was not found in the Treatment Administration Record. On 8/27/18 at 2:30 P.M., LPN 1 and the DON were interviewed. LPN 1 indicated she was working 2:00 A.M. to 2:00 P.M. on 8/12/18. She indicated when she came in to work, LPN 2 had already changed Resident B's dressing on her right foot the prior evening. She indicated LPN 2 initially saw the maggots in the wound, and saved them for her. She indicated LPN 2 cleaned the wound, and redressed it, and saved the dressing with the larva on it. LPN 1 indicated after she saw the maggots, she then phoned the physician, and the resident was transported to the emergency room . LPN 1 indicated she was the staff member who usually took care of the wounds. She indicated that the resident went to the Wound Care Clinic on a Monday, and the facility was not to change the dressing until Saturday 8/11/18. The DON and LPN 1 indicated they had not noted any odor. The DON indicated the resident's toes were open to air, and it is possible a fly could have entered the wound that way. The DON and LPN 1 indicated LPN 2 probably was just mentally stressed, and so she did not immediately call an physician. On 8/27/18 at 3:35 P.M., Resident B was interviewed. She indicated she went to the Wound Care Clinic on a Monday. She noticed a bad odor on Wednesday or Thursday, and could tell it was draining because she could see the drainage on the dressing. She indicated she kept telling the staff about it, but the staff could not take the dressing off until Saturday. She indicated the staff told her they could wrap more on, but could not take anything off. She indicated the nurse finally changed the dressing Saturday evening, and kept saying, Oh my, Oh my, because the smell was so bad. Resident B indicated the nurse then started Screaming, and said there were maggots in the wound. She indicated the nurse stated she would wait until LPN 1 got there to find out what to do. Resident B stated, I was freaking out. They sent me to the ER, and got it cleaned up. She added the physician at the hospital told her to keep the flies off of herself. Resident B indicated she still is having nightmares about bugs crawling on her. On 8/28/18 at 1:30 P.M., during an interview with the DON, she indicated she was unaware that the resident was having nightmares about the maggots. She indicated the staff was just following the Wound Care Clinic orders regarding the dressing change. She indicated the Weekly Wound Review, completed on 8/10/18, was a summary of the wound, and that the staff did not look at the wound that date. She indicated staff does wound rounds on a Monday, and then fill out the Weekly Wound Review on a Friday. She indicated the wound had not been observed by facility staff, due to the resident going to the Wound Care Clinic. The DON indicated the resident is very non-compliant with bathing and hoards items in her room, which would contribute to flies. On 8/28/18 at 11:35 A.M., the DON provided the current facility policy, Skin Management Program, revised 4/2018. The policy included: The wound nurse is responsible for communicating to IDT (interdisciplinary team) on a weekly basis .Wound Management for ulcers (arterial, diabetic .) will be updated weekly until resolved .A plan of care will be initiated to include resident specific risk factors and contributing factors with appropriate interventions implemented. IDT will review residents with alterations in skin integrity weekly following the IDT Weekly Wound Review Policy This Federal tag relates to Complaint IN 721. 3.1-35(g)(1)

Based on observation, interview, and record review, the facility failed to provide adequate supervision to prevent a resident from burning his arm on a baseboard heater, for 1 of 4 residents reviewed for accident prevention, in a sample of 4. (Resident B) Findings include: On 1/16/18 at 9:30 A.M., the Administrator provided an Indiana State Department of Health (ISDH) incident form. The incident form included: Incident Date: 01/09/2018. Incident Time: 01:50 PM. Residents Involved (Resident B) .Brief Description of Incident: Staff went into room to perform a bed check on (Resident B), a hospice patient, it was noted that his right arm was lying off the bed and against the wall just above the base board heater Included with the incident were staff statements, documentation of inservices, and a Quality Assurance Tool for audit purposes. A written statement by Activity Staff 1, dated 1/9/18, indicated, I dropped my daily cronical (sic) (newspaper) about 1:00 P.M. Resident was covered up and asleep. A written notation by the local heating and air company, dated 1/10/18, indicated: We have checked operation of Baseboard heater in (Resident B's room). Heater is cycling on and off as it should be. Temperatures are reaching anywhere from 115 (degrees) to 135 (degrees) on heater A Record of Facility Inservice, dated 1/9/18 through 1/15/18, indicated, Subject: Proper Body Alignment when in bed. Safety in Room Ergonomics. A Quality Assurance Tool, undated, indicated: Ensure the stated rooms/bathrooms have all items away from baseboard heater. Heater to be left unobstructed at all times. Nursing Staff to monitor Resident Rooms for safety hazards, trip hazards, hazards (with) room ergonomics, equipment issues. On 1/16/18 at 11:10 A.M., the closed clinical record of Resident B was reviewed. [DIAGNOSES REDACTED]. A quarterly Minimum Data Set (MDS) assessment, dated 12/1/17, indicated Resident B scored a 10 out of 15 for cognition, with 15 indicative of no memory problem. Resident B required extensive assistance of two + staff for bed mobility, transfer, and toilet use. He did not ambulate. A Care Plan, initially dated 8/29/17 and revised 12/21/17, indicated: Resident needs assistance with ADLs (Activities of Daily Living) including bed mobility, transfers, eating and toilet use . The Approaches included: 2 assist with transfers .Assist with bed mobility as needed Nurses Notes included the following notations: 12/29/17 at 11:18 A.M.: .Opens eyes when spoken to. Makes no attempts to speak .Hospice nurse and aide here to see resident .Turned and repositioned q (every) 2 hours. 1/2/18 at 11:49 A.M.: IDT (Interdisciplinary Team) met to review fall from 1/1 noted resident was found laying on his right side beside his bed. Resident states he was going to work and rolled OOB (out of bed). No injuries noted .Root cause: resident is confused an (sic) attempted to get OOB unassisted. Current care plan interventions include .bed in lowest position 1/4/18 at 8:45 P.M.: (Recorded as Late Entry on 01/05/2018 12:02 AM) .Turned and repositioned q 2 hours .Bed in low position .Hallucinating intermittently. States sees motorcycles in his room .Continues to receive Hospice services as ordered. 1/6/18 at 9:43 P.M.: Resident cont. to be confused medicated with [MEDICATION NAME] (an anti-anxiety medication) and [MEDICATION NAME] (pain medication) with effectiveness .sister came in a few times today to check him and discussed her worries of his confusion and taking his covers off, instructed that staff would keep checking him will cont. to monitor. 1/8/18 at 9:17 P.M.: Slept peacefully throughout shift .Sips of fluids taken occasionally .Turned and repositioned q 2 hours 1/9/18 at 1:50 P.M.: CNA reported to this nurse that res (resident) arm appeared burned. CNA stated 'arm was against wall when entering room.' CNA then moved arm onto bed. Res assessed by this nurse, VS (vital signs) taken, res nonresponsive, warm to touch, resp (respirations) labored. PRN (as needed) pain med given .Hosipice (sic) nurse arrived at facility; N/Os (new orders) per (name of physician); debridement (removal of dead skin) done by hospice nurse, measurements obtained then treatment applied to wound .Family at bedside at this time and aware of orders. A New Skin Event, dated 1/9/18 at 1:50 P.M., indicated, Site/Location of Wound/Area: Right arm. Wound/Area measurements: 70 x 35 (centimeters). Wound/Area type: Burn. Wound/Area color: Bright red .Red/Warm/Hot around the wound/area .list the preventive measures that have been put in place: Keep res away from heated wall. On 1/16/18 at 11:15 A.M., LPN 1 was interviewed. LPN 1 indicated she performed a treatment on Resident B at approximately 9:00 A.M. She indicated the resident was semi alert at that time. She did not have any other interaction with Resident B that morning. She continued stating, two of the CNAs alerted the nursing staff after lunch to come see the resident. LPN 1 stated, It was bad. (CNA 3) was holding his arm. His right arm was purplish from below the shoulder to his fingers. His skin was coming off. LPN 1 indicated the resident was non-responsive at that time. LPN 1 indicated the resident's bed was in the low position due to a recent fall. She further added, the resident was able to use his call light at times. On 1/16/18 at 11:25 A.M., LPN 3 was interviewed. LPN 3 indicated she did not usually work the floor, but was at the nursing station when the CNA alerted the nurses that something was not right with Resident B. She described, LPN 2 and herself went to the room and saw Resident B's right arm almost black, with blisters, from his shoulder to his fingertips. She added, CNA 3 stated she had to move Resident B's arm off of the heater. LPN 3 added, the resident was not responding and the resident's bed was in the low position. On 1/16/18 at 11:35 A.M., LPN 2 was interviewed. LPN 2 indicated she came to work at 10:00 A.M. on 1/9/18, but did not see Resident B until after lunch. She added, CNA 2 informed her Resident B's arm was purple and blistered. CNA 3 stated she was pretty sure he was burned. She indicated the CNAs told her they had moved the resident's bed away from the wall. She further added, CNA 3 informed her she lifted up the resident's arm and his skin came off. She described, when she entered the room, the resident's arm was on the bed. She described, the hand was black, purple, and blistered, and the arm was red to his shoulder. LPN 2 stated, They assumed it was on the heater. She indicated Resident B did not respond. She indicated she obtained his vital signs, and his temperature was 105.7 axillary (under the arm). She also obtained pain medication for the resident and called the hospice nurse. On 1/16/18 at 11:45 A.M., CNA 1 was interviewed. CNA 1 indicated she changed Resident B on 1/9/18 at approximately 11:30 A.M. She described, she turned the resident so he would be facing the wall. She added, she asked the resident if he needed anything, and he said, No, I'm good. She further added, the resident was in a low bed close to the floor, but she didn't think he was too close to the wall. CNA 1 added, Resident B preferred to have his door shut. She indicated he would use his call light sometimes, but would usually just holler out. On 1/16/18 at 1:25 P.M., CNA 3 was interviewed. CNA 3 explained she and CNA 2 came on shift at 1:00 P.M., and were passing ice water at approximately 1:30 P.M.-1:45 P.M. on 1/9/18. She described, CNA 2 told her, (Resident B) doesn't look right. She added, she observed Resident B's eyes were fixed, and he wasn't responding. She indicated the resident felt really hot. She indicated they thought Resident B was dying. CNA 3 indicated the resident's right arm was all black and had blisters. She indicated the arm was laying on top of the heater. She indicated they moved the bed from the wall, and told CNA 2 to get the nurse. CNA 3 indicated the resident was in a low bed, close to the floor. She stated, We checked on him a lot. He didn't use his call light anymore. He would holler out. She added, she never would shut his door all the way, but would leave it cracked so they could hear him. On 1/16/18 at 1:40 P.M., CNA 2 was interviewed. She indicated she and CNA 3 were passing ice water between 1:30 P.M.-1:45 P.M. on 1/9/18. She indicated when she entered Resident B's room, she thought the resident didn't look right. She indicated, He was kind of gasping for air. I felt his forehead and he was really hot. I felt his feet and they were really hot. She indicated she noticed his bed was against the wall. She indicated CNA 3 and herself moved the bed, and noticed the resident's arm. She indicated his right arm was blue/black with blisters from his shoulder to his fingers. She indicated, When (CNA 3) raised his arm, part of his skin came off. She indicated she went and got the nurse, and they checked his temp and it was 105.7. On 1/16/18 at 2:10 P.M., the Administrator was interviewed. She indicated the resident's bed was put in the low position after a fall. She indicated when the bed was in the low position, it could move easily. She indicated the resident was able to move himself in bed. She indicated the hospice nurse felt like the resident was actively dying that day, because there was no way he could've felt that and not grimaced or something. At that time, Resident B's bed was lowered to the lowest position. When pushed next to the wall, the top of the baseboard heater was approximately 3 inches lower than the top edge of the mattress. At that time, the Administrator indicated she had received different reports that the bed may have been approximately 14 inches from the wall when the resident was found, and not next to the wall. She indicated she did not know why the resident's arm would have been burned. On 1/16/18 at 2:45 P.M. Hospice RN 1 was interviewed. She indicated she received a call from the nursing home that the resident had a burn. She indicated, He was actively dying or he would have felt it. It was pretty bad. She indicated the right hand was bright red; from the wrist to the elbow was very black with fluid filled blisters. She indicated the skin was red above the elbow. She indicated she spoke to the family and to the physician and received treatment orders. She indicated the resident's skin was still very hot, and when she applied wet wash rags and then removed them, the resident's skin sloughed off. On 1/16/18 at 4:00 P.M., the Administrator provided the Manufacturer's Guidelines, undated, for the baseboard heater used in Resident B's room. The Guidelines included: Important Instructions .This heater is hot when in use. To avoid burns, do not let bare skin touch hot surfaces .Installation Instructions .Maintain at least 12 inches minimum clearance in front of baseboard .and 6 inches minimum on both sides. This Federal tag relates to Complaint IN 989. 3.1-45(a)

Based on observation, interview, and record review, the facility failed to ensure a resident admitted without a pressure wound did not develop a pressure wound for 1 of 3 residents reviewed for pressure wounds. This deficient practice resulted in Resident 8 developing an unstageable pressure wound to the coccyx and buttocks. (Resident 8) Findings include: During an interview on 6/27/17 at 10:05 A.M., LPN 4 indicated Resident 8 had an area on his buttocks caused by moisture. During an observation and interview on 7/2/17 at 1:12 P.M., CNA 16 and CNA 17 used a mechanical lift to transfer Resident 8 to bed. CNA 17 indicated Resident 8 wore a chuck (bed pad) under his shorts when seated in the wheelchair because disposable briefs may have caused the skin breakdown on his buttocks. The chuck pad was saturated with urine. CNA 16 and CNA 17 cleaned between Resident 8's buttocks and the wound area, but did not clean the front of his periarea. A wound covered with tan slough, the size of a quarter, was noted on Resident 8's coccyx. Open wound areas were located on Resident 8's buttocks which had speckles of tan slough noted in wound bed. There was depth to the wounds noted on the coccyx and the left and right buttocks. CNA 17 indicated the nurse would come in and apply barrier cream to the wounds later. The CNA's laid a new chuck pad (moisture barrier pad) on the bed, rolled Resident 8 onto his right side, and placed a blanket behind his back. During an Interview on 7/6/17 at 10:20 A.M., RN 1 indicated good peri care for an incontinent resident would be to thoroughly wash the front peri area if the resident had urinated in the brief. The clinical record for Resident 8 was reviewed on 7/2/17 at 10:30 A.M. The record indicated the [DIAGNOSES REDACTED]. The Admission MDS (Minimum Data Set) assessment, dated 6/2/17, indicated Resident 8 was admitted to the facility on [DATE] and experienced severe cognitive impairment, needed the assistance of two staff for transferring, bed mobility, and experienced no unhealed pressure ulcers. A Braden Scale Assessment, dated 5/26/17, indicated Resident 8 was at a moderate risk to develop a pressure ulcer. A Braden Scale Assessment, dated 7/7/17, indicated Resident 8 was at a high risk to develop a pressure ulcer. The Physicians orders for 6/7/17 included, but were not limited to: .Remedy Calzamine protectant Paste Cream .1 application .Indication: open areas to bilateral buttocks .every shift .PRN . The Physicians orders for 6/9/17 included, but were not limited to: .Magic Butt Cream apply every shift for 7 days .Apply to left and right buttock (MASD) (moisture associated skin damage) . The Physicians orders for 7/6/17 included, but were not limited to: .Use chuck pads instead of briefs for incontinence . The Physicians orders for 7/6/17 included, but were not limited to: .Cleanse wound to coccyx with 20 ml of NS (normal saline) with piston syringe, pat dry, apply Santyl to slough areas on wound bed, cover with foam dressing . The care plan for .Pressure Ulcer . initiated on 5/31/17 included, but was not limited to: .Assess and document skin condition weekly and as needed . house barrier at bedside - use as needed . Incontinent care as needed using peri wash and moisture barrier . pressure reducing/redistribution cushion in chair/wheelchair . pressure reducing/redistribution cushion mattress on bed . Turn and reposition at least every 2 hours . A care plan for .Resident has impaired skin integrity : MASD .buttocks . initiated on 6/1/17, included but was not limited to: .Assess for pain, treat as ordered . Assess wound weekly and document measurements and description . Notify MD of worsening or no change in wound or for signs of infection . Observe for signs of infection .increase in size/depth of wound . The care plan for .Resident has infection .to coccyx . initiated on 7/5/17 included but was not limited to: .Assess wound weakly documenting measurements and description . Treatment as ordered . The care plan for .Pressure Ulcer .Unstageable wound .Coccyx . initiated on 7/6/17 included but was not limited to: .Assess wound weekly documenting measurements and description . Incontinent care as needed: check and change q2h (every 2 hours) . To utilize chuck pads of incontinence . Wound clinic visits as ordered to start 7/12/17 . A Resident Progress Note dated 6/7/17 at 9:46 A.M., read as follows: .Meals in dining room and attends programing in rec (recreation room). Dozes at times during the day . A Resident Progress Note dated 6/7/17 at 7:40 P.M., read as follows: .New areas noted to buttocks . A Physician's progress note dated 6/16/17 5:25 P.M., read as follows: .Reason for evaluation : Patient continues to have trouble with decubitus ulcer in the gluteal area .Skin: examination of the bottom reveals .patient has skin breakdown .Assessment and plan .Patient will be reevaluated in 7 days and we would consider follow up with wound care clinic if .symptoms not improved . A Resident Progress Note dated 6/20/17 at 1:25 A.M., read as follows: .ATB (antibiotic) continued for MASD (Moisture Associated Skin Damage) to buttocks, treatment with magic butt cream continues q (every) shift, area seems to have worsened over the weekend, will continue to monitor . A Resident Progress Note dated 6/23/17 at 6:42 P.M., read as follows: . (Doctors' name) here to see resident and examined area of MASD with treatment order change. Red periphery with yellow bed noted . Bilateral buttocks: A New Skin Event Report dated 6/7/17 at 6:28 P.M. indicated Resident 8 had a new wound area on his bilateral buttocks. The wound was described as open pink with a scant amount of blood. A New Skin Event Report dated 6/8/17 at 2:38 P.M. indicated Resident 8 had a new wound area on his inner buttocks measuring 4.5 x (by) 3 and had an order for [REDACTED].>Right buttock: An IDT Weekly Update Skin Events dated 6/13/17 for the right buttock indicated Resident 8 had a red area of moisture associated damage measuring 3 x 1.5 (cm) noted. An IDT Weekly Update Skin Events dated 6/20/17 for the right buttock indicated Resident 8 had a red area of moisture associated damage measuring 11x 7 (cm) noted. An IDT Weekly Update Skin Events dated 6/26/17 for the right buttock indicated Resident 8 had a red area of moisture associated damage measuring 9 x 4 (cm) noted. An IDT Weekly Update Skin Events dated 7/3/17 for the right buttock indicated Resident 8 had a red area of moisture associated damage measuring 11x 6 (cm). Left Buttock: An IDT Weekly Update Skin Events dated 6/20/17 for the left inner buttock indicated Resident 8 had a red area of moisture associated damage measuring 12.5 x 7.3 (cm) noted. An IDT Weekly Update Skin Events dated 6/26/17 for the left inner buttock indicated Resident 8 had a red area of moisture associated damage measuring 10 [MEDICAL CONDITION] x 3.0 (cm) noted. An IDT Weekly Update Skin Events dated 7/3/17 for the left inner buttock indicated Resident 8 had a red area of moisture associated damage measuring 10 x 5 (cm) noted. A New Skin Event Report dated 7/6/17 at 11:41 A.M., read as follows: .Wound to coccyx .originally noted 07/06/2017 .Location of Wound .left and right buttocks including coccyx, butterfly shaped .Area measurements .L (length) W (width) D (depth) .10 x (by) 12 x 0.5 (cm) .wound edges red, towards center of wound pink, area inside left buttock has a depth of 0.2 (cm) and wound bed has slough present, coccyx has slough present as well. Area extends from buttocks in towards the coccyx, coccyx depth 0.5 (cm) .Resident had MASD to left and right buttock from incontinence that started on 6/7/17, noted today the wound is unstageable pressure wound . During an observation and interview on 7/7/17 at 10:15 A.M., RN 1 indicated Resident 8's wound on his coccyx and both buttocks appeared to be an unstageable pressure area due to the tan slough. LPN 1 measured the coccyx, left, and right buttock as one wound. RN 1 indicated the three wounds had merged together to form one wound. During an interview on 7/7/17 at 12:30 P.M., LPN 1 indicated the physician had been notified and an order was received for a debridement treatment and foam dressing along with an appointment to the wound care clinic. During an interview on 7/7/17 at 12:35 P.M., the Health Care Administrator indicated it was the goal of the facility to prevent pressure ulcers from developing. On 7/10/17 at 10:35 A.M., The National Pressure Ulcer Advisory Panel was reviewed. The National Pressure Ulcer Advisory Panel described an unstageable pressure ulcer as the following: .Obscured full-thickness skin and tissue loss. Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed . 3.1-40(a)(1)

Based on observation, interview, and record review, the facility failed to ensure psychiatric services were provided in a timely manner (23 days) for 1 of 1 residents who met the criteria for review of psychiatric care. This deficient practice resulted in Resident #13 calling the behavior unit and an ambulance requesting to receive psychiatric services while displaying increased anxiety, agitation and suicidal threats. (Resident #13) Findings include: On 5/10/16 at 2:55 P.M., Resident #13 was observed to be propelling herself down the hallway. Resident #13 appeared to be in no distress. The clinical record for Resident #13 was reviewed on 5/10/16 at 1:15 P.M., the admitting [DIAGNOSES REDACTED]. The Nursing notes for Resident #13 were reviewed and included, but were not limited to the following: 8/3/15 at 7:30 P.M., .A O x 2 (alert and oriented by 2), pleasant, (up sign) w/c (wheel chair) propels self .Appetite good . 8/4/15 at 4:00 A.M., This nurse was called into RM (room) because '[MEDICAL CONDITION] bag was leaking. When bag was observed it was secured (with) (zero) leaking. Res (Resident) was attempting to pull it apart. Explained to res. to leave alone. Res. became angry, hit wall et (and) said you always say that. CNA burped bag. Res aggressively hits hands on the side of bed . 8/5/16 at 7:00 A.M., .Res very pre-occupied with [MEDICAL CONDITION] To (sic) BR (bathroom) several x's (times) each day et wants [MEDICAL CONDITION] bag et flange changed. Becomes tearful then verbally abusive to staff. Calls daughter several x's daily 8:30 A.M., Res has been sitting in BR x 20 minutes. Has turned on call light numerous x's requesting her [MEDICAL CONDITION] bag et flange changed . 6:00 P.M., Daugh (daughter) returning res. to facility .went to (local restaurant), res would not get out of car. After turning into drive, res opened door Et got out of car arguing (with) daugh. Res would not get back into car, so daugh called for assistance to facility. Two CNA's Responded Et coaxed res. to return .Res et daug were in sight of this nurse Et staff @ (at) all x upon notification of being in driveway. Res was very difficult Et combative in returning Raised (sic) Her arm, took swing @ staff, pointing fingers ET cursing @ staff, daugh. 6:30 P.M., .Inside bldg. seated .disoriented x 3. Thoughts/speech went from moving, to call the police to wasn't to see Dr. to hates daugh. to trying to poison her food. 8/6/16 at 8:10 A.M., .Resident in bathroom, turning call light on numerous times Crying and requesting [MEDICAL CONDITION] bag to be changed . bag checked no leaks noted. Resident requested to speak (with) (Name of SSD #2) . 8/7/16 at 10:15 P.M., .Has been up to nurses Station (sic) making frequent phone calls. Gave this nurse a note regarding Suspicions (sic) of others - caregivers. States she needs something for her nerves .(Name of Daughter) at nurses Station stating she is upset because her mother is not being cared for properly she went on further to say her mother is a manic depressive (and) needs to be on an anti - depressant, states also that she has a family hx (history of suicide (and) has suicidal ideation and tendencies . 8/8/16 at 8:00 P.M., .Propelling self around the facility seeking an exit. All doors are secure with codes and several staff members are aware. Pt at nurses' station requesting for her daughter to be called . 9:20 P.M., .daughter in facility to visit. At nurse station talking to (name of resident) .(name of daughter) states her mother just mentioned feeling and expressing verbally her desire to commit suicide. This nurse spoke to pt (patient) (and) pt did say that sometimes she does want to die 'what's the point in living?' Pt affect is flat .eyes squinted .teeth clenched. D.O.N (Director of Nursing) notified. 10:15 P.M., Pt placed on suicide precautions per D.O.N.'s discretion. All jewelry, necklaces, sharp objects, potential hanging articles (and) cords removed from pt room . 8/9/16 at 5:49 A.M., Pt reports her [MEDICAL CONDITION] is leaking. Upon inspection it was noted the entire [MEDICAL CONDITION] bag and Stoma (sic) (flange) had been removed .new bag for collection . Advised pt that entire apparatus should not be necessarily changed daily .She states that she could not help it. 7:00 A.M., Res remained in her room. Cont (continue) to pull @ [MEDICAL CONDITION] bag . 8:15 A.M., Res to nurses' desk. States she wants her things back, Reinforced to Res that due to statements she made to her daughter, for her safety, those items were removed Assured when MD (medical doctor) et daughter felt it was safe she could have them back . 9:30 A.M., .Res has been in her room in BR pulling @ her [MEDICAL CONDITION] bag. Has removed x 2 . 10:00 A.M., Res up around entrance states she is just looking when asked if she needs anything, returns to the dining room. 10:40 A.M., Res back in BR has removed [MEDICAL CONDITION] bag et flange. Has stool all over her and et pants .New flange et [MEDICAL CONDITION] bag in place per staff. Taped around edges. 12:30 P.M., Wander guard placed on Res per SS (social service). 8/10/16 1:00 A.M., Res hit call light. In BR on toilet et removed [MEDICAL CONDITION] et flange et bag et put in trash can. Soiled self (with) stool .she stated 'because it was a mess . 8/14/15 at 5:00 P.M., (name of Medical Doctor) in to see Resident (sic). Continue orders for 30 days. The physician telephone orders for Resident #13 were reviewed and included, but were not limited to, 8/14/15 .1 please report to (name of behavior unit) that she says she is depressed and wants to go to Hospital - does have flat affect (and) [MEDICAL CONDITION] Dx. (diagnosis) ? (question) med adjustment . This order was a handwritten order from the Resident's attending physician. The nurse's notes continued and included, but were not limited to the following: 8/14/15 at 7:30 P.M., .Pt asked when she would get her radio back. Advise pt that her daughter (and) her attending (name of psychiatric physician) would need to make that decision to see if pt were continuing her suicidal ideation (and) veribage . 8/15/15 at 5:30 P.M., (Up) in w/c, alert and agitated. Res c/o (complaints of) others res going in room; states 'will not stay in room anymore and wants to be moved, if not moved will call doctor to be admitted to hospital' . 6:00 P.M., .Pt states she is going to go back to her room because a male resident has been in her room 'getting into thing and messing with thermostat'. Pt stats she wants a room change or else. 6:30 P.M., .Res (up) in w/c in lobby alert. Res agitated when spoken to . 8/16/15 at 7:30 P.M., Arguing (with) daugh, subject (symbol for change) ing back/forth makes no sense in her discussion, says she wants to leave, then she don't have to leave. Wants daug visit tomorrow, then says she don't want to see her anymore. Says she can handle her own business (and) money then says she's crazy, wants to go to 2nd floor to (name of psychiatric physician) because she is crazy. Wants a lock on BR door, Is paranoid re: male res . 8/18/15 10:00 P.M., Res went to phone in rec (recreation). rm (room) (and) called for an ambulance. Told them she was in pain (and) wanted to go to the ER (emergency room ) They contacted facility .She states she will keep calling them until they come. Cursed @ evening shift nurse (and) threatened to kick her a**. Went back to B wing desk (and) called daughter . 8/19/15 at 12:00 A.M., Rang and asked if the doctor was on his way to (symbol for check) her back. Was told he doesn't come out @ night. Writer (checked) her back and (Right) inner buttock where she hurts. 0 bruising noted in either place . 7:15 A.M., Res up ad lib, Angry this AM. Has been marching around facility yelling @ staff returns to her room . 8/21/15 at 7:45 P.M., .Propelling in the hallways in her W/C (without) difficulty. Screamed loudly in the computer room on B wing while maintaining a calm affect. When asked what was wrong she state 'that man, there he is, tried to pour coffee all over me! You're going to have to do something!' Pt stayed behaving this nurse insisting something be done. Reassured pt that the male pt she was referring to was not going to harm her and distance needed to be kept. Pt became enraged when this nurse would not remove the pt from the lounge or take her outside away from said pt (with) coffee. No incident . 8:45 P.M., Pt up to nurses' station to make phone calls. After the conversation she told 2 attending nurse's aide (sic) to pack her things-she was going to go camping at (local campground) with her sister. This nurse instructed the CNA's not to help her pack. That the pt could not leave with anyone except POA (Power of Attorney) .POA was notified of events .Pt at nurses' station to listen to the conversation and became extremely agitated stood up at desk and began yelling at this nurse .Pt states she has rights and that she had went to the band earlier today and had her POA changed .Pt left the nurses' station propelling self down hallway angrily . 8/23/15 at 12:00 A.M., yelling, 'help' down E wing hallway doors down from her room. Standing (without) W/C or walker close by. States male resident opened bathroom door while she was in the bathroom. Male resident in next room was lying in bed with eyes closed. Reassured pt .Pt stated 'you don't believe me-I'm not going to back to that bathroom Pt then got in her w/c and is now propelling herself through facility hallway. 8:15 A.M., Call from (Name of behavior unit) stating Res called there looking for (Name of psychiatric physician). Had also called ambulance to see if they could pick her up . 10:00 A.M. Res @ nurses desk Has parked her W/C in entrance to nurses station et refuses to move, 10:10 nurse asks resident to move her chair so she can leave nurses station. Res states no Attempts to strike nurse as she attempts to move her w.c then backs w/c up bumping into nurse in hallway. When reinforced not appropriate due to could hurt someone Res states 'I don't care' . 2:00 P.M., .Res cont (continued) to be argumentative et aggressive toward staff et other pt. 3:20 P.M., .noted Res does not have her smart guard alarm on. Another res reported that she told her she had cut the alarm off et flushed it down the toilet. Res placed on 15 min checks et all staff alerted to monitor doors .DON aware of alarmed off. 8:00 P.M., . At 10 am when this RN came on duty Resident was combative (with this RN, pushed her and hit her .Q (every) 15 min checks continue D/t 0 smart alarm . 8/24/15 at 9:00 P.M., Remains on 15 min checks . 8/25/16 at 1:00 P.M., .Res becomes agitated and rude with staff during Res care and yelling. Res redirected, non effective. Care done and Res left alone . 8/27/15 at 10:00 P.M., Resident did not eat her supper .Resident states she was cold and wants RN to call the Dr. RN checked VS .RN Stated she would not call the Dr as the resident wasn't sick. Resident became angry and attempted to call her daughter .Threw the phone down .called this RN (B****) and became more agitated. She stated she was going to kill herself and started down the hall to her room saying I'll be dead by the time you get here .CNA followed her to her room. Resident attempted to strangle herself (with) a sheet (Resident had stated that she knew how to kill herself as her dad had killed himself). (name of CNA) called for help. (Names of 3 CNA's) pulled the sheet off of resident's neck. Resident was brought into lounge and monitored 1 on 1 until she was transported to (Name of behavior unit). The behaviors culminated in the self harm attempt at 7:50 pm. Once Resident was safe (Name of on call Physician) was paged .gave order to transfer resident to a behavioral unit . Daughter was called multiple times starting at 8:00 pm .(name of town) PD (police department) called and asked to find daughter .(name of ambulance service) picked up resident for transport to (local hospital) at 9:15 pm . The nurses notes lacked any documentation that the residents attending and psychiatric care physicians had been notified of the suicidal ideation expressed by resident on 8/8/15 at 9:00 P.M. Documentation was also lacking that Resident #13's psychiatric physician had been notified as ordered by Resident #13's attending physician on 8/14/15. Resident #13's admission orders [REDACTED]. The care plans were reviewed and included, but were not limited to, a care plan for risk for adverse side effects related to use of [MEDICAL CONDITION] medication initiated on 7/24/15. The interventions included, but were not limited to, Administer meds as ordered, observe for and document side effects, Interdisciplinary team to review routinely to attempt gradual dose reduction and pharmacist to review medications routinely. The care plans lacked any interventions for the behaviors Resident #13 was experiencing. A care plan dated 8/28/15 included, but was not limited to, 8/27/15-Makes statement that she was going to kill herself knew how to do it. I'll be dead by time you get here CNA followed her to room, she attempted to strangle self with sheet CNA intervened brought back to desk-placed on 1 on 1 till she left the building . The Social Service notes were reviewed and lacked any documentation of behavior monitoring from 8/6/15 (the day the behaviors began) to 8/24/16 (23 days) the day Resident #13 called a psychiatric care facility and requested to be seen. Documentation the 15 min checks for the safety or Resident #13 had been initiated on 8/8/15 following the expression of her thoughts and wishes of to do self harm. During an interview with the Social Service Director (SSD) on 5/11/16 at 2:10 P.M., she indicated she had recently taken over the social service care of Resident #13. She indicated when a resident expresses wishes to do self harm or to be dead, the facility would ensure they were safe by monitoring and doing an in depth interview to see if the resident had a plan. She indicated at that time that documentation was lacking that the SSD on 8/8/15 had completed this interview. She indicated the facility would then notify the physician of the comments and the results of their interviews to see if further treatment was warranted. She further indicated a behavior care plan would be initiated for residents that addressed the issues and the resident involved would be monitored. The SSD indicated documentation was lacking that a comprehensive behaviors care plan had been implemented for Resident #13. The SSD further indicated no documentation could be provided that the attending physician for Resident #13 had been notified of the incident on 8/8/15. The SSD indicated documentation could not be provided that the psychiatric physician had been notified on or after 8/14/15 when Resident #13's attending physician had wrote an order to notify them of increased depression and flat affect. During an interview with the DON on 5/12/17 at 8:10 A.M., he indicated that Resident #13's behaviors had been caused by an ongoing difficult relationship with her daughter and attention seeking behaviors. He indicated that following review of the investigation completed, he did not believe the incident on 8/27/15 was a suicide attempt but rather an attention seeking behavior. The DON indicated for the incident to actually be a suicide attempt the sheet would have had to be attached to something stationary as her twisting it was not an actual attempt. The DON indicated documentation could not be provided that the resident's physician and psychiatric physician had been notified of her behavior or a care plan for the behaviors was in place. The investigation was requested and the DON indicated it would not be provided. The policy titled Suicidal Precaution Policy dated 3/2010 was provided on 5/11/16 at 1:34 P.M., by the MDS nurse. The policy included but was not limited to, .It is the policy of this facility to provide for the safety of all resident and to prevent injury/harm from suicide attempts. It is the policy of this facility that it will not admit or keep residents or persons that are active suicide risks in the facility . Resident who verbalize an intent to attempt suicide and is not actively harming him/herself or verbalize a definitive plan . Interview the resident using the following questions even if the resident has a [DIAGNOSES REDACTED]. i. Do you have a suicide plan?, ii. Do you have what you need to carry out you plan? . iii. Do you know when you would do it? . iv. Do you intend to commit suicide If based on the interview there is not definitive plan to cause harm continue with the following steps .document in the Social Service or nursing progress notes; quoting the exact questions asked and the resident actual response .The resident is not to be left alone during the immediate period of time and thereat of suicide has been made. Once the resident is no longer verbalizing intent of suicide they will be placed on 15 minute checks that may be extended to grater periods of time with physician guidance/direction .The clinical standard of monitoring shall be no less than 72 hours or until resident is transferred out of the facility Attempt to calm resident-do not minimize resident's feelings .Notify the physician and family or responsible part .Out of facility intervention is to be determined by the resident's attending physician given the resident status and suicidal threat and/or actions. A policy titled Behavior Management Policy dated 1/16, included, but was not limited to, It is the policy of (name of company) to provide behavior interventions for residents with problematic or distressing behaviors. Integrations provided are both individualized and non homological .Care plans should be initiated for any behavior issue that affects , or has the potential to affect, the resident or other resident Care plan should also be initiated for the behavioral symptoms that relate to [MEDICAL CONDITION] medication use and associated diagnosis .When behavior occurs the staff communicate to the nurse what behavior occurred. The nurse records the behavior on the monitor form including what interventions were attempted during the episode and whether or not they we effective. New or worsening behaviors are reviewed by the IDT (Interdisciplinary team). All alterations should be reviewed by the IDT as they are considered a worsening behavior. A policy titled Incident Reporting Policy dated 8/2015, included, but was not limited to, .A reportable incident is defined as any occurrence not consistent with the routine operation of the nursing facility, which may have caused or may have the potential for causing injury to residents, visitors .Each facility must weigh all relevant facts when determining if the event is reportable. When a reasonable doubt exists in determining if an even is reportable, the event should be reported Reporting within 24 hours of occurrence: 1. Occurrence that directly threatens the Welfare, Safety, or Health of a Resident .suicide attempt . During an interview with the Administrator on 5/12/16 at 10:22 A.M., she indicated the incident had not been reported to the Indiana State Department of Health as the facility had felt it was not a valid suicide attempt. She indicated it was the policy of the facility to monitor behaviors and implement a care plan with effective interventions to ensure a resident with suicidal ideation safety. She further indicated it was the facility's policy to report any actual suicide attempt. 3.1-43(a)(1)

Based on interview and record review, the facility failed to ensure fall prevention interventions were implemented, effective, and immediate interventions were initiated after falls for 2 of 3 residents who met the criteria for review of falls and failed to ensure a wheelchair was in good repair to prevent injury for 1 of 1 resident who met the criteria for review of accidents. This deficient practice resulted in Resident T experiencing a left hip fracture and an injury caused by a broken wheelchair which resulted in a MRSA infection requiring antibiotic treatment and contact isolation. (Resident T, Resident Q) Findings include: 1. The clinical record of Resident T was reviewed on 5/9/16 at 11:40 A.M. The record indicated the [DIAGNOSES REDACTED]. The record further indicated Resident T was discharged from the facility on 5/1/16 at 2:10 P.M. An Annual MDS (Minimum Data Set) assessment dated [DATE] indicated Resident T experience moderate cognitive impairment, required the extensive assist of two staff for transfers, unsteady balance, and had history of falls with injury. The most recent Quarterly MDS assessment dated [DATE] indicated Resident T experience moderate cognitive impairment, required the extensive assist of one staff for two staff for transfers, unsteady balance, and had a history of [REDACTED]. A undated Care Plan dated for, Patient is at risk for fall . included the following interventions: .call light in reach .non skid footwear .personal items in reach .therapy screen During an interview on 5/11/16 at 3:00 P.M., RN #77 indicated the plan was the active plan of care for falls prior to 12/19/16. Fall #1: A Nursing Fall Event note dated 12/19/16 at 2:00 P.M. indicated, Resident T experienced an unwitnessed fall in the bathroom. The note further indicated the immediate intervention implemented to ensure the safety of Resident T was, Assist Res up and toilet. Remind staff he is on scheduled toileting The Nursing notes dated 12/19/16 through 12/20/16 lacked any documentation related to the implementation of an immediate intervention to ensure the safety of Resident T. An IDT (Interdisciplinary Team) note dated 12/21/16 at 11:00 A. M. indicated, .Resident had fall on 12/19/15 attempting to go to the bathroom without assist .Will add bed and chair alarm X (times) 1 week to evaluate frequency of attempting to stand without assist . A Nursing note dated 12/21/15 at 2:00 P.M. Res has transferred self to bed X 2 this day. Up from bed et (and) to BR (bathroom by self X 1. Reinforced to Res to use call light for assist . The note lacked any documentation to indicate a bed or chair alarm was in use or new interventions were implemented. Fall #2: A Nursing Fall Event dated 12/22/16 at 6:15 P.M. indicated Resident T experienced a witnessed fall in the Resident's room and further indicated, .witnessed by roommates wife .was trying to get into bed from .wheelchair to the bed, she heard .say help and she turned around and .had falled (sic) to the floor from wheel chair (sic) .What intervention(s) was put into place to prevent another fall .Resident need (sic) an alarm on chair . The note lacked any documentation to indicate a new, immediate intervention was implemented to ensure the safety of Resident T. A Nursing note dated 12/22/15 at 6:15 P.M. indicated, .I feel the Resident needs chair alarm and not to be left alone in wheel chair (sic) after supper . The note lacked any documentation to indicate a chair alarm was utilized prior to the fall, a new, immediate intervention was implemented, or supervision was provided to ensure the safety of Resident T. An IDT note dated 12/23/15 at 10:40 A.M. indicated, .resident had fall on 12/22/16 at 6:10 P.M. fell (sic) when attempting to put self to bed .to continue chair alarm. staff (sic) to toilet after supper et to be promptly put to bed if resident wishes. will (sic) have OT (Occupational Therapy) to screen for fall et cont (continue) current safety careplan (sic). Accident #1: A Nursing note dated 4/15/16 at 10:32 P.M. indicated, .During check and change a denuded (bare) area measuring 5 cm (centimeters) long by 1/5 cm wide was noted on anterior (front) upper left thigh. The area is pink in color and tender on palpation . A Nursing note dated 4/16/16 at 6:55 A.M. indicated, Reddened area noted to left upper thigh. No edema noted to area. Resident denies any pain . A Nursing note dated 4/17/16 at 12:51 A. M. indicated, Denuded area persists and is bright pink in color compared to surrounding skin . A Nursing note dated 4/17/16 at 6:30 A.M. indicated, Reddened area to left upper thigh continues A Nursing note dated 4/17/16 at 8:59 P.M. indicated, .Red area on Left upper thigh continues . A Nursing note dated 4/18/16 at 8:40 A.M. indicate, .Area is dry and red. No increased warmth noted to area . A Nursing note dated 4/19/16 at 6:45 A.M. indicated, .Red area on left upper thigh is sore to the touch . A Nursing note dated 4/19/16 at 9:10 A. M. indicated, Area to Left upper thigh scabbed over, red around the edges and warm to touch. Res guards area when staff tries to touch. C/O (complaint of) pain when touch . An Appointment Transfer form dated 4/19/16 at 12:37 P.M. indicated, .Res has wound on Left upper thigh-Unsure of where wound came from; would like to know what kind of wound you think this is .we found a spot on res w/c where it could of scraped his leg but (sic) we are unsure . A Nursing note dated 4/19/16 at 4:01 P.M. indicated, Res went out to .NP (Nurse Practitioner) .for area to leg to be assess (sic) .NO (new order) for Bactrim DS (an antibiotic) .for cellulitis (a bacterial infection of the inner layers of the skin) . A Nursing note dated 4/19/16 at 4:11 P.M. indicated, .Antibiotic was ordered for cellulitis and treatment obtained for area. Review of area and residents (sic) wheelchair have indicated that most likely cause of the area was from friction/scraping from broken panel on side of wheelchair. It lines up perfectly in relationship to the area on .thigh and is consistent with the shape of the area. Wheelchair was immediately repaired . A Nursing note dated 4/24/16 at 5:25 A.M. indicated, Area on anterior aspect of left thigh remains red and inflammed (sic), the center is dark brown with pink tissue noted underneath the scab which is sloughing. Tender to ouch. A Wound Culture Report of the left thigh wound dated 4/23/16 indicated a result of, Methicillin (Oxacillin) Resistant Aureus ( a heath care-associated infection typically associated with invasive procedures or devices) . A Physician's Telephone Order dated 4/25/16 at 2:25 P.M. indicated, Contact isolation during wound care . Fall #3: A Nursing note dated 4/30/16 at 10:30 P.M. indicated, resident (sic) found on floor near bed flat on back . The note lacked any documentation to indicate a bed alarm was activated or an immediate intervention was implemented to ensure the safety of Resident T. A Nursing Fall Event dated 4/30/16 at 11:58 P.M. indicated Resident T experienced an unwitnessed fall in the Resident's room and further indicated an immediate intervention of door kept open was implemented. A Radiology Report dated 5/1/16 indicated, .subacute complete slightly displace left .hip fracture . A Nursing note dated 5/1/16 at 11:40 P.M. indicated, .(name of ambulance service) transfers Resident via (by way of) gurney out of facility. Ambulance transfer and paper work (sic) for (name of hospital sent with resident . An IDT note dated 5/2/16 at 4:30 P.M. indicated, .met to review fall from 4/29/16 (sic) .Bed alarm did sound and alerted staff to enter room, where they found him on the floor, next to the bed .Immediate intervention at the time of the fall, Resident was assessed by charge nurse with no apparent injury to hip noted. Resident was assisted back to bed with assist of 2-3 staff and neuro-checks initiated . During an interview on 5/11/16 at 3:30 P.M., the DON indicated all alarms used in the building were pressure alarms and only activate when pressure is relieved. The DON further indicated, the bed alarm of Resident T was placed under the buttocks and would not have activated until Resident T had completely exited the bed. The DON then indicated it wouldn't have mattered if staff was standing right outside the room of Resident T, because Resident T was so quick. During an interview on 5/12/16 at 9:30 A.M., the DON indicated no documentation could be provided to indicate an immediate intervention was implemented after the fall on 12/19/15, a bed/chair alarm was utilized or supervision provided before or immediately after the fall on 12/22/15, the left anterior thigh injury was immediately assessed for root cause, or a new, immediate intervention was implemented or adequate supervision was provided after the fall on 4/30/16. 2. During an observation on 5/5/16 at 11:30 A.M., Resident Q was observed sitting on a chair in the TV lounge. Resident Q stood up from his chair, his alarm sounded and CNA #17 instructed Resident Q to sit down. Resident Q sat in the chair for a few seconds then stood up again, the chair alarm sounded, and CNA #17 asked Resident Q if he wanted water or soda. Resident Q walked away from CNA #17. CNA #17 requested help from another CNA and they walked Resident Q down the hall to his room and assisted Resident Q into bed and left the room. During an observation on 5/5/16 at 11:40 A.M., Resident Q was observed trying to stand up from his bed and the alarm was sounding. Resident Q sat back on the bed for 2 minutes then stood up again. CNA #17 entered the room and asked Resident Q if he wanted to lay back down. Resident Q was then escorted to the dining room where he was seated at a table. During an interview on 5/5/16 at 11:32 A.M., CNA #17 indicated Resident Q was confused today and needed close supervision. The clinical record of Resident Q was reviewed on 5/6/15 at 3:30 P.M. The record indicated the [DIAGNOSES REDACTED]. A Quarterly MDS (Minimum Data Set) assessment dated [DATE] indicated Resident Q experienced moderate cognitive impairment, required the extensive assistance of two staff for transfers, ambulating, and toileting. The May 2016 physician's orders [REDACTED].MAY USE BED AND CHAIR ALARMS FOR RES (resident) SAFETY . A Care Plan for falls dated 1/22/16, included, but was not limited to, .Resident is at risk for fall due to: impaired mobility, impaired vision, IED (intermittent explosive disorder), psychotropic medications, history of falls .Approach .Call light in reach .Non skid footwear .Personal items in reach .Therapy screen . A Care Plan for falls dated 1/22/16, and updated on 2/18/16 included, but was not limited to, .To be in area of close supervision when in recliner so staff can anticipate needs and wants . The Care Plan for falls was updated on 4/25/16, and included, but was not limited to, .Remove floor mat .Scoop mattress to bed The Care Plan for falls was updated on 4/26/16, and included, but was not limited to, .Resident to be near staff during meals. Assist of 2 for transfers, ambulation . The Care Plan for falls was updated on 5/9/16, and included, but was not limited to, .Assist resident from dining area as soon as possible after meals, per resident's preference . The current care plan for falls initiated 5/9/16, lacked documentation of the intervention initiated on 4/26/16, Resident to be near staff during meals . During an interview on 5/10/16 at 10:21 A.M., RN #77 indicated the intervention, Resident to be near staff during meals was not transcribed to the current care plan. A Resident Care/Need Sheet was provided by the Health Care Administrator on 5/4/16 at 11:00 A.M., and it read as follows, .SPECIAL NEEDS .Legally Blind .To be near staff during me (sic) meals . Fall #1 An Event Report indicated Resident Q experienced a witnessed fall on 1/11/16 at 7:12 P.M., and it read as follows, . CNA stated, 'Resident rolled out of bed.' .intervention .Place bed alarm et (and) pad on floor . An IDT (Interdisciplinary team) note dated 1/12/16 at 10:12 A.M., read as follows: .immediate interventions were mat on floor, bed alarm, bed lowest position . A Nursing note dated 1/11/16 at 11:49 P.M. read as follows: .CNA came and got this nurse et took to res room. found res lying on R (right) side facing bed . Fall #2 An Event Report indicated Resident Q experienced a witnessed fall on 2/17/16 at 9:30 P.M., and it read as follows: .res (resident) was sitting in recliner .Resident or witness statement of how fall occurred .unwitnessed .intervention .changed chairs . An IDT note dated 2/18/16 at 11:01 A.M., read as follows: .Resident had scooted self to end of recliner and as chair tilted forward he slid off the end and onto floor . A Resident Progress Note dated 2/18/16 at 1:20 A.M., read as follows: .Up in recliner for 1 on 1 monitoring. Scoots buttocks down in chair, tipping it forward . Fall #3 An Event Report indicated Resident Q experienced a witnessed fall on 4/24/16 at 5:27 A.M., and it read as follows: .Resident was standing up at bedside attempting to ambulate towards this nurse. Stated he had to go to work. His feet slid out from underneath him when he walked on the seizure pad that had been placed by his bed to prevent injury in case he fell .intervention .remove seizure pad An IDT note dated 4/25/16 at 11:14 A.M., read as follows: .Mat caused resident to lose balance and fall to floor .will put lipped mattress in place . Fall #4 An Event Report indicated Resident Q experienced a witnessed fall on 4/25/16 at 5:55 P.M., and it read as follows, .eating dinner .in dining room .stood up, turned and fell . (Name) CNA .intervention .More frequent checks . An IDT note dated 4/26/16 at 3:56 P.M., read as follows: .resident to be near staff during meals . Fall #5 An Event Report indicated Resident Q experienced a witnessed fall on 5/6/16 at 1:14 P.M., and it read as follows: .Just finished lunch .CNA (name) was entering dining room and noted Resident up by chair. Chair alarm was sounding. Resident took a few wobbly steps and went down on his buttocks and onto the floor .Resident will be taken out of dining room as soon as he is finished with his meal . During an interview on 5/10/16 at 3:48 P.M., the MDS nurse indicated Resident Q required increased supervision while in the dining room due to his previous fall in the dining room and his impulsiveness. The policy and procedure for Fall Management Program provided by RN #77 on 5/10/16 at 4:11 P.M., indicated .A fall event .identify possible root causes of the fall and provide immediate interventions . This Federal tag relates to complaint IN 923. 3.1-45(a)(2)

Based on observation, interview, and record review, the facility failed to provide supervision to prevent falls,resulting in falls with resulting hospitalization s for a subdural hematoma and fractured left hips,for 7 of 11 residents reviewed for falls, in a sample of 11. Residents F, K, B, C, J, A, L Findings include: 1. On 8/19/15 at 9:00 A.M., during the initial tour, the Assistant Director of Nursing (ADON) indicated Resident F had not had a recent fall. The clinical record of Resident F was reviewed on 8/20/15 at 11:45 A.M. [DIAGNOSES REDACTED]. A quarterly Minimum Data Set (MDS) assessment, dated 4/8/15, indicated Resident F scored a 2 out of 15 for cognition, with 15 indicating no memory impairment. The MDS assessment indicated the resident required extensive assistance of two+ staff for transfer and ambulation. A test for balance indicated, Not steady, only able to stabilize with staff assistance for Moving from seated to standing position, Walking, Turning around, Moving on and off toilet, and Surface-to-surface transfer. The MDS assessment indicated the resident had fallen since the previous MDS assessment, and sustained a non-major injury. A Care Plan, initially dated 9/23/14 and updated 3/18/15, indicated, Fall/Injury Risk related to: Unsteady .Cognitive Impairment Factors Dementia, Alzheimer's .Interventions: Ambulation: 1A (assist), Transfer: 1A, Resident Supervision General .Broda chair standard foot rests Nurses Notes included the following notations: 6/3/15 at 8:15 P.M.: Res. (resident) found sitting on buttocks on floor next to her Broda (reclining wheelchair) chair, 2 cm (centimeter) skin tear on (left) elbow .New order for (lab work) in a.m. d/t (due to) exacerbation of dementia .Denies pain. (No) other injuries noted A Behavioral Health Progress Note, dated 6/10/15, indicated, Behavior, Confused; Symptoms, Anxious, gets out of chair repeatedly at evening needs 1:1 .Judgment/Insight: Poor; Memory: Poor Nurses Notes continued: 6/13/15 at 11:00 P.M.: Alert (with) confusion. Mult. (sic) attempts to get (up) unassisted .(Up) in Broda chair 6/26/15 at 6:55 P.M.: (Up) in Broda chair, got (up) (without) assist, fell on to floor onto left side lying (sic). Has 2 mm (millimeter) S/T (skin tear) @ outer (left) brow (with) hematoma (raised bruise) (left) side forehead. Also sustained lg (large) S/T above post. (posterior) (left) heel (with) laceration into tissue. (No) LOC (loss of consciousness) The resident was transferred to the hospital on [DATE] at 7:25 P.M. A Nurses Note, dated 6/26/15 at 10:20 P.M., indicated, Res discharged to (name of hospital) (with) dx (diagnosis) of subdural hematoma On 8/20/15 at 3:35 P.M., Resident F was observed to be sitting in a Broda chair by the nurses station, asleep. No staff were observed to be supervising the resident. On 8/21/15 at 9:45 A.M., during an interview with the Administrator, Director of Nursing (DON), and ADON, the Administrator indicated the staff were attempting to keep Resident F in the recreation room to provide increased supervision. On 8/21/15 at 10:10 A.M., the Director of Nursing provided an incident report regarding the resident's fall on 6/26/15. The report included: Nurse was doing med pass and saww (sic) resident stand up and take step from Broda chair and then fall down onto floor. Resident was too far away to reach in time to prevent fall. 2. The closed clinical record of Resident K was reviewed on 8/19/15 at 2:15 P.M. [DIAGNOSES REDACTED]. Nurses Notes included the following notations: 11/23/14 at 5:00 P.M.: Summoned Rec Rm (recreation room) et (and) noted res sitting floor front of her w/c (wheelchair) on buttocks (sic) .Assisted chair (2) .To monitor. 11/24/14 and untimed: IDT (Interdisciplinary team) met to review Res. sliding out of w/c on 11/23/14 while @ dining table. Slid out of chair and on to bottom .Care plan changed for resident to sit in dining chair during meals (and) not in wheelchair. Will monitor for effectiveness A Care Plan, initially dated 4/18/14 and updated 11/24/14, indicated, Fall/Injury Risk related to: Pain, Osteoarthritis .Dementia, Alzheimer's .Interventions: Resident Supervision General .11/24/14 Res. to be in dining chair during meals and not in wheelchair. A quarterly Minimum Data Set (MDS) assessment, dated 12/5/14, indicated Resident K scored a 4 out of 15 for cognition, with 15 indicating no memory impairment. The MDS assessment indicated the resident required extensive assistance of two+ staff for transfer, and had not ambulated in the corridor for the previous 7 days A test for balance indicated, Not steady, only able to stabilize with staff assistance for Moving from seated to standing position, Walking, Turning around, Moving on and off toilet, and Surface-to-surface transfer. The MDS assessment indicated the resident had not fallen since the previous MDS assessment. Nurses Notes continued: 12/7/14 at 11:40 A.M.: (Up) in w/c, alert. (Up) at dining table and res pushes self backwards in w/c causing w/c to flip backwards .Res assisted up and taken to recliner with legs elevated 12/7/14 at 12:00 P.M.: (Name of physician) aware situation A Physical Therapy Progress Note, dated 12/9/14, indicated, Communicated with nursing per pt's (patient's) status and functional mobility .Decrease technique, wt (weight) acceptance, and pt effort noted with tasks this date A Physical Therapy Progress Note, dated 12/10/14, indicated, Communicated with nursing per pt's status and per pt's decline with functional transfers A Nurses Note, dated 12/11/14 at 5:00 P.M., indicated: Swelling noted to (left) leg from hip to foot .N/O (new order) for x-ray Documentation indicated an x-ray of the resident's left hip, femur, knee, and foot was completed on 12/12/14 at 11:40 A.M. Nurses Notes, dated 12/12/14 at 4:30 P.M., indicated, X-ray results back demonstrates an acute complete slightly displaced comminuted left intratrochanteric fracture Nurses Notes, dated 12/13/14 at 2:00 A.M., indicated, Received report .Res. admitted to (hospital) with fractured (right) (sic) hip 3. The closed clinical record of Resident B was reviewed on 8/19/15 at 11:45 A.M. [DIAGNOSES REDACTED]. A Care Plan, initially dated 3/5/15 and updated 5/4/15, indicated: Fall/Injury Risk related to: cervical disc disease, dementia .Interventions: Ambulation 2 A 4/13/15, Transfer 2A, Resident Supervision General, Increased Supervision . Alarms were not listed as an intervention. Progress Notes, dated 4/13/15 at 2:00 P.M., indicated, IDT met to review readmission orders [REDACTED]. is currently assist of (2) for transfers (and) ambulation. Alarms in place to prevent fall A quarterly Minimum Data Set (MDS) assessment, dated 5/4/15, indicated Resident B scored a 11 out of 15 for cognition, with 15 indicating no memory impairment. The MDS assessment indicated the resident required extensive assistance of two+ staff for transfer, and extensive assistance of one staff for locomotion. A test for balance indicated, Not steady, only able to stabilize with staff assistance for Moving from seated to standing position, Walking, Turning around, Moving on and off toilet, and Surface-to-surface transfer. The MDS assessment indicated the resident had not fallen since the previous MDS assessment. A physician progress notes [REDACTED]. Nurses Notes, dated 5/22/15 at 1:45 A.M., indicated, Found resident on floor on her left side after hearing her bed alarm. Res. assisted back to bed after assessment. Res c/o (complains of) (left) knee pain rated 5/10 and (left) hip pain .Small skin tear to left elbow .(Physician) notified and ordered res to (hospital) ED (emergency department) for evaluation Nurses Notes, dated 5/22/15 at 9:45 A.M., indicated, Res admitted to (hospital) with (left) fractured hip. On 8/21/15 at 11:45 A.M., the DON provided an incident report, dated 5/22/15. The report included: Found resident on left side at the door of her room .Resident c/o pain in left knee and left hip .Resident states that she was trying to close the door to her room and fell .Care prior to fall Toileted 05/22/2015 0130 (1:30 A.M.) .Alarm sounding 4. On 8/19/15 at 9:00 A.M., during the initial tour, the ADON indicated Resident C had fallen in the previous 3 months. On 8/19/15 at 10:05 A.M., Resident C's door was observed to be closed. After knocking and entering, Resident C was observed to be standing in her room, with her walker. The clinical record of Resident C was reviewed on 8/20/15 at 10:45 A.M. [DIAGNOSES REDACTED]. Nurses Notes included the following notations: 6/3/15 at 5:00 A.M.: Alert (with) confusion. Difficult to redirect @ x's (times) .(Up) ad lib with walker 6/3/15 at 5:45 P.M.: This nurse heard the Resident yell 'Help!' Went into Resident's room (and) found her laying on the floor in the doorway of the bathroom. Resident stated she slipped (and) fell on her butt. Says her butt hurts where she landed on it but nothing else and it does not hurt bad. Helped Resident up (and) onto bed where she is now eating her supper A quarterly Minimum Data Set (MDS) assessment, dated 6/4/15, indicated Resident C scored a 9 out of 15 for cognition, with 15 indicating no memory impairment. The MDS assessment indicated the resident required supervision of one staff for transfer and walking in her room. A test for balance indicated, Not steady, but able to stabilize without staff assistance for Moving from seated to standing position, Walking, Turning around, Moving on and off toilet, and Surface-to-surface transfer. The MDS assessment indicated the resident had fallen 1 time with no injury since the previous MDS assessment. Nurses Notes continued: 6/5/15 at 5:00 A.M.: Gait unsteady. Feet slipping on floor. Refuses to (change) shoes. Hits staff if they attempt to assist her in any way. Refuses any assistance. Uncooperative (and) difficult to redirect. 6/5/15 at 12:00 P.M.: .Res on floor hollering. C/O (left) hip pain. Refused vital signs. MD ordered send to ER for Eval The resident was admitted to the hospital on [DATE] with a [DIAGNOSES REDACTED]. A hospital transfer sheet, dated 6/7/15, indicated, Needs help, Feeding, Bathing, Dressing, Ambulation, Up in chair, Wt bearing .Patient's behavior Confused Nurses Notes included the following notations: 6/7/15 at 5:05 P.M.: Res readmitted to facility .Assist x (one) (with) transfers .Seems a little confused 6/8/15 at 9:45 A.M.: Call light in resident's room going. CNA went in room and found resident on floor on bottom beside bed. (No) injuries noted .Res states 'trying to get up and slipped.' Notify family; suggested to buy new shoes and maintenance to apply skid strips by bed, recliner, and toilet 6/19/15 at 4:50 P.M.: Res sitting on floor yelling help me. Skin assess done; (no) injuries noted. (No) c/o pain. Res was trying to get up and fell , states 'she is fine, nothing is wronge (sic), that went to stand up and ended on floor.' Res assisted up and directed towards dining room. Will monitor 6/22/15 at 5:00 A.M.: (Up) ad lib. Confused. Refuses assist. 6/23/15 at 7:15 P.M.: Res fell in room. Heard cries for help. Found sitting in floor with large hematoma on (left) forehead. Assessed head to toe. No other injuries .resident agitated .Could not tell me what happened or what she hit. Yelling. Repeating self. Pupils sluggish to react to light .N.O. (new order) to send to E.R. to evaluate and treat The resident was transferred to the hospital on [DATE] at 8:15 P.M., and returned on 6/23/15 at 11:15 P.M. Nurses Notes continued: 6/23/15 at 11:15 P.M.: Returned from (hospital) per cart. Was lifted to her bed. Very angry .Res enc (sic) not to get (up) (without) assist. 6/24/15 at 3:45 A.M.: Staff heard a cry for help (and) entered rm. Res was standing in front of toilet (with) walker .(Left) side of forehead bruised (with) some bruising (lower) (left) eye 6/25/15 at 11:30 A.M.: (Up) ad lib with walker, alert and slightly confused. Gait slow and steady .Bruise cont to (left) side of face .Will cont to monitor. 7/5/15 at 3:00 A.M.: Facial bruising cont. (No) c/o pain. Cont to be (up) ad lib. A Fall Event, dated 7/7/15, indicated, Walking down the hall (and) heard the Resident call out for help. Found her sitting on the floor. Resident stated she fell on her butt (and) needed help up .C/O pain to her backside .Resident or witness statement of how fall occurred: Fixing privacy curtain (and) just fell on her butt .What intervention (s) was put into place to prevent another fall? (Left blank). A Fall Event, dated 7/11/15, indicated, Resident in dining room after lunch, housekeeping staff said Resident got tangled in walker (and) fell to ground .Describe injuries, if any .Hematoma, abrasion to back .What intervention (s) was put into place to prevent another fall? (Left blank). 7/20/15 at 8:00 P.M.: (Up) amb (with) walker ad lib. Resistive (with) care. Difficult to redirect. 8/6/15 at 4:30 A.M.: Res hollering (and) screaming. Res was half on bed, staff not sure if an unwitnessed fall occurred. Res would not let nurse assess her for injuries. 8/6/15 at 6:00 A.M.: Res complained of (left) leg pain, allowed nurse to observe and assess her upper (left) leg, in which a 4 x 2 in knot was found on Res upper left leg outer thigh 8/6/15 at 11:15 A.M.: Res. c/o pain/tenderness (left) thigh. Refuses to keep ice pack on area. Notified (physician), order obtained for x-ray 8/8/15 at 8:00 A.M.: Resident ambulating in hall (with) walker, gait slow (and) steady .Refuses to allow staff to look at (left) (upper) thigh. A Care Plan, initially dated 2/25/15 and updated 8/6/15, indicated, Fall/Injury Risk related to: unsteady, osteoporosis .dementia, Psychosis .Interventions: Ambulation 1 A PRN (as needed), Transfer 1 A PRN Device: walker, Resident Supervision General .6/18/15 Non skid strips by bed .6/29/15 Room rearrangement will attempt (sic) to be made On 8/19/15 at 4:00 P.M. and on 8/20/15 at 9:15 A.M., Resident C's door was observed to be closed. After knocking and entering, Resident C was observed to be up in her room. Her walker was in the room on both occasions, but was not being used by the resident. On 8/21/15 at 9:45 A.M., during an interview with the Administrator, DON, and ADON, the ADON indicated Resident C liked to have her door closed. The DON indicated Resident C had refused therapy services. The Administrator indicated staff had moved the resident's room around, and were now trying to encourage Resident C to visit the Recreation Room more often. 5. On 8/19/15 at 9:00 A.M., during the initial tour, the ADON indicated she was sure (Resident J) had fallen recently. On 8/20/15 at 9:25 A.M., Resident J was interviewed. Resident J indicated he had Parkinson's and sometimes my legs go out on me. Resident J indicated, I've fallen 100 times since I've been here. He indicated he took himself to the bathroom, but was supposed to get help to get out of bed. The clinical record of Resident J was reviewed on 8/20/15 at 9:45 A.M. [DIAGNOSES REDACTED]. An annual Minimum Data Set (MDS) assessment, dated 5/19/15, indicated Resident J scored a 12 out of 15 for cognition, with 15 indicating no memory impairment. The MDS assessment indicated the resident required extensive assistance of two + staff for transfer, and walking in the room or corridor had occurred only once or twice in the previous 7 days, requiring the assist of two + staff. A test for balance indicated, Not steady, only able to stabilize with staff assistance for Moving from seated to standing position, Walking, Turning around, Moving on and off toilet, and Surface-to-surface transfer. The MDS assessment indicated the resident had not fallen since the previous MDS assessment. A Behavioral Health Progress Note, dated 6/10/15, indicated: Thought Process Poor Content; Judgment/Insight: Fair; Memory: Fair Nurses Notes included the following notations: 6/13/15 at 9:00 P.M.: Res's roommate activated call light. This nurse responded et (and) found resident sitting on floor in front of toilet in BR (bathroom). Res wheeled self to BR attempted to transfer self et sat self down on floor. Very slight abrasion noted to L (left) hip .Educated resident on the importance of utilizing call light before transferring self 6/22/15 at 6:50 P.M.: Res. pulled call light. Was kneeling on floor, holding wheelchair. Said attempted to get up and legs got weak. Lowered self to floor. No injury. Res was educated again not to attempt self transferring self alone. Voices understanding. Assisted x 2 into wheelchair A Fall Event, dated 7/2/15 at 12:20 P.M., indicated, Therapist walking by room and saw resident on floor .States he was trying to get in w/c. Was in w/c when staff last in his room .Shoes off (due to blisters on heels) .What intervention(s) was put into place to prevent another fall? (Left blank) A Fall Event, dated 7/5/15 at 8:50 P.M., indicated, Resident pulled call light in bathroom. Had fallen, taking self to bathroom. Did not ask for assistance. Was trying to get back to wheelchair after toileting self. Sitting in floor .'My legs gave out' .Resident educated to ask for assistance with all transfers and not to attempt alone Nurses Notes continued: 7/8/15 at 11:10 A.M.: Res turns on call light. Found Res sitting on floor in BR in front of toilet. DON talks (with) Res. Reinforces to use call light for assist. 7/8/15 at 4:30 P.M.: Resident turns on call light. This nurse found Resident sitting on floor in front of recliner. DON spoke (with) Resident again on importance of using call light for assistance before attempting to get up. A Fall Event, dated 7/9/15 at 1:00 P.M., indicated, Resident pulled call light in bathroom. Had fallen going to BR by self. Did not ask for help to get on toilet. Sitting on floor .'My legs could not hold me up What intervention(s) was put in place to prevent another fall? To make sure Res is toileted before and after meals. Nurses Notes, dated 7/11/15 at 9:00 P.M., indicated, Res pulled call light et found on floor in front of recliner. Trying to self transfer into w/c .Educated res. about the importance of asking for help from staff . Will continue to educate. A Fall Event, dated 7/18/15 at 3:30 P.M., indicated, Res on floor beside door on back. States 'trying to pick up Doritos.' Staff had just been in room few minutes before .Educated Res to ask for help. Nurses Notes continued: 7/28/15 at 1:30 P.M.: In recliner, resting. Res use call light for assist at x's; but transfers self at most times A Physical Therapy Plan of Care, dated 8/14/15, indicated, .Patient has complaints of impaired balance and dec (decreased) strength with resulting impairments in all functional standing, transfers and gait tasks .resulting in decreased safety and an increased need for assistance .Patient will have assistance from nursing staff for all functional mob (mobility) skills PRN (as needed) for safety .Precautions: Hx (history) of multiple falls. Behavior risk. Dec safety awareness. Impulsive A Care Plan, dated 5/19/15, indicated, Fall/Injury Risk related to: History of Falls, pain, unsteady, Dementia, Parkinson's .Interventions: Transfer: W/C, Resident Supervision: General, Nonskid strips in front of recliner et toilet, Positioning bars 6. The closed clinical record of Resident A was reviewed on 8/19/15 at 10:20 A.M. [DIAGNOSES REDACTED]. An Admission Assessment, dated 3/9/15 at 12:30 P.M., indicated, Alert, Confused .Transfer, Extensive Assist, Physical Assist, 2A, Walk in Room: Extensive Assist, Physical Assist, 2A Nurses Notes included the following notations: 3/22/15 at 9:45 A.M.: Alert (with) confusion. (Up) ad lib. Walks in hallways. Enc (encouraged) to use walker. Not cooperative (with) care 3/23/15 at 3:00 A.M.: Res fell in his rm (room) @ approx 0250, hit the (right) side of his head .(no) injuries noted. Staff assist res to feet, res is confused this is not unusual behavior .res has been restless 3/25/15 at 12:45 P.M.: This nurse responded to staff call for assistance. Found resident to be on his back in the hallway just outside his doorway .Res had been attempting to amb in hallway (without) walker 4/29/15 at 11:45 A.M.: Housekeeper approached nursing staff stating that res had lost his balance while standing in his room et res fell backwards into closet doors hitting back of head in closet doors. Nursing staff went to res. room assisted res to is feet res then verbally expressed pain on (right) (lower) side unable to rate pain . The resident was transferred to the hospital on [DATE] and returned to the facility on [DATE] at 3:50 P.M. An emergency room note, dated 4/29/15, indicated, Instructions .Ambulate with help only or to stay in bed till pain at Rt (right) (and) Lt (left) hips is leaving. Nurses Notes, dated 4/29/15 at 3:50 P.M.,. indicated, Ret (return) from (name of hospital) ER .Xrays of Bil (bilateral) hips, 3-view lumbar spine, CXR (chest x-ray) all neg (negative) for FX (fracture) .Amb ad lib (with) walker, FWB (full weight bearing) .To monitor A Multi-Disciplinary Therapy Screening Tool, dated 4/29/15, indicated, Cognition (Includes Safety Awareness): No Change, fair (secondary to) Dx (diagnosis) .Toileting, assist per staff .Transfers, (Sit to stand) (without) (assist); Ambulation, No change, amb up ad lib needs to have (illegible); Balance & Falls: change noted, in room loss of balance in room Nurses Notes continued: 5/10/15 at 6:30 P.M.: Unwitnessed fall in (room number) found by (name) .CNA contacted this nurse who assessed resident A quarterly Minimum Data Set (MDS) assessment, dated 5/16/15, indicated Resident A scored a 1 out of 15 for cognition, with 15 indicating no memory impairment. The MDS assessment indicated the resident required extensive assistance of two + staff for transfer and walking in the room. A test for balance indicated, Not steady, only able to stabilize with staff assistance for Moving from seated to standing position, Walking, Turning around, Moving on and off toilet, and Surface-to-surface transfer. The MDS assessment indicated the resident had fallen twice since the previous MDS assessment, resulting in no injury, and a non-major injury. Nurses Notes continued: 5/31/15 at 7:10 A.M.: Res was found by this nurse to be seated on the floor in front of his lift chair, which was in the highest position. Resident had small abraded area on (left) cheek. Upon investigation, it appears resident slid out of lift chair while it was raised et that he scraped his cheek on the edge of his mini refrigerator .Resident lifted to standing et placed in chair A Care Plan, dated 3/10/15, indicated: Fall/Injury Risk related to: History of Falls .Alzheimer's (with) behavior disturbance .Interventions: Educate resident/responsible party/staff as needed, Up ad lib (with) walker, Resident Supervision: General, Keep walker within reach On 8/21/15 at 2:05 P.M., during an interview with the DON, he indicated Resident A did not require extensive assist with his ambulation. The DON indicated the resident was up by himself all over the building. 7. On 8/20/15 at 3:35 P.M., during observation of the A unit, a personal alarm was heard sounding. No staff was nearby. Resident L was observed to be standing in her room, looking through her refrigerator. Her alarm continued to sound for at least 5 minutes, until she sat back down in her recliner, which silenced the alarm. Nursing Assistant Assignment Sheets, provided by the Administrator on 8/19/15 at 10:30 A.M., were reviewed. The sheets indicated Resident L required a bed alarm and chair alarm as safety devices. On 8/21/15 at 9:25 A.M., during an interview with the Administrator, DON, and ADON, the DON indicated the facility had tried to decrease their alarms used for fall prevention. The Administrator indicated they had recognized the facility had a lot of residents who had fallen, and had just implemented a new activity program to increase supervision for the residents. On 8/21/15 at 11:00 A.M., the DON provided the current facility policy Fall Management Program, revised 2/2015. The policy included: It is the policy .to ensure residents residing within the facility will maintain maximum physical functioning through the establishment of physical, environmental, and psychosocial guidelines to prevent injury related to falls .3. A care plan will be developed at time of admission specific to each resident's fall risk factors. 4. The resident specific requirements will be communicated to the assigned caregiver .Post fall .All falls will be discussed by the interdisciplinary team at the 1st IDT meeting after the fall to determine root cause and other possible interventions to prevent further falls This Federal tag relates to Complaint IN 865. 3.1-45(a)(2)

Based on observation, interview and record review, the facility failed to ensure residents at risk of falls received supervision to prevent falls, in that Resident #12 had experienced a fall resulting in a laceration requiring 3 staples to close and continued to experience repeated falls without new interventions consistently implemented, Resident #49 with repeated falls was left alone in the bathroom without supervision resulting in a fall and Resident #22 lacked the implementation of safety precautions during a transfer resulting in a bruise and skin tear and was left unattended in the bathroom, for 3 of 6 residents reviewed for accidents in the sample of 15. Findings include: 1. During the initial tour, on 1/17/12 at 8:50 A.M., RN # 1 indicated Resident # 12 was up in a wheelchair, required assistance of staff with activities of daily living, was confused and had behavior related to falls. The clinical record for Resident # 12 was reviewed on 1/17/12 at 2:00 P.M. The record indicated Resident # 12 has [DIAGNOSES REDACTED]. The MDS (Minimum Data Set) assessment, dated 10/12/11, indicated Resident # 12 had severe cognitive impairment. Resident # 12 required extensive assistance of one with bed mobility, transfers, ambulation and toilet use. Resident # 12 had not fallen since the previous assessment. A Fall/Injury Assessment: Prevention and Management Plan of Care, dated 3/3/11 and updated on 3/21/11, 4/6/11, 4/7/11, 5/2/11, 5/6/11, 5/19/11, 7/6/11, 7/21/11, 8/1/11, and 8/11/11, indicated a problem of "Fall/Injury Risk related to: restless leg syndrome, cardiovascular diagnosis, dementia, MMR (mild mental retardation), hearing HOH (hard of hearing), visual macular degeneration, antianxiety, cardiovascular meds- digoxin, plavix, antidepressant- remeron, antipsychotic- Zyprexa, lithium, Hx (history) of Fall/Injury: 9/29/10 sat on floor no injuries, 11/26/10 found on floor c/o (complaints of) left hip pain, 11/30/10 fall on floor no injury, 1/12/11 fall to floor "ankle gave out" thought to be behavior, 3/21/11 lost balance et (and) fell to floor no injuries, 4/5/11 on floor in therapy." An Accident/Incident Report, dated 4/30/11, indicated "...12:30 P.M...res ambulating in B wing hallway res leaned to her left side et fell directly on her left side onto the floor...Immediate action taken to prevent further incidents: encourage res to ask for assist with ambulation..." A Progress Note, dated 5/2/11, no time, indicated "Resident reported fall on 5/1/11. Noted edema and bruising to left hand and elbow. X-ray obtained were negative. Res (resident) cont (continues) on therapy caseload. Staff encourage resident to use w/c that has been provided. She is able to propel self in chair without difficulty but resident refuses chair at times. Res was informed recently of near date of discharge from therapy. IDT (Interdisciplinary Team) concern of continued purposeful falling with previous history of that type of behavior. Will encourage use of w/c while therapy continues to explore options for walker that would assist resident with balance. Resident will not be informed of next upcoming d/c (discharge) date from therapy to the restorative program. Plan will be for resident to not feel need for continued fain of attention from therapy staff if she recognizes that she will continue to have individualized time with restorative staff. Will monitor for safety." The fall care plan was updated on 5/2/11 to include the intervention of "xray obtained (neg) (negative). On therapy caseload staff to encourage use of w/c for mobility." An Accident/Incident Report, dated 5/6/11, indicated "...12:40 P.M...Res ambulating past A wing desk fell on to buttocks et (and) hit back of head on floor sustaining laceration top back of scalp 3.2 mm...Immediate action taken to prevent further incidents: (blank)..." In an interview with the Director of Nursing, on 1/19/12 at 9:45 A.M., he provided the second page of the accident/incident report, dated 5/6/11, which indicated "...May still be behavior but unable to control fall, recent med changes, 3 staples, alarming lap belt..." The fall care plan was updated on 5/6/11 to include the intervention of "Out to ER for evaluation cont on therapy case load, SRALB (self release alarming lap belt), ambulation 1 assist and transfer 1 assist." A Progress Note, dated 5/6/11, no time, indicated "IDT met to review due to fall from 5/6/11. Res received staples in the ER (emergency room ) at (hospital name) and was returned. Res cont to have unsteady gait and is non-compliant with use of w/c due to decreased safety awareness. Res in w/c and res agreeable with self releasing alarming lap belt to promote her to remember to allow staff to assist with ambulation and transfers. Cont to be on therapy. Neuro checks continue. Wound care to be done as ordered to staples." The fall care plan was updated on 5/10/11 to include the intervention of "chair alarm." An Accident/Incident Report, dated 7/5/11, indicated "...11:45 A.M...Resident stood from w/c to sit in chair in lobby and fell on to L (left) side. c/o L hip pain...Tab alarm sounding. Noted resident laughing at incident...Immediate action taken to prevent further incidents: Encourage resident to ask for assist with transfers ambulation..." The fall care plan was updated on 7/5/11 to include the intervention of "continue with behavior plan." A Progress Note, dated 7/6/11, no time, indicated "IDT met to review fall from 7/5/11. Res found in floor shortly after she tried to get from DR (dining room). Res denied injury and was laughing about putting self on floor. Behavioral intervention cont will monitor as needed." An Accident/Incident Report, dated 7/20/11, indicated "...1445 (2:45 P.M.)...Res up w/c (sic) propelling self down hallway. Laying on floor left side...1 cm x 1 cm abrasion L (left) knee...Immediate action taken to prevent further incidents: Enc (encourage) request assist from staff to be up. Placed in nsg (nursing) direct supervision..." An Accident/Incident Report, dated 7/31/11, indicated "...11:00 A.M...sat easily onto floor et stated I fell then layed (sic) over et started crying no fall no injuries...Immediate action taken to prevent further incidents: placed direct nsg supervision enc call for assist..." An Accident/Incident Report, dated 7/31/11, indicated "...1300 (1:00 P.M.)...amb (ambulated) hallway. Sat easily down onto floor et cryed (sic) I fell ...Immediate action taken to prevent further incidents: placed direct nsg supervision. Enc call for assist..." In an interview with the Director of Nursing, on 1/19/12 at 9:50 A.M., he indicated the alarm did sound to alert staff Resident # 12 was up unassisted. A Progress Note, dated 8/1/11, no time, indicated "IDT met to review ongoing behavior. Resident observed easing herself to the floor x (times) 2 over the weekend then claiming she fell . This is ongoing pattern of behavior. noted that resident has long history of self injurious behavior when wanting attention. Will ensure psychiatrist is aware of recent behavior." An Accident/Incident Report, dated 8/8/11, indicated "...12:30 P.M...res alarm sounded CNA entered room. Res lost her balance when rising from bed fell on to floor. Landing on L hip...Immediate action taken to prevent further incidents: Assisted res to bed, alarms reapplied, call light in place..." A Fall/Injury Assessment: Prevention and Management Plan of Care, dated 8/11/11, indicated "Fall/Injury Risk related to: restless leg syndrome, cardiovascular diagnosis, dementia, MMR (mild mental retardation), hearing HOH (hard of hearing), visual macular degeneration, antianxiety- ativan, cardiovascular meds- digoxin, plavix, antidepressant- remeron, antipsychotic- Zyprexa, lithium, Hx (history) of Fall/Injury: 3/21/11 fall, 4/5/11 fall, 4/6/11 fall, 5/1/11 fall, 5/6/11 fall, 7/5/11 fall, 7/20/11 fall, 7/31/11 fall, 7/31/11 fall and 8/8/11 fall." An Accident/Incident Report, dated 10/22/11, indicated "...12:15 P.M...Resident was ambulating in room (number) unassisted. Stated she lost her balance fell on to her bottom before staff could get to her...Denied pain. No injury noted...Immediate action taken to prevent further incidents: Encourage resident to ask for assistance when ambulating..." A Progress Notes, dated 10/24/11, no time, indicated "IDT met to review. Res had fall on 10/22/11. She fell after removing her bed tabs alarm while attempting to ambulate no injury noted. Currently on therapy caseload. Will receive balance test on 10/26/11. Will request order for Lithium level. Continue current safety plan and restorative walking program. Will cont to monitor for pattern of behaviors and review as needed..." An Accident/Incident Report, dated 11/9/11, indicated "...1330 (1:30 P.M.)...Resident was found on floor in bathroom in sitting position. Resident had removed tabs alarm herself and whet to bathroom. No apparent injury Denies any pain...Immediate action take to prevent further incidents: Assisted resident up and back to bed. Tab alarm secured to clothing on residents back diff (difficult) to reach and remove..." A Progress Note, dated 11/10/11, no time, indicated "IDT met to review. Res sat self in floor on 11/9/11 no injuries noted. Staff report res removed alarm and unhooked...Alarms adjusted to prevent tampering. Res has ongoing pattern of behavior and placing self on floor. Therapy reports res gait is steady. Will cont to monitor and review as needed." An Accident/Incident Report, dated 11/15/11, indicated "...1930 (7:30 P.M.)...This nurse head alarm sounding found resident on floor next to recliner...no apparent injuries. Assisted back to chair x (times) ii (two) assist sensor alarm in recliner...immediate action taken to prevent further incidents: continued sensor alarm in recliner et close monitoring..." An Accident/Incident Report, dated 12/24/11, indicated "...0615 (6:15 A.M.)...CNA saw res leaning forward in w/c in A wing lounge attempting to pick up trash CNA called res to lean back at that time res fell forward onto floor hitting R (right) side of forehead causing a 1.7 x 0.2 abrasion area cleansed bandaid applied neuro checks started after res placed back in chair alarm did sound...immediate action taken to prevent further incidents: res placed in view of nurse..." An Accident/Incident Report, dated 12/24/11, indicated "...1930 (7:30 P.M.)...Resident found on floor by bed. Abrasion from earlier fall reopened. Bleeding stoped (sic) et bandaid re-applied...Immediate action taken to prevent further incidents: monitored for rest of shift and while in bed. Assured that pressure alarm working..." A Progress Note, dated 12/27/11, no time, indicated "IDT met to review res fell x 2 on Christmas eve while attempting to self transfer. Received a hematoma on forehead. Neuro checks completed with no abnormals noted. Res cont to exhibit falling behaviors at this time. Noted dx (diagnosis) of borderline personality disorder. Dr (name) on call for Dr (name) over the weekend. He was updated on falls with new orders received to obtain CBC, BMP and Lithium levels. Awaiting results. Will cont to monitor for safety and review as needed. Res denies pain." On 1/19/12 at 10:00 A.M., the Director of Nursing indicated the alarm had malfunctioned and was replaced following this fall. 2. Resident #49 was identified on the initial tour of the facility on 1/17/12 at 8:45 A.M., with the Assistant Director of Nursing, as having Downs syndrome, walking with assistance and also using a wheelchair. Resident #49 was observed on 1/18/12 at 11:00 A.M., to ambulate with assistance of 2 staff members and a gait belt, her gait was slow and steady. She was observed to have alarms in the chairs to alert staff of unassisted movement. Resident #49's clinical record was reviewed on 1/17/12 at 1:00 P.M. The most recent Minimum Data Set, dated dated [DATE], indicated the resident was cognitively impaired and required extensive assistance with transfers and ambulation, and had a fall since the last assessment. An "Accident Incident Report," dated 8/21/11 at 12:50 P.M., indicated "Resident was crossing rec (recreation) room floor when she stumbled and went down on left knee...requires no assist with transfers, immediate action was to monitor resident when ambulating and make sure pathways clear." Nurses notes indicated on 9/19/11 the resident started crying in pain, stating her abdomen hurt and refusing to ambulate. The resident was sent to the hospital were she was found to have a fracture of her proximal left humerus (upper arm) and had surgical repair on 9/20/11. During interview with the Director of Nursing on 1/17/12 at 1:30 p.m., he provided an investigation concerning the fracture and indicated at that time the resident could have fallen and gotten up on her own without staff having been aware. The facility was unable to determine what had happened to cause the fracture. A care plan for fall/injury assessment:prevention and management plan of care, dated 8/23/11, indicated 8/21 fall, 7/17/11 fall, 10/6 fall and 10/13/11 fall. Interventions included but were not limited to: ambulate and transfer with 1 assist, 10/5/11 alarms to all seats, 10/6/11 alarms to couch, 1 assist, 10/13 attempt self release alarming seat belt, 12/12/11 continue safety plan CNA educated. The accident/incident reports, included as part of the nurse's notes indicated the following: 10/5/11 1850 (6:50 p.m.) recreation room- stood up for wheelchair and as she was falling pushed a side table away then came down slowly on right side then landed or ended up on bottom all the time hold her left arm with right arm...immediate action to prevent further incidents "brought wheelchair closer to myself." 10/6/11 1230 PM in recreation room, witnessed by a visitor, Res stood up from couch in rec room, takes few steps away from seat and stumbles lands on buttocks then rolls to side and lays down on left side...immediate action-will review resident for use of mobility monitor at meal times until safe to ambulate by self again..." 10/13/11 2000 (8 p.m.) lounge area. sitting in wheelchair, stood up from wheelchair then sat down onto floor on buttocks , exhibiting behavior symptoms just before the incident, yes several attempts to get up unassisted, immediate action to prevent further incidents- keep direct supervision, required 2 assist to get up.. 12/11/11 1310 (110 p.m.) rec room bathroom, Resident was toileting and CNA turned around to cabinet to get new brief when resident apparently slid from toilet to floor on right side between toilet and wall.. This fall was unwitnessed The bathroom in the recreation room was observed on 1/18/12 at 11:00 A.M. An area has been set up in front of the bathroom with several cabinets of supplies and a curtain, which leads to the actual bathroom. The cabinets are outside the actual bathroom door and a resident could not be seen from the cabinet area while sitting in the bathroom. During interview on 1/18/12 at 11:00 A.M. with the Assistant director of nursing, he indicated the alarms were started on 10/6/11 not 10/5/11, as the interdisciplinary team would not have met until 10/6 following the 10/5/11 fall. He further indicated documentation was lacking as to if the alarm was in place on 10/13/11 or if it had rang. 3. On 01/18/12 at 9:00 a.m., Resident #22 was observed in a shower room to be seated sideways on a commode. The Resident was observed to be unattended by staff. The resident was noted to whimper and attempt to button her robe. After a few minutes, the resident started mumbling, "Wonder why nobody's come to help me." The resident was observed to have a reddened skin tear on her lower right leg which was held together with steri-strips. At 9:15 a.m., the resident indicated, "Guess I'll ring the bell." The resident then pulled the call light string. At 9:16 a.m., CNA # 1 and CNA # 2 entered the shower room. Using a gait belt, the CNA's assisted the resident to stand and after providing incontinence care, the CNA's were observed to transfer the resident from the commode to her wheelchair. During the incontinence care, the resident's bottom was observed to be reddened and to have an indentation on her outer buttocks from sitting on the commode. During interview of LPN #2 (Nurse working floor Resident #22 resided on) on 01/18/12 at 10:00 a.m., indicated LPN #2 was not certain how Resident #22 was supposed to be transferred. LPN #2 indicated the last she heard was that Resident #22 was to be evaluated by Physical Therapy for transfers, but she was not sure whether or not this had been done. Review of Resident #22's clinical record on 01/18/12 at 9:40 a.m. indicated the following: Resident #22 had [DIAGNOSES REDACTED]. A quarterly MDS (Minimum Data Set) assessment, dated 11/25/11, indicated the resident had severe cognitive impairment, was unable to recall 3 words, was frequently incontinent of bladder, and required extensive assistance of staff for toileting and transfers. An "Accident/Incident Report," dated 12/03/11 at 7:20 p.m., indicated, "During transfer from toilet to w/c (wheelchair), Res (Resident #22) eased to sitting position onto floor per CNA's. 0 (No) injury sustained. Denies pain....Immediate Action Taken To Prevent Further Incidents: Use stand up lift to enable secure transfers...." The report indicated the resident was being transferred by 2 CNA's and with assist of a gait-belt at the time of the incident. An "Accident/Incident Report," dated 12/23/11 at 10:00 a.m., indicated, "Res (Resident #) bumped hand on bathroom rail during transfer. Noticed bruise dark purple and black 5.5 x 5 across nuckles (sic). 0 (No) s/s (signs or symptoms) pain. 0 changed ROM (range of motion)." The "Reason" section of the report had not been filled out. The report indicated the resident was not compliant with assistive devices. An IDT (Interdisciplinary Team) progress note, dated 12/27/11, indicated, "IDT met to review Res (Resident #22) noted to have bruising to knuckles on her left hand. Res had bumped it on the handrail in the bathroom. Hand was x-rayed to R/O (rule out) fx (fracture) c (with) results being negative. Denies c/o (complaint of ) pain or discomfort. Will monitor for healing & review as needed." A physician's telephone order, dated 01/03/12, indicated, "PT (Physical Therapy) eval (evaluation) done. Pt (Resident #22) not appropriate for skilled PT at this time. A physician's telephone order, dated 01/04/12, indicated, "OT (Occupational Therapy) eval on 1/3/12 - No indication for OT intervention at this time. An "Accident/Incident Report," dated 01/14/12 at 11:45 a.m., indicated, "Three CNA's attempting to transfer resident from recliner to w/c (wheelchair). Resident's feet slid under the bed and shin was injured on underside of bed frame....Immediate Action Taken To Prevent Further Incidents: CNA's educated to use mechanical lift for all future transfers of this resident until therapy can evaluate needs. The report indicated the resident sustained [REDACTED]. The report indicated the resident was wearing "socks only" at the time of the incident. The report indicated the socks were not "gripper socks." An IDT progress note, dated 01/18/12, indicated, "IDT met to review-discussed fall for 12/3/11. Safety plan was ii (2) person assist for transfer. Res cont (continues) to show increased difficulty c transfers. Res noted to have another recent fall that resulted in a skin tear - this also during transfer. PT to re-eval (re-evaluate) for safe transfer & evaluate appropriateness of mechanical lift. Will continue to monitor and review as needed. The IDT did not meet until 4 days after the resident's fall on 01/14/12. Documented interviews from two of the CNA's were provided by the DON on 01/18/12 at 2:30 p.m. Both interviews indicated Resident #22's feet were slipping & slipped under the bed and the bed railing cut the resident's leg. A "Fall/Injury Assessment/Prevention and Management Plan of Care," dated 08/30/11 with updates of 11/29/11 and 12/23/11, indicated the resident was a fall risk related to pain, osteoarthritis, osteoporosis, poor weight bearing, fall history, and severe thoracic (curvature of the spine). The plan of care listed several interventions to prevent falls such as non-skid socks and non-skid strips to floor. No interventions on the list were check marked as being implemented. Hand written on the last page of the plan of care was, "Encourage resident to use gait belt but allow her to choose." This intervention was dated 10/02/10. No additional plans/interventions to prevent the resident from being injured during transfers were provided by the facility. 3.1-45(a)(2)

Based on observation, interview and record review, the facility failed to ensure a resident at risk of pressure ulcers, was assessed and provided measures to prevent pressure ulcers, with the resident developing a Stage 3 pressure ulcer above her right ear from the oxygen tubing, for 1 of 4 residents reviewed who were at risk of pressure ulcers in the sample of 15. Resident #27 Findings include: On 1/17/12 at 8:50 A.M., during the initial tour with RN # 1, she indicated Resident # 27 had a fall with a [MEDICAL CONDITION] and had been receiving palliative care. She indicated Resident # 27 was doing much better now and was no longer palliative care. She stated Resident # 27 was participating in therapy services. She further indicated Resident # 27 required oxygen per nasal cannula. Resident # 27 was observed to be in a low bed with a mat to the side of the bed. Resident # 27 was observed to be on her back with the head of the bed elevated. On 1/17/12 at 10:15 A.M., Resident # 27 was observed to be in bed on her back with the head of the bed elevated. Resident # 27 was observed to have oxygen per nasal cannula. On 1/17/12 at 10:45 A.M., Resident # 27 was observed to be in bed on her back with the head of the bed elevated. Resident # 27 was observed to have oxygen per nasal cannula. On 1/17/12 at 11:40 A.M., Resident # 27 was observed to be in bed on her back with the head of the bed elevated. Resident # 27 was observed to have oxygen per nasal cannula. PT staff (physical therapy) was observed to be in the room with Resident # 27. PT staff # 1 was observed to remove Resident # 27's nasal cannula and looked at the top of Resident # 27's ear. There was observed to be an open area with a yellow base the size of a dime. The nasal cannula was observed to have a 4 inch by 4 inch piece of gauze taped around the tubing that was resting on this area. There was a moderate amount of drainage noted on the gauze. PT staff # 1 stated "It doesn't look as bad as I thought it would." PT staff # 1 was then observed to place the nasal cannula with the soiled gauze back on Resident # 27. On 1/17/12 at 12:35 P.M., Resident # 27 was observed to be in bed on her back with the head of the bed elevated. Resident # 27 was observed to have oxygen per nasal cannula. On 1/17/12 at 12:45 P.M., in an interview with RN # 1, she indicated weekly skin checks are done by the charge nurse. She stated the nurse would then document on the treatment sheet either a negative or positive sign. A negative sign meant there was no skin issues. A positive sign meant there was an issue with the skin and the charge nurse would then describe and measure the area and document on a skin sheet. On 1/17/12 at 12:55 P.M., Resident # 27 was observed to be in bed on her back with the head of the bed elevated. Resident # 27 was observed to have oxygen per nasal cannula. On 1/17/12 at 2:10 P.M., Resident # 27 was observed to be in bed on her back with the head of the bed elevated. Resident # 27 was observed to have oxygen per nasal cannula. On 1/17/12 at 3:15 P.M., Resident # 27 was observed to be in bed on her back with the head of the bed elevated. Resident # 27 was observed to have oxygen per nasal cannula. On 1/17/12 at 4:00 P.M., Resident # 27 was observed to be in bed on her back with the head of the bed elevated. Resident # 27 was observed to have oxygen per nasal cannula. On 1/17/12 at 4:30 P.M., in an interview with LPN # 1, she indicated she had been the charge nurse for Resident # 27's hall since 2:00 P.M. She indicated she had received report at that time from RN # 2. She further indicated she had not been given any information regarding Resident # 27 during the report. On 1/17/12 at 4:35 P.M., LPN # 1 was observed to enter Resident # 27's room. LPN # 1 indicated she was not aware there was an area on the top of Resident # 27's right ear. She further stated she was the wound nurse and would stage the area at a stage II. She indicated on the top of the left ear had a scabbed area. The clinical record for Resident # 27 was reviewed on 1/17/12 at 4:50 P.M. and included a Progress Notes, dated 1/17/12 at 1645 (4:45 P.M.), which indicated " noted res (resident) having an area on R (right) top back ear d/t (due to) O2 tubing. 1.5 x (by) 1.0 x < (less than) 0.1 area ...new tubing with padding applied. Tylenol given d/t (due to) discomfort. " The Director of Nursing provided the facility policy and procedure for wound prevention and treatment, dated April 2009, on 1/17/12 at 4:45 P.M. The policy indicated "...Stage III: Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss...The depth of a stage III pressure ulcer varies by anatomical location. The bridge of the nose, ear...do not have subcutaneous tissue and stage III ulcers can be shallow...Weekly skin assessment...requires centers to complete a Weekly Skin Assessment. This assessment includes a head to toe visualization of the residents skin..." On 1/17/12 at 5:25 P.M., in an interview with LPN # 1 she indicated she had notified Resident # 27's physician concerning the areas behind each ear. She indicated the physician had given a treatment order for the area to the right ear. The clinical record for Resident # 27 was reviewed on 1/17/12 at 9:30 A.M. The record indicated Resident # 27 had [DIAGNOSES REDACTED]. The resident had a phyican's order, dated 1/14/12, for oxygen 4 liters per nasal cannula. The MDS (Minimum Data Set) assessment, dated 11/10/11, indicated Resident # 27 had moderately impaired cognition. Resident # 27 required extensive assistance of two with bed mobility, transfers and toilet use. Resident # 27 had no pressure sores. A care plan, dated 11/15/11 and updated on 1/6/12, indicated a problem of "Skin Integrity Assessment: Prevention and Treatment Plan of Care. Braden Risk Assessment Score At Risk (15-18) Pressure-reduction support surface if bed or chair bound. At risk related to: bowel incontinence, Bladder incontinence, rt (right) [MEDICAL CONDITION] and repair, [MEDICAL CONDITIONS]. Healthy Skin: Clean, well hydrated, normal skin color." The interventions included but were not limited to "complete Braden Scale upon admission and quarterly, and with change of condition, Keep skin clean, dry and free of body wastes, perspiration and wound drainage, and inspect the skin for signs and symptoms of breakdown." The Braden Risk Assessment Scale, dated 1/4/12, indicated a score of 9. The form indicated a score of 0-9 Very High Risk. The January 2012 treatment record indicated a skin assessment was done on Resident # 27 on 1/16/12. No areas were documented to have been red or open. A Pain Data Collection and Assessment, dated 1/17/12, indicated " ...Pain Scale. On a scale of 0-10, with 0 being ' no pain ' and 10 being the " most intense pain imaginable " , what would you rate the severity or intensity of your pain right now? 6...Vocal Complaints of Pain- " ouch " . Facial expressions- wrinkled forehead...Resident Current Conditions: Pressure Ulcer d/t (due to) O2 tubing...Over the past five days, what precipitates/exacerbates pain: pressure from tubing... " 3.1-40(a)(1)