Every finding on record at Rawlins House Health & Living Community

Based on observation, interview, and record review, the facility failed to ensure residents with a diagnosis of dementia were free from antipsychotic medications being used as a chemical restraint due to lack of gradual does reductions (GDR), statements of contraindication, and failed GDR without documented psychotic behaviors for 3 of 4 residents reviewed for antipsychotic use. (Residents 42, 46, and 10) Findings include:1.Resident 42's clinical record was reviewed on 12/18/25 at 1:47 p.m. Current diagnoses included dementia with psychotic disturbance, dementia without behaviors, depression, and anxiety. The resident resided on a secured dementia/memory care unit. Current orders included olanzapine/Zyprexa 5 mg (antipsychotic medication) administer 1 tablet daily (5/13/25). A 11/24/25, annual, MDS (Minimum Data Set) assessment indicated the resident was severely cognitively impaired, did not have delusions, hallucinations, or display any maladaptive behaviors during the assessment period. The resident received an antipsychotic medication. The resident had not had a gradual reduction of the antipsychotic medication. The resident had a statement of contraindication for a reduction of the antipsychotic medication on 8/28/25.An 8/13/25, Nursing Home Psychiatric Visit Form indicated the resident was cooperative. The resident had a poor memory. The resident did not display delusions or hallucinations during the visit. The resident had poor insight and poor memory. The resident was oriented to person but not place or time. He counseled with the resident about risks and benefit of treatment options and the importance of compliance with chosen treatment. The Treatment Plan contained the no documentation regarding gradual or a statement of contraindication and indicated the olanzapine was used for (unspecified) intermittent distressful psychotic symptoms.An 8/27/25 Nursing Home Psychiatric Visit Form indicated the resident was stable/recovering/improved. She was cooperative. She was calm, pleasant and attending an activity. The resident had a poor memory. The resident did not display delusions or hallucinations during the visit. The resident had poor insight and poor memory. The resident was oriented to person but not place or time. The Treatment Plan did not contain a statement regarding a GDR for Zyprexa, nor a statement of contraindication.An 11/20/25, Nursing Home Psychiatric Visit Form indicated the resident was cooperative. She was calm and pleasant. The resident had a poor memory. The resident did not display delusions or hallucinations during the visit. The resident had poor insight and poor memory. The resident was oriented to person but not place or time. The Treatment Plan did not contain documentation regarding gradual or a statement of contraindication. The note indicated to continue olanzapine at current dose for intermittent distressful psychosis.The clinical record lacked documentation of a failed gradual does reduction for the antipsychotic medication Zyprexa/Olanzapine since it was originally ordered on 5/13/25. The clinical record lacked a statement of contraindication for the reduction of the antipsychotic medication which included an analysis of the medications risks and benefits. The clinical record lacked documentation of how the medication maintained, improved, or enhanced the resident's quality of life or quality of care. An 8/28/25 statement of contraindication was not located in the resident's clinical record.During an observation on 12/17/25 at 10:06 a.m., Resident 42 was in the common area during an activity. She was calm and engaged in the event.During an observation on 12/22/25 at 3:02 p.m., Resident 42 was in the common area during an activity. She was calm and engaged in the event. 2.Resident 56's clinical record was reviewed on 12/18/25 at 1:42 p.m. Current diagnoses included unspecified dementia without behavioral disturbances, mood disturbances, or anxiety; psychotic disorder with delusions, depression, and insomnia. The resident resided on a secured dementia/memory care unit. Current orders included olanzapine/Zyprexa 5 mg administer 1 tablet daily (8/3/23).A 9/24/25, Nursing Home Psychiatric Visit Form indicated the resident was cooperative. The resident had a poor memory. The resident did not display delusions or hallucinations during the visit. The resident had poor insight and poor memory. The resident was oriented to person but not place or time. He counseled with the resident about risks and benefit of treatment options and Importance of compliance with chosen treatment. The Treatment Plan contained the following documentation regarding gradual or a statement of contraindication: No change to Olanzapine dose at this time but monitor for escalation in psychotic symptoms.A 10/8/25, Nursing Home Psychiatric Visit Form indicated the resident was cooperative. The resident had a poor memory. The resident did not display delusions or hallucinations during the visit. The resident had poor insight and poor memory. The resident was oriented to person but not place or time. The Treatment Plan contained the following documentation regarding gradual or a statement of contraindication: No adjustment to her treatment plan today. A 10/30/25, quarterly, MDS assessment indicated the resident was severely cognitively impaired, did not have delusions, hallucinations, or display any maladaptive behaviors during the assessment period. The resident received an antipsychotic medication. The resident had not had a gradual reduction of the antipsychotic medication. The resident did not have a statement of contraindication for a reduction of the antipsychotic medication. The clinical record for 2024 and 2025 lacked documentation of a failed gradual does reduction for the antipsychotic medication olanzapine since it was originally ordered on 8/3/23. The clinical record lacked a statement of contraindication for the reduction of the antipsychotic medication which included an analysis of the medications risks and benefits. The record lacked documentation of how the medication maintained, improved, or enhanced the resident's quality of life or quality of care. During an observation on 12/17/25 at 10:06 a.m., Resident 56 was in the common area during an activity. She was calm and engaged in the event.During an observation on 12/22/25 at 3:02 p.m., Resident 56 was in her room in bed. She was calm and resting with her eyes closed. 3.Resident 10's clinical record was reviewed on 12/18/25 at 1:39 p.m. Current diagnoses included dementia with psychotic disturbance, dementia without behavioral disturbances, mood disturbances or anxiety, and anxiety. The resident resided on a secured dementia/memory care unit. Current orders included olanzapine/Zyprexa 7.5 mg administer 1 tablet daily, starting 9/11/25. The medication was reduced to 5 mg daily on 8/29/25 and returned to 7.5 mg daily on 9/11/25. An 11/19/25, quarterly, MDS assessment indicated the resident was severely cognitively impaired, did not have delusions, hallucinations, or display any maladaptive behaviors during the assessment period. The resident received an antipsychotic medication. The resident had a gradual reduction of the antipsychotic medication on 9/3/25. The resident did not have a statement of contraindication for a reduction of the antipsychotic medication.The resident had the following behavioral notes during the 14 days (8/29/25 to 9/11/25) when the clinical record documented she had a failed GDR and increased the Zyprexa to the previous dosage:An 8/30/25 at 10:30 p.m., Progress Note indicated nursing staff would continue to monitor and document for any adverse reactions, signs and symptoms of psychosis, agitation, and increased wandering/intrusiveness, and delusions. No new behaviors observed or reported this shift. Resident has been easily directed and redirected this shift, currently resting in bed. Will continue to monitor. An 8/31/25 at 1:59 p.m., Progress Note indicated the resident showed no adverse reactions or psychosis: elder has been agreeable with care, easily redirectable/distracted, no increased wandering, no intrusive behaviors. Resident was currently sitting in dining room listening to music and interacting with peers appropriately. Nursing staff to continue to monitor and document any new behaviors.A 9/1/25 at 12:21 a.m., Progress Note indicated the resident had been very cooperative during the evening shift, she was easily redirected and had a few episodes of wandering into other residents space and rooms. The resident was very hard of hearing, which caused her to be intrusive at times. Nursing staff would continue to redirect and monitor for behaviors. A 9/3/25 at 1:38 a.m., Progress Note indicated the resident was wandering a lot this evening and into the night, and was redirected back to bed but was up shortly thereafter. The resident was assisted with toileting, given fluids and snacks, and took meds without difficulty. No indications of pain or discomfort. The resident was redirected out of other residents' rooms. The resident thought the nurse was her husband and repeatedly told other residents that approached to find their own man. The resident was polite but insistent. She was in her own bed at this time.The progress note did not indicate signs of distress nor that the resident's belief that the nurse was her husband negatively impact her quality of life. A 9/4/25 at 10:57 p.m., Progress Note indicated the resident had been very pleasant and at ease this shift with other residents and staff, and was very easy to direct and redirect. Nursing staff would continue to monitor and observe for any behaviors, increased wandering and adverse reactions.A 9/6/25 at 10:59 p.m., Progress Notes indicated the resident showed no adverse reactions or psychosis related to the recent medication change. The resident was agreeable with care, easily redirectable/distracted, had no increased wandering, and no intrusive behaviors. The resident was awake periodically tonight but easily redirected back to bed.A 9/8/25 at 4:12 a.m., Progress Note indicated the resident was awake multiple times this shift. Redirected easily to toilet then back to bed. There were no signs or symptoms of psychosis, agitation or delusions.A 9/8/25 at 3:17 p.m., Progress Note indicated the resident was very active this shift. Very difficult to redirect. Would not lay down or rest at all, even though she stated several times that she was very tired. Wandered hallways all day. Intrusive to other residents. Wandering into their rooms and trying to touch their belongings.There was no documentation of delusions, hallucinations, or psychotic episodes. A 9/11/25 at 12:46 p.m., Progress Note indicated the MD was notified of increased wandering, intrusive behaviors, anxiety, and agitation. New order received to increase Zyprexa back to 7.5mg.A 9/25/25, Nursing Home Psychiatric Visit Form indicated the resident was cooperative. The resident had a poor memory. The resident did not display delusions or hallucinations during the visit. The resident had poor insight and poor memory. The resident was oriented to person, but not place or time. During an observation on 12/17/25 at 10:06 a.m., Resident 10 was walking around the dementia unit restlessly, but was smiling.During an observation on 12/22/25 at 3:02 p.m., Resident 10 was in bed in her room. The room was dark. She was calm and resting with her eyes closed. During an interview on 12/22/25 at 10:08 a.m., the Social Services Director indicated the facility did not have statements of contraindication for antipsychotic medications that included a risk benefit analysis for Residents 42 and 56. She also indicated the facility did not have any episodes of delusions, hallucinations, or psychotic behaviors during the 14 day period when Resident 10 had a failed GDR for her antipsychotic medication. A current, undated, facility policy titled, Behavioral Health and Management Program, which was provided by the Administrator in 12/22/25 at 2:49 p.m. indicated the following: .Reduction.Residents who are admitted with an anti-psychotic medication, the facility must re-evaluate the use of the antipsychotic medication at the time of admission and/or within two weeks of admission and consider whether the medication can be reduced/tapered/discontinued. Residents who are on an antipsychotic medication will have a dose reduction attempt documented by the attending physician and clinical team two (2) separate times within the first 12 months from the admission date. The two (2) separate attempts should be at least one (1) month apart from each attempt unless this is clinically contraindicated and documented by the physician. If a dose reduction is clinically contraindicated the physician will document the clinical rationale why a reduction would likely impair the resident's ability to function or cause psychiatric instability by exacerbating an underlying medical or psychiatric disorder which may lead to the resident being in danger of harming self or others. If the physician does not believe a dose reduction is warranted, he/she will also document the resident is taking the lowest possible dose and the current risk of reducing this dose outweighs the potential benefits of a reduction at this time. If an existing psychotropic medication dose is increased the IDT will re-evaluate the effectiveness and ongoing need for that dose within ninety (90) days and annually thereafter and collaborate with the provider and family related to the best interest of the residents condition. After the first year, a tapering should be attempted annually unless clinically contraindicated (2013.). 3.1-3 (w)3.1-26(k)(1)(o)

Based on record review and interview, the facility failed to provide notice of transfer/discharge and bed hold policy to the resident or resident representative for 4 of 5 residents reviewed for hospitalizations. (Resident 112, 25, 3, and 64, )Findings include:1. Resident 112's clinical record was reviewed on 12/19/25 at 9:15a.m. Diagnoses included congestion heart failure, Parkinson's disease, and Alzheimer's disease. An admission Minimum Data Set (MDS) indicated the resident was moderately cognitively impaired. A 11/7/25, nursing note indicated the resident was sent to the emergency room (ER) after a physician's visit to the facility for impending respiratory failure. Family was contacted by phone. The record lacked indication that the resident and/or their representatives were educated on the notice of transfer and bed hold policy. An 11/7/25 transfer form lacked indication as to who the transfer notice paperwork was provided to. A 12/22/25, bed hold document provided by the DON., lacked indication the resident or their representative was notified of the bed hold policy. 2. Resident 25's clinical record was reviewed on 12/18/2025 at 1:53 p.m. Diagnoses included dementia, hypertension, and hyperlipidemia. A 12/9/25, discharge MDS assessment indicated Resident 25 discharged with a return anticipated. A 12/9/25, progress note indicated the resident went to the hospital via an emergency ambulance following a fall with a suspected fracture. The note indicated continuity of care information, the Bed Hold Policy, and guardianship papers were sent with the resident. The resident's family was contacted regarding the fall and need for hospitalization. Resident 25's, 12/9/25, Notice of Transfer or Discharge form and copy of the Bed Hold Policy, with the resident's name in the upper right corner, were both provided by the DON on 12/22/25 at 10:29 a.m., and lacked documentation of who received the forms. The record lacked documentation that discharge paperwork and the Bed Hold Policy had been provided to the family/guardian in person or through the mail. 3. Resident 64's clinical record was reviewed on 12/19/25 at 2:28 p.m. Diagnoses included acute on chronic systolic (congestive) heart failure, age-related cognitive decline, and unspecified sepsis (severe infection). A 10/18/25, admission Minimum Data Set (MDS) assessment indicated Resident 64 was cognitively intact. An 11/25/25, discharge, MDS assessment indicated Resident 64 discharged with a return anticipated. A 11/25/25 progress note indicated Resident 64 was lying in bed, confused and mumbling words that could not be understood. The nurse received an order from the on call doctor to send the resident to the hospital. The resident's representative was called, and papers were filled out and sent to the hospital. Report was given to emergency room. A 11/25/25, Resident Transfer Form observation note indicated the resident was sent the hospital. The document lacked indication that the resident or their representative was notified of transfer rights or bed hold policy. A 11/25/25, Notice of Transfer or Discharge form and copy of the Bed Hold Policy, were provided by the DON on 12/22/25 at 10:29 a.m., and lacked documentation of who received the forms. The record lacked documentation that discharge paperwork and the Bed Hold Policy had been provided to the resident or resident representative in person or through the mail. 4. Resident 3's clinical record was reviewed on 12/19/25 at 1:33 p.m. Diagnoses included moderate vascular dementia, insomnia, and recurrent major depressive disorder. A 9/30/25, discharge, Minimum Data Set (MDS) assessment indicated the resident discharged with a return anticipated. A 10/20/25, quarterly, MDS indicated Resident 3 was cognitively intact. A 9/29/25, progress note indicated Resident 3 was having escalating behaviors such as calling people vulgar names, yelling, and threatening to call the police. The resident's Power of Attorney (POA) asked that the resident be sent to the hospital. The emergency medical technicians (EMTs) arrived, and all appropriate paperwork was sent. The resident was arguing with the EMTs. Report was called to the hospital. A 9/29/25, Resident Transfer Form observation note indicated the resident was sent the hospital. The document lacked indication that the resident or their representative was notified of transfer rights and bed hold policy. A 9/29/25, Notice of Transfer or Discharge form and copy of the Bed Hold Policy, were provided by the DON on 12/22/25 at 10:29 a.m., and lacked documentation of who received the forms. The record lacked documentation that discharge paperwork and the Bed Hold Policy had been provided to the resident and/or resident representative in person or through the mail. During an interview, on 12/22/25 at 9:58 a.m., LPN 6 indicated when a resident needed to be sent the emergency room she would immediately contact the doctor to get an order for the discharge. She printed out the following resident documents: Continuity of Care document (CCD), face sheet, and pertinent labs. She would call the resident's family, the facility DON and the Administrator. She would provided the printed documents to the EMTs to ensure the documents are taken to the hospital. LPN 6 made note in the resident's clinical record of the entire situation. During an interview, on 12/22/25 at 10:04 a.m., LPN 7 indicated when a resident required a transfer to the emergency room, she contacted the doctor to get an order for the discharge. She printed out the following documents: Bed Hold Policy, CCD, recent labs, and a face sheet. She contacted the resident's family, the DON, and the Administrator. She would call report to the emergency room. She indicated she would stay with the resident until the EMTs arrived and provided the EMTs with the printed documents to ensure the hospital received the information. She would complete the transfer observation and make a progress note in the resident's clinical record. During an interview, on 12/22/25 at 2:23 p.m., the DON indicated the expectation for the discharge process was for the nurse to print up the resident specific information, the notice of transfer/discharge, and the bed hold policy. The nurse should make multiple copies of the forms so they can be provided to the EMTs to take the hospital and uploaded into the resident's clinical record. The discharge/transfer notice did not have a place to sign or document who received the papers. The nursing staff completed the Resident Transfer Form observation note but the form did not have a place to document who received the papers. The DON indicated she did not ask the resident or resident representatives to sign the documents and the staff did not always document in the clinical record who received the papers. A facility policy, revised 6/5/19, titled, Bed Hold Policy, provided by the Administrator on 12/22/25 at 2:46 p.m., indicated the following: [NAME] and Associates, Inc. and its member communities will provide the resident and resident representative written notice which specifies the duration of the bed-hold policy when a resident is admitted and again if the resident is hospitalized or on a therapeutic leave . A facility policy, effective 11/24/14, titled, Clinical- Resident Discharge & Transfer Policy, provided by the Administrator on 12/22/25 at 3:33 p.m., indicated the following: . Before an interfacility transfer or discharge occurs, the facility must use the State approved form and do the following: (1) Notify the resident of the transfer or discharge and the reason for the move in writing and in a language and manner that the resident understands. The facility must place a copy of the notice in the resident's clinical reord and transmit a copy to the following: (a) The resident. (b) A family member of the resident if known . An undated current facility policy, titled, Ombudsman Reporting Process of All Notice of Transfer/Discharge, provided by the Administrator on 11/22/25 at 3:33 p.m., indicated the following: .For any transfer to the hospital or discharge with no return anticipated, two copies of Bed Hold, Notice of Transfer/Discharge (2 pgs) and Request for Hearing must be created for the resident. Resident/family should sign a copy for facility to upload to Resident Documents. Resident/family should retain a copy . 3.1-12 (a)(4) 3.1-12(a)(6)(A)(i) 3.1-12 (a)(26)

Based on record review and interview, the facility failed to administer the appropriate Pneumococcal vaccinations per the Center for Disease and Control (CDC) guidance for 1 of 5 residents reviewed for infection control. (Resident 2) Findings include:Resident 2's clinical record was reviewed on 12/19/25 at 11:29 a.m. Diagnoses included unspecified dementia, repeated falls, and neuromuscular dysfunction of the bladder. A 12/9/25, quarterly, Minimum Data Set (MDS) assessment indicated the resident had severe cognitive impairment. Review of the resident's vaccinations included the following:The resident had a historical administration of Pneumovax 23 on 7/13/05, prior to admission to the facility.A Pneumococcal Vaccine Consent Form, dated 10/6/25, indicated the resident representative was provided education and verbally consented to the administration by telephone. The clinical record lacked documentation of the administration of the appropriate Pneumococcal vaccination. The clinical record lacked documentation of the refusal of administration of the appropriate Pneumococcal vaccination. During an interview on 12/22/25 at 12:58 p.m., the Infection Preventionist indicated he was not the staff member responsible for vaccination tracking and administration in October 2025 and the previous staff member had retired. He indicated all refusals of administration of any vaccination should be documented in the resident clinical record. A facility policy, revised 2/23, titled, Pneumonia Vaccination Policy, provided by the Administrator on 12/22/25 at 3:19 p.m., indicated the following: .A. Once a resident has been admitted into the facility, the resident will be offered a pneumonia vaccine and receive a VIS. They will either sign their consent or declination. B. If the resident signs a consent to receive the pneumonia vaccine, the following information will be obtained. If the resident has received a pneumonia vaccine previously and the date received .The age and eligibility of the recipient of the vaccination. The physician's preference and order for administration. After the review of the above collected information, the vaccine will be administered per the recommendations of the above and in accordance to the physician preference .3.1-18(b)(5)

Based on record review and interview, the facility failed to administer the appropriate COVID-19 vaccinations per the Center for Disease and Control (CDC) guidance for 1 of 5 residents reviewed for infection control. Findings include:Resident 18's clinical record was reviewed on 12/19/25 at 1:18 p.m. Diagnoses included unspecified dementia with psychotic disturbances, adult failure to thrive, and unspecified schizoaffective disorder.A 10/13/25, quarterly, Minimum Data Set (MDS) assessment indicated the resident's Brief Interview for Mental Status (BIMS) (to quickly screen and track cognitive function) was not performed.Review of the resident's vaccinations included the following: The resident had a historical refusal of the COVID-19 vaccination on 7/17/24.A COVID-19 Vaccine Consent Form, dated 10/13/25, indicated the resident representative was provided education and verbally consented to the administration by telephone. The clinical record lacked documentation of the administration of the appropriate COVID-19 vaccination. The clinical record lacked documentation of the refusal of administration of the appropriate COVID-19 vaccination. During an interview on 12/22/25 at 12:58 p.m., the Infection Preventionist indicated he was not the staff member responsible for vaccination tracking and administration in October 2025 and the previous staff member had retired. He indicated all refusals of administration of any vaccination should be documented in the resident clinical record. A facility policy, revised 8/6/23, titled, COVID-19 VACCINE POLICIES AND PROCEDURES-Resident, provided by the Administrator on 12/16/25 at 2:15 p.m., indicated the following: . Residents/Representatives will be provided the opportunity to refuse the vaccine and/or change their decision about vaccination at any time . The Community will maintain documentation for all residents on COVID-19 vaccination. For Residents, the information will be documented in their medical record .which vaccination was administered, which dose was administered, date of vaccination . 3.1-18(b)(5)

Based on observation, interview and record review, the facility failed to ensure menus were followed for 4 of 4 residents reviewed for receiving diets/menus as ordered (Residents 45, 10, 42 and 60). Findings include: A current facility document titled Week at a Glance, provided by Administrator following the entrance conference on 9/3/24, indicated the following: Lunch Menu 9/6/24 Lunch: Tomato Basil Soup- 6 oz Saltine crackers- I pack Ultimate grilled cheese sandwich -1 sandwich Breaded green beans- 4 oz Ranch dressing -2 oz Pineapple tidbits 1/2 cup. A current facility document titled Spring/Summer, 2024 Diet Guide Sheet, provided by the Certified Dietary Manager (CDM) on 9/6/24 at 12:15 p.m., indicated the following diet types were menued to receive lunch as follows: Regular Diet Tomato Basil Soup- 6 ounces Saline Crackers- 1 pack Ultimate grilled cheese sandwich -1 sandwich Breaded [NAME] Beans - 4 ounces Ranch dip -2 ounces Pineapple tidbits - 1/2 cup Mechanical Soft Diet Tomato Basil Soup- 6 ounces Saline Crackers- 1 pack Ultimate grilled cheese sandwich -1 sandwich Breaded [NAME] Beans - 4 ounces Ranch dip -2 ounces Pineapple crushed- 1/2 cup Finger Foods Tomato Basil Soup- 6 ounces- in a mug Ultimate grilled cheese sandwich -1 sandwich Breaded [NAME] Beans - 4 ounces Ranch dip -2 ounces Pineapple tidbits - 1/2 cup During a lunch meal service observation of the secured dementia unit dining room [ROOM NUMBER]/6/24 from 11:56 a.m. to 12:40 p.m., not all residents were being served tomato soup, nor was another soup or alternate to tomato soup, offered. Residents 45, 10, 42 and 60 were not served tomato soup, another soup, or an alternate for tomato soup. During an interview on 9/6/24 at 12:14 p.m., [NAME] 9, who was dipping up portions and serving the meal trays on the dementia unit, indicated there was no alternate soup nor was she aware of any alternate for the tomato soup. She only served the items listed on the resident's meal tickets. The items on the meal ticket were the items the resident had selected for the meal. She did not know who completed the resident's selections or how they were selected. During an interview on 9/6/24 at 12:15 p.m., the CDM indicated there was no alternate soup for tomato soup, nor a substitute for tomato soup. The select menu system did not call for a replacement if not selected by the resident. She had no information regarding who selected the meals for the residents on the dementia unit. It could be the family, the resident themselves might have chosen, or the staff who knew what the resident liked might have chosen for them. The facility did not have an approach to ensure the caloric values from the menu were received if the meal ticket did not selection did not meet the menus values. During an interview on 9/6/24 at 12:18 p.m., LPN 10 indicated residents with orders for finger food diets did not have soup because they could spill it. During an observation on 9/6/24 at 12:20 p.m., Resident 45 was eating in the dining room on the secured dementia unit. She had a grilled cheese sandwich and no tomato soup, other soup, or alternate for tomato soup. She indicated she liked tomato soup. During an observation on 9/6/24 at 12:25 p.m., Resident 60 was eating in the dining room on the secured dementia unit. She had a grilled cheese sandwich and no tomato soup, other soup, or alternate for tomato soup. She indicated she liked tomato soup. During an observation on 9/6/24 at 12:27 p.m., Resident 42 was eating in the dining room on the secured dementia unit. She had a grilled cheese sandwich and no tomato soup, other soup, or alternate for tomato soup. She indicated she liked tomato soup. During an observation on 9/6/24 at 12:29 p.m., Resident 10 was eating in the dining room on the secured dementia unit. She had a grilled cheese sandwich and no tomato soup, other soup, or alternate for tomato soup. She indicated she liked soup and would enjoy some soup, but she did not like tomato soup. During an interview on 9/6/24 at 12:40 p.m., RD 7 (registered dietitian) indicated 235 calories was a fair estimate of the calories contained in six ounces of tomato soup. 1. Resident 45's clinical record was reviewed on 9/9/24 at 9:46 a.m. Current diagnoses included mixed dementia, psychotic disturbance, mood disturbance, anxiety, mixed receptive-expressive language disorder, vitamin deficiency, and cognitive communication deficit. The resident had a current September 2024 physician's order for a regular diet. This order originated 5/18/23. This resident had a current, September 2024, physician's order to reside on a secured dementia unit. A 7/4/24, quarterly, Minimum Data Set (MDS) assessment indicated the resident was severely cognitively impaired. The resident had a current care plan problem need related to nutrition risk due to dementia. This problem originated 5/19/23. Approaches to this problem included serve a regular diet as ordered. The resident had a current care plan problem need related to vitamin deficiency. This problem originated 6/5/23. Approaches to this problem included to serve a diet as ordered by the physician. During an interview on 9/9/24 at 2:32 p.m., Resident 45's responsible party indicated they had never been asked to complete a select menu for their resident. They had never been asked anything about their resident's food preferences. It would be a good idea to get their input about food likes. The resident loved grilled cheese and tomato soup. 2. Resident 10's clinical record was reviewed on 9/6/24 at 9:02 a.m Current diagnoses included dementia with psychotic disturbances, mixed receptive-expressive language disorder, and depression. The resident had a current September 2024 physician's order for a diet mechanical soft texture with ground meat, with nectar thickened liquids diet. This order originated 6/24/24. This resident had a current, September 2024, physician's order to reside on a secured dementia unit. A 6/12/24, quarterly, MDS assessment indicated the resident was cognitively intact. The resident had a current care plan problem need related to nutritional risk. This problem originated 3/29/24. Approaches to this problem included to serve a diet as ordered. During an interview on 9/4/24 at 10:39 a.m. Resident 10 indicated she was often times very confused. During an interview on 9/9/24 at 3:47 p.m., Resident 10's responsible party indicated the resident did like soup, but not tomato soup. At this point in time, most days the resident could state what they would like to eat. The facility had never asked them about resident food preferences and select menus. They believed their input would be helpful. 3. Resident 42's clinical record was reviewed on 9/9/24 at 9:52 a.m. Current diagnoses included Alzheimer's disease expressive language disorder, vitamin deficiency, anxiety and depression. The resident had a current September 2024 physician's order for a finger foods diet. This order originated 6/22/23. This resident had a current, September 2024, physician's order to reside on a secured dementia unit. A 7/16/24, quarterly, MDS assessment indicated the resident was severely cognitively impaired. The resident had a current care plan problem need related to nutritional risk due to dementia. This problem originated 4/14/23. Approaches to this problem included serve diet per physician's orders. During an interview on 9/9/24 at 2:25 p.m., Resident 42's responsible party indicated the facility had never asked them to choose a select menu for their resident. They had often times told people the resident liked peanut butter and jelly, bananas, and yogurt. The resident was so advanced in their illness that they should maybe be asked each meal, at the time of the meal what they would like to eat. A good idea would be to offer them an item and see if they liked it that day. 4. Resident 60's clinical record was reviewed in 9/9/24 at 9:49 a.m. Current diagnoses included dementia severe with psychotic disturbance, anxiety, vitamin deficiency, and mixed expressive-receptive language disorder. The resident had a current September 2024 physician's order for a diet. a regular diet. This order originated 2/15/24. This resident had a current, September 2024, physician's order to reside on a secured dementia unit. A 6/24/24, significant change, MDS assessment indicated the resident was severely cognitively impaired. The resident had a current care plan problem need related to nutritional risk related to dementia. This problem originated 6/22/20. Approaches to this problem included serve diet as ordered. The resident had a current care plan problem need related to a risk for weight loss due to dementia. This problem originated 6/11/20. Approaches to this problem included serve diet per order. During an interview on 9/9/24 at 1:26 p.m., the Administrator indicated the facility's select menu system did not indicate who made the selections for the residents selected meal ticket. On the dementia unit, many families chose. The system did not address if residents who had dementia or memory impairment had not chosen an alternate for food items. The residents chose their alternate when they made their selections. During an interview on 9/9/24 at 1:49 p.m., RD 6 indicated the facilities system did not indicate who made the selections on the resident select menu. Their was no system to ensure residents who could not make their wants and needs known had their likes and dislikes honored. There was not a system for ensure alternatives were offered to residents with dementia. A current facility policy titled, Meal Service, dated 2012 and provided by the Administrator on 9/10/24 at 11:10 a.m. indicated the following: .Individual Substitutions .Policy: The Dining Services Department strives to meet the preferences of residents. Substitutions are available to individual residents as listed on the planned menu and through a standard stock to substation alternatives A current facility policy titled, Nutrition and Clinical Care, dated 2012 and provided by the Administrator on 9/10/24 at 12:34 p.m. indicated the following: .Diet Orders .Policy: Diet orders are written by the physician based on the medical needs and physical capabilities of the resident. They follow the approved diet manual and the regimens included in the menu program 3.1-20(i)(4)

Based on observation, interview, and record review, the facility failed to ensure resident food preferences were reviewed and honored for 4 of 4 residents reviewed for food preferences (Residents 45, 10, 42 and 60). Findings include: 1. During an observation on 9/6/24 at 12:20 p.m., Resident 45 was eating in the dining room on the secured dementia unit. She had a grilled cheese sandwich and no tomato soup, other soup, or alternate for tomato soup. She indicated she liked tomato soup. During an interview on 9/9/24 at 2:32 p.m., Resident 45's responsible party indicated they had never been asked to complete a select menu for their resident. They had never been asked anything about Resident 45's food preferences. It would be a good idea to get their input about food likes. The resident loved grilled cheese and tomato soup. Resident 45's clinical record was reviewed on 9/9/24 at 9:46 a.m. Current diagnoses included mixed dementia, psychotic disturbance, mood disturbance, anxiety, mixed receptive-expressive language disorder, vitamin deficiency, and cognitive communication deficit. The resident had a current September 2024 physician's order for a regular diet. This order originated 5/18/23. This resident had a current, September 2024, physician's order to reside on a secured dementia unit. A 7/4/24, quarterly, Minimum Data Set (MDS) assessment indicated the resident was severely cognitively impaired. The resident had a current care plan problem need related to nutrition risk due to dementia. This problem originated 5/19/23. Approaches to this problem included provide resident with food and snacks they enjoy. The clinical record lacked indication of the resident's food preferences and/or food likes or dislikes. 2. During an observation on 9/6/24 at 12:25 p.m., Resident 60 was eating in the dining room on the secured dementia unit. She had a grilled cheese sandwich and no tomato soup, other soup, or alternate for tomato soup. She indicated she liked tomato soup. Resident 60's clinical record was reviewed in 9/9/24 at 9:49 a.m. Current diagnoses included dementia severe with psychotic disturbance, anxiety, vitamin deficiency, and mixed expressive-receptive language disorder. The resident had a current September 2024 physician's order for a diet. a regular diet. This order originated 2/15/24. This resident had a current, September 2024, physician's order to reside on a secured dementia unit. A 6/24/24, significant change, MDS assessment indicated the resident was severely cognitively impaired. The resident had a current care plan problem need related to nutritional risk related to dementia. This problem originated 6/22/20. Approaches to this problem included honor food preferences. The resident had a current care plan problem need related to a risk for weight loss due to dementia. This problem originated 6/11/20. Approaches to this problem included honor resident's food preferences. The clinical record lacked indication of the resident's food preferences and/or food likes or dislikes. 3. During an observation on 9/6/24 at 12:27 p.m., Resident 42 was eating in the dining room on the secured dementia unit. She had a grilled cheese sandwich and no tomato soup, other soup, or alternate for tomato soup. She indicated she liked tomato soup. During an interview on 9/9/24 at 2:25 p.m., Resident 42's responsible party indicated the facility had never asked them to choose a select menu for their resident. They had never been asked about the resident's food preferences. They had often times told people the resident liked peanut butter and jelly, bananas, and yogurt. The resident was so advanced in their illness that they should maybe be asked each meal, at the time of the meal what they would like to eat. A good idea would be to offer them an item and see if they liked it that day. Resident 42's clinical record was reviewed on 9/9/24 at 9:52 a.m. Current diagnoses included Alzheimer's disease expressive language disorder, vitamin deficiency, anxiety and depression. The resident had a current September 2024 physician's order for a finger foods diet. This order originated 6/22/23. This resident had a current, September 2024, physician's order to reside on a secured dementia unit. A 7/16/24, quarterly, MDS assessment indicated the resident was severely cognitively impaired. The resident had a current care plan problem need related to nutritional risk due to dementia. This problem originated 4/14/23. Approaches to this problem included honor residents food preferences and involve family in plan of care. The clinical record lacked indication of the resident's food preferences and/or food likes or dislikes. 4. During an observation on 9/6/24 at 12:29 p.m., Resident 10 was eating in the dining room on the secured dementia unit. She had a grilled cheese sandwich and no tomato soup, other soup, or alternate for tomato soup. She indicated she liked soup and would enjoy some soup, but she did not like tomato soup. During an interview on 9/9/24 at 3:47 p.m., Resident 10's responsible party indicated the resident did like soup and did not like tomato soup. At this point in time, most days the resident could state what they would like to eat. The facility had never asked them about the resident's food preferences or a select menu. They believed their input would be helpful. Resident 10's clinical record was reviewed on 9/6/24 at 9:02 a.m Current diagnoses included dementia with psychotic disturbances, mixed receptive-expressive language disorder, and depression. The resident had a current September 2024 physician's order for a diet mechanical soft texture with ground meat, with nectar thickened liquids diet. This order originated 6/24/24. This resident had a current, September 2024, physician's order to reside on a secured dementia unit. A 6/12/24, quarterly, MDS assessment indicated the resident was cognitively intact. The resident had a current care plan problem need related to nutritional risk. This problem originated 3/29/24. Approaches to this problem included honor resident's food dislikes, and provide the resident's with food and snacks which they enjoy. The clinical record lacked indication of the resident's food preferences and/or food likes or dislikes. During an interview on 9/4/24 at 10:39 a.m. Resident 10 indicated she was often times very confused. A current facility document titled Week at a Glance, provided by the Administrator following the entrance conference on 9/3/24, indicated the following: Lunch Menu 9/6/24 Lunch: Tomato Basil Soup- 6 oz Saltine crackers- I pack Ultimate grilled cheese sandwich -1 sandwich Breaded green beans- 4 oz Ranch dressing -2 oz Pineapple tidbits 1/2 cup. During the lunch meal service observation on the secured dementia unit dining room on 9/6/24 from 11:56 a.m. to 12:40 p.m., not all residents were being served tomato soup nor was another soup or alternate to tomato soup being offered. Residents 45, 10, 42 and 60 were not served tomato soup, another soup or an alternate for tomato soup. During an interview on 9/6/24 at 12:14 p.m., [NAME] 9, who was dipping up portions and serving the meal trays on the dementia unit, indicated there was no alternate soup nor was she aware of any alternate for the tomato soup. She only served the items listed on the resident's meal tickets. The items on the meal ticket were the items the resident had selected for the meal. She did not know who completed the resident's selections or how they were selected. During an interview on 09/06/24 at 12:15 p.m., the Certified Dietary Manager (CDM) indicated she had no information regarding who selected the meals for the residents on the dementia unit. It could be the family, the resident themselves might have chosen, or the staff who knew what the resident liked might have chosen for them. The facility did not interview the residents and/or their families about their food likes and dislikes. During an interview on 9/9/24 at 1:26 p.m., the Administrator indicated the facility's select menu system did not indicate who made the selections for the residents selected meal ticket. The facility did not interview residents and/or their families about food likes/dislikes or food preferences. The select menu was supposed to identify the likes and dislikes. The select menu system did not identify who made the selections for the resident nor when the selection were made. During an interview on 9/9/24 at 1:49 p.m., RD 6 indicated the facility's system did not indicate who made the selections on the resident select menu. Their was no system to ensure residents who could not make their wants and needs known had their likes and dislikes honored. There was not a system for ensure alternatives were offered to residents with dementia. A current facility policy titled Resident Food Preference, dated 7/2017 and provided by Administrator on 9/9/24 at 4:05 p.m., indicated the following: .Individual food preferences will be assessed upon admission and communicated to the interdisciplinary team . 1. Upon the resident's admission (or within twenty- four (24) hours after his/her admission) the Dietitian or nursing staff will identify a resident's food preference. 2. When possible staff will interview the resident directly to determine current food preferences based on history and life patterns related to food and mealtimes A current facility policy titled Meal Service, dated 2012 and provided by the Administrator on 9/10/24 at 11:10 a.m., indicated the following: .Policy: The Dining Services Department strives to meet the preferences of residents. Substitutions are available to individual residents as listed on the planned menu and through a standard stock to substation alternatives

Based on observation and interview, the facility failed to appropriately date stored medications, discard expired insulin vials, and label medications with resident information in 4 of 5 medication carts observed for medication storage. (South 1 medication cart, South treatment cart, North medication cart, and North treatment cart) Findings include: 1. During a medication storage observation of the South 1 medication cart, accompanied by RN 11 on [DATE] at 1:45 p.m., the following was observed: One Lantus Solostar (insulin glargine) injection pen, with approximately 150 units remaining, lacked an open date. RN 11 indicated the insulin pen should have an open date written on the label. 2. During a medication storage observation of the South treatment cart, accompanied by LPN 12, on [DATE] at 1:55 p.m., the following items were observed: a. One tube of Biofreeze (a topical pain relief cream/gel), partially labeled with the last name of a discharged resident. b. One medium sized tube of hydrocortisone cream 1% (used to treat skin conditions that cause redness, swelling, rashes, and itching) without resident identifiers. c. One large tube of skin protectant cream without resident identifiers. d. One large tube of Eucerin Skin Calming Itch Soothing Cream, partially labeled with the last name of a discharged resident. e. One medium sized tube of Aspercreme (a topical pain relief cream/gel) without resident identifiers. During that same time, LPN 12 indicated she was unaware these multi-use skin treatments should be labeled. The treatments were used for more than one resident. Some of the tubes had the names of discharged residents on them. 48146 3. During a medication storage observation of the North medication cart, accompanied by RN 4, on [DATE] at 1:55 p.m., the following was observed: a. One Humalog (insulin) Kwikpen with approximately 120 units remaining, lacked an open date. b. One Novolog (insulin) Flexpen with approximately 160 units remaining, with an open date of [DATE]. c. One Levermir (insulin) Flexpen with approximately 250 units remaining, with an open date of [DATE]. During an interview, at the time of the observation, RN 4 indicated all insulin pens should be dated when opened, and insulin was good for 28 days. RN 4 indicated neither expired insulin pen should be used to provide resident medication. 4. During a medication storage observation of the North treatment cart, accompanied by RN 5, on [DATE] on 2:03 p.m., the following was observed: a. One tube of triple antibiotic (to treat infection) ointment, maximum strength without resident identifiers. b. One tube of Medihoney (to treat wounds) wound gel without resident identifiers. c. One tube of hemorrhoid treatment ointment without resident identifiers. d. One tube of Triad (to treat wounds) wound cream without resident identifiers. During an interview, at the time of the observation, RN 5 indicated medications arrived in large packages and resident identifier information should be written on the separate tubing or bottles. A current, undated, facility policy, titled, Drug Storage, provided by the Administrator on [DATE] at 4:05 p.m., indicated the following: . All expired, damaged and/or contaminated medications are removed from resident care areas and stored separately from medications available for administration A current, undated, facility skills validation sheet, provided by the Administrator on [DATE] at 12:30 p.m., indicated the following: .5. Check for date opened, expiration date . A current, undated, facility policy, titled, Medication Labeling, provided by the Administrator on [DATE] at 12:15 p.m., indicated the following: .All labeling of prescriptions filled . will be the responsibility of the dispensing pharmacist and will be consistent with State and Federal requirements . Over the counter medications used for a specific resident must identify that resident and have an appropriate pharmacy label applied 3XXX,d+[DATE](j) 3XXX,d+[DATE](k)

Based on observation, interview, and record review, the facility failed to follow infection prevention and control procedures during wound care related to Enhanced Barrier Precautions (EBPs) for 1 of 2 resident reviewed for skin impairments. Findings include: During an observation on 9/5/24 at 1:15 p.m., Resident 100 was lying in bed. On the wall by the window, a small plastic container holding personal protective equipment (PPE) and an orange sign indicated EBP lying on top of the container. Resident 100's clinical record was reviewed on 9/6/24 at 10:48 a.m. Diagnoses included wedge compression fracture of first thoracic vertebra, dementia in other diseases classified elsewhere, and age-related physical debility. Resident 100's current physician's order, dated 8/28/24, indicated cleanse coccyx wound with normal saline, pat dry, apply Xeroform (to treat wounds), and cover with Alleyvn (foam dressing) daily and as needed for spoilage and displacement. A precautions care plan, dated 8/19/24, indicated Resident 100 required enhanced barrier precautions related to a wound. Approaches included the following: apply gown and gloves for high contact activities and wound care, and provide family, staff, and resident education as needed. A pressure ulcer care plan, dated 8/20/24, indicated an unavoidable stage 2 (partial thickness loss of dermis) pressure wound to the sacrum. Approaches included the following: administer treatment as ordered, assist resident with turning and repositioning, and family and resident education. A Wound Note, dated 9/2/24, indicated a stage 2 pressure ulcer (an open sore that can appear as a blister, abrasion, or shallow crater in the skin) measuring 0.5 centimeters (cm) by 0.5 cm (the size of a pea). The wound was improving, the tissue remained fragile, and was unable to blanch effectively. During a wound care observation on 9/6/24 at 10:50 a.m., LPN 10 and LPN 13 entered Resident 100's room. On the wall, above the head of the resident's bed, was an orange sign that indicated EBP. The resident was lying in a low bed. LPN 10 deposited wound treatment supplies on a towel-covered bedside table. LPN 10 and LPN 13 completed hand washing and donned gloves. LPN 10 removed the previous dressing, dated 9/5/24. The dressing had minimal yellow colored drainage. LPN 10 cleaned the wound using normal saline, patted the area dry with gauze, removed her dirty gloves, and completed hand hygiene using hand sanitizer. LPN 13 was asked to exit the room to gather additional supplies needed. LPN 13 removed her gloves and completed hand hygiene utilizing hand sanitizer. LPN 10 donned clean gloves and applied the ordered treatment to the wound bed and applied the appropriate dressing on top of the treatment. LPN 13 returned with towels and a brief and donned gloves. LPN 10 and LPN 13 changed the resident's brief and did peri-[NAME] care. Neither LPN 10 or LPN 13 donned a gown during the wound care observation. During an interview, on 9/6/24 at 10:50 a.m., LPN 10 and LPN 13 both indicated they should have worn gowns during the wound care treatment. LPN 13 further indicated EBP's were to protect residents and others from infections. During an interview, on 9/9/24 at 4:03 p.m., the Administrator indicated he was advised only chronic wounds over 3 months required EBP and his staff were not required to wear gowns during the previous wound care observation. During an interview, on 9/9/24 at 4:21 p.m., the DON indicated EBP was for the protection of residents, families, and staff to prevent the spread of infection. She indicated EBP was utilized for chronic wounds and any skin opening requiring a dressing. A current facility policy, revised 4/1/24, titled, Enhanced Barrier Precautions Policy and Procedure, provided by the Administrator, on 9/9/24 at 4:05 p.m., indicated the following: . EBP is used in conjunction with standard precautions and expand the use of PPE to donning gown and gloves during high-contact resident care activities .Use of EBP is indicated for residents with: .Any skin opening requiring a dressing 3.1-18(l)

Based on observation, interview, and record review, the facility failed to evaluate residents for self-administration of medications prior to leaving medications unattended at the bedside for 2 of 7 residents reviewed for infection control. (Residents 255 and 315) Findings include: 1. During an interview at the time of a random observation on 7/24/23 at 11:18 a.m., Resident 39's family member came out of the resident's room with a medication cup that contained two pills. She indicated these pills were left on the resident's overbed table and she didn't know what the medications were for because the resident was also uncertain which medications were left in the medication cup. She took the medications to the nurse's station and gave them to an unknown male staff member, who indicated he would get the resident's nurse. During an interview on 7/24/23 at 2:50 p.m., a resident representative indicated he had been in the resident's room this morning when the nurse brought the resident her medications. The nurse administered part of the resident's medication, placed the medication cup with the last two pills on the resident's overbed table, then left the room to retrieve some chocolate milk. The resident representative had followed the nurse to get the chocolate milk. The nurse did not return immediately to the room to administer the remaining medications. The nurse returned to the room after a family member went to the nurse's station and asked about the medications left in the resident's room. During an interview on 7/24/23 at 4:06 p.m., LPN 5 indicated she left two pills at the resident's bedside on the overbed table this morning when she left the room to get the resident some chocolate milk. She would not typically leave medications in the resident's room while she retrieved other items, but she planned to come right back to the resident's room. Medications should not have been left unattended at the resident's bedside. Resident 255's clinical record was reviewed on 7/25/23 at 3:24 p.m. Diagnoses included oral phase dysphasia, essential primary hypertension and gastro-esophageal reflux disease without esophagitis. The clinical record lacked an order to self-administer medications, an intra-disciplinary team (IDT) note regarding medication self-administration, and a self-medication administration assessment prior to the interview with LPN 5 on 7/24/23. An admission Minimum Data Set (MDS) assessment, dated 7/20/23, indicated the resident had moderate cognitive impairment. A current care plan, dated 7/21/23, indicated the resident was unable to independently perform late loss activities of daily living. Interventions included the following: monitor for swallowing issues, report any issues, and provide assistance and encouragement. During an interview on 7/28/23 at 11:32 a.m., the DON indicated the following items should have been in place before medications were left at the resident's bedside: medication self-administration assessment, the IDT meeting note, and the physician's agreement for medication self-administration. 48146 2. During an observation on 7/26/23 at 2:18 p.m., Resident 315 had an albuterol (to treat asthma/COPD) rescue inhaler and a Trelegy Ellipta (to treat asthma/COPD) inhaler on his bedside table. On 7/27/23 at 9:13 a.m., he was observed with an albuterol rescue inhaler and a Trelegy Ellipta inhaler on his bedside table. On 7/27/23 at 1:38 p.m., he was observed with an albuterol rescue inhaler and a Trelegy Ellipta inhaler on his bedside table. Resident 315's clinical record was reviewed on 7/27/23 at 11:03 a.m. His diagnosis included chronic obstructive pulmonary disease (COPD), chronic respiratory failure, and COVID-19. A physicians order, dated 7/21/23, indicated albuterol sulfate inhaler 90 microgram (mcg); administer two puffs by inhalation, every six hours as needed (PRN). A physicians order, dated 7/22/23, indicated Trelegy Ellipta inhaler; 100-62.5-25 mcg; administer one puff by inhalation, once a day, upon rising between 7:00 a.m.- 11:00 a.m. Resident 315's physicians orders lacked an order for self administration, and the resident's clinical record lacked a self administration assessment or a self administration care plan. During an interview, on 7/26/23 at 2:18 p.m., the resident indicated the nurse practitioner was aware he had these medications at his bedside. He took the albuterol for his rescue inhaler and the Trelegy was for him to take at night before bed. During an interview, on 7/27/23 at 1:50 p.m., the DON indicated for a resident to have medications at bedside, the facility would need to complete a self administration assessment and obtain a physician's orders. She indicated that Resident 315's medication was left at his bedside to prevent his medications from being on the nursing cart since he was positive for COVID-19. Review of a current, revised December 2012, policy, titled Administering Medications, provided by the Corporate Nurse Consultant on 7/27/23 at 3:25 p.m., indicated the following: .Policy Interpretation and Implementation .24. Residents may self-administer their own medications only if the Attending Physician, in conjunction with the Interdisciplinary Care Planning Team, has determined that they have the decision making capacity to do so safely 3.1-11(a)

Based on interview and record review, the facility failed to develop and/or implement a comprehensive care plan regarding communication for a resident with hearing loss for 1 of 21 residents review for care plan development and implementation. (Resident 3) Finding Includes: During an interview on 7/24/23 at 3:42 p.m., Resident 3 indicated she had been evaluated for hearing aides and had not heard any update regarding them. Many times, when she received care from staff, she had to ask them to repeat themselves. On Wednesdays, she played piano to accompany a gentleman who came to the facility and sang. It became difficult to hear the hymn number he announced and she had to ask him to repeat the number. She felt frustrated when she had to ask him to repeat himself. She missed most of the conversations at lunch because the female resident she sat with had a soft voice. She was anxious to receive her hearing aids and not have to ask everyone to repeat themselves. Resident 3's clinical record was reviewed on 7/25/23 at 3:28 p.m. Diagnoses included Parkinson's disease, major depressive disorder, and anxiety disorder. An audiologist's assessment, completed on 2/23/23, indicated the resident had complained of newly decreased ability to hear. The clinical findings of the assessment indicated a moderate to profound hearing loss to the resident's left ear and moderate to severe hearing loss in the resident's right ear. Recommendations for the attending physician and/or nursing staff included, to use slow, clear speech using visual cues when communicating and to favor the resident's right ear. Hearing aids were recommended for both ears and impressions for the hearing aids were obtained. The resident's care plan lacked any plan regarding resident's hearing deficit or to address the resident's hearing loss while awaiting the delivery of hearing aids. During an interview on 7/26/23 at 11:42 a.m., the Social Services Director (SSD) indicated he had become frustrated with the provider due to the lack of a delivery date. He had reached out several times to request a status of the resident's hearing aids and had not been given an estimated date of delivery. He understood the resident's anxiety regarding the lengthy wait for delivery. During an interview on 7/26/23 at 2:27 p.m., CNA 4 indicated she was not aware the resident was hard of hearing. She had not noticed difficulty during Resident 3's care, but was familiar with care for those who were hard of hearing. On 7/31/23 at 11:36 a.m., the Administrator provided a copy of the current, revised 12/2016, facility policy titled, Care Plans, Comprehensive Person-Center. The policy indicated the following: .Policy Interpretation and Implementation .8. The comprehensive, person-centered care plan will: .g. Incorporate identified problem areas; .10. Identifying problem areas and their causes, and developing interventions that are targeted and meaningfulto [sic] the resident, are the endpoint of the interdisciplinary process 3.1-35(a)

Based on observation, record review, and interview, the facility failed to follow a physician's order for bilateral pressure relief boots for a dependant resident for 1 of 3 residents reviewed for pressure ulcers. (Resident 100) Finding includes: During an observation on 7/25/23 at 9:22 a.m., Resident 100 was laying in bed, barefoot, with a bandage dated 7/25 to the top and left side of his left foot. His heels rested on the bed and no pressure relief boots were in place. On 7/26/23 at 9:19 a.m., he was observed laying in bed wearing socks and his heels rested on the bed. He had no pressure relief boots on. On 7/27/23 at 8:30 a.m., he was observed sitting up in bed, barefoot, with his heels rested on the bed. He had no pressure relief boots on. Resident 100's clinical record was reviewed on 7/26/23 at 2:35 p.m. His diagnoses included fracture to unspecified part of neck of left femur, unspecified fracture of left tibia, unspecified fracture of shaft of left fibula, and unspecified fracture of T11-T12 vertebra. A MDS (Minimum Data Set) assessment, dated 6/22/23, indicated he required extensive assistance with bed mobility and transfers. Walking did not occur. He had current physician's orders (5/31/23) to elevate/offload heels while in bed as tolerated and (6/1/23) for bilateral heel float boots when in bed. A review of the electronic medication administration record (eMAR) for July 1, 2023- July 27, 2023 indicated Resident 100 wore his bilateral heel float boots daily. During an interview on 7/26/23 at 2:03 p.m., the resident indicated he had not worn pressure relief boots to his feet in weeks and there were no boots for his feet in his room. During an interview on 7/27/23 at 2:04 p.m., RN 3 indicated Resident 100 did not have boots on and refused to wear them. When treatments were refused, staff were to document refusals in the clinical record and report to the physician. During an interview on 7/27/23 at 2:36 p.m., the DON indicated Resident 100 used to wear bilateral pressure relief boots when first admitted to the facility, but no longer wore them. She should have discontinued his order for pressure relief boots. Review of a current facility policy, effective 4/3/17 and titled Protocol for Following Physician Orders, provided by the Corporate Nurse Consultant on 7/27/23 at 3:51 p.m., indicated the following: .Procedure: All licensed staff will verify and follow the physician orders as written. If for any reason, the physician order cannot be followed, the professional will contact the physician for further instructions. Care Plan: The resident's plan of care will reflect the physicians orders and direction for the resident's plan of care 3.1-40(a)(2)

Based on interview and record review, the facility failed to document, monitor, and notify the physician regarding a medication error event for 1 of 1 resident reviewed for IV (intravenous) medications (Resident C). Findings include: Resident C's clinical record was reviewed on 7/11/23 at 10:20 a.m. Diagnoses included osteomyelitis, hyperkalemia, essential (primary) hypertension and chronic kidney disease, stage 3. Her physician orders included cefepime (antibiotic) in dextrose 5% piggyback 1gm/50 ml gram/milliliter via IV every 12 hours, 1 liter of normal saline at 75 ml/hr (milliliters/hour) immediately on 6/13/23, and vancomycin (antibiotic) 1000 mg via IV every 12 hours at 10:00 a.m. and 10:00 p.m. A nurse practitioner progress note, dated 6/14/23, indicated per nursing, the vancomycin was administrated quicker than the one hour administration time due to an IV pump error. No adverse effects were noted from the vancomycin. Repeat labs were ordered and were pending. No rash was noted. She denied any swallowing issues. Continue to monitor closely. She did not appear to be in any distress. A nurse practitioner progress note, dated 6/15/23, indicated STAT (immediate) labs were ordered due to IV antibiotic infusion. Her kidney function improved. No adverse side effects noted on exam from vancomycin administration and she did not appear in any distress. Her clinical record lacked nursing documentation, monitoring, and immediate notification to the physician of the vancomycin being infused quicker than an hour, or when the event had occurred. During an interview with LPN 23, on 7/11/23 at 1:17 p.m., she indicated Resident C's vancomycin infused faster than normal, although she was not aware of how fast it infused. She called the pharmacy and verified the settings on the IV pump, but she thought the IV pump malfunctioned. She pulled the IV pump from Resident C's room and retrieved the house IV pump for her next IV antibiotic. The nurse practitioner was made aware. During an interview with the Nurse Consultant, on 7/12/23 at 10:28 a.m., she indicated LPN 23 did not document the IV incident in Resident C's clinical record. During an interview with the Nurse Consultant, on 7/12/23 at 12:04 p.m., she indicated LPN 23 did not complete an incident report regarding the IV incident. Upon further review, the incident took place on 7/12/23. A current facility policy, titled Adverse Consequences and Medication Errors, revised 2/14 and provided by the Nurse Consultant, on 7/12/23 at 12:04 p.m., indicated the following: .Policy Interpretation and Implementation .13. The Attending Physician is notified promptly of any significant error or adverse consequence. a. The physician's orders are implemented, and the resident is monitored closely for 24 to 72 hours or as directed .15. The following information is documented in an incident report and in the resident's clinical record: a. Factual description of the error or adverse consequence. b. Name of physician and time notified. c. Physician's subsequent orders. d. Resident's condition for 24 to 72 hours or as directed This Federal tag relates to Complaint IN00411619 and IN00411859. 3.1-37(a)

Based on observation, interview and record review, the facility failed to ensure a resident's ordered continuous positive airway pressure ([CONDITION(S)]) machine mask fit properly for use (Resident 85), and an order and care plan were in place for a [CONDITION(S)] machine (Resident 79) for 2 of 3 residents reviewed for respiratory services. Findings include: 1. A clinical record review for Resident 85 was completed on 6/15/22 at 9:41 a.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 6/13/22 at 2:17 p.m., Resident 85 indicated she had an order to wear a [CONDITION(S)] at night, but her mask had not fit her for awhile and she was unable to use her machine. She had attempted to wear it several times, but was unable to tolerate it. A current physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The order indicated the resident applied the device herself. A care plan, edited 5/26/22, indicated the resident had potential for respiratory distress related to [CONDITION(S)], asthma, and history of [CONDITION(S)]. Interventions included, but were not limited to, C-PAP per physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] A care plan, edited on 5/26/22, indicated the resident required the use of a [CONDITION(S)] machine related to sleep apnea and refused to wear the device at times. Interventions included, but were not limited to, resident will use [CONDITION(S)] as order by physician. A review of the resident's electronic treatment administration record for June 2022, indicated the resident had refused to wear her [CONDITION(S)] machine on 6/7/22 with a nursing comment of Res states mask is all wrong will not wear. The record indicated the resident refused to wear her [CONDITION(S)] machine on 6/11/22, 6/12/22, and 6/13/22 without indication of reason for refusal. During an interview on 6/15/22 at 3:18 p.m., RN 5 indicated she works frequently with the resident and was unaware that the reason for her refusal to wear her [CONDITION(S)] was due to her mask not fitting correctly. A respiratory therapy progress note, dated 6/16/22 at 11:08 a.m., indicated the resident was refitted with a large mask. During an interview on 6/17/22 at 8:47 a.m., the resident indicated someone came to her room on 6/16/22 and had fitted her with a new mask and indicated to her that her current mask had been too small. She indicated she slept very well last night and had no issues with her device. She felt better this morning. 2. The clinical record for Resident 79 was reviewed on 6/15/22 at 9:21 a.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During observation and interview in the resident's room on 6/13/22 at 9:58 a.m., a [CONDITION(S)] machine was observed on the resident's night stand. She indicate she used it each night. The resident's record lacked a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 6/13/22 at 10:32 a.m., the Director of Nursing (DON) indicated the resident applies her machine herself at bedtime. She had not realized the resident's clinical record lacked a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A current facility policy, dated May 2015, titled, Non-Invasive Ventilation, provided by the Administrator on 6/17/22 at 2:38 p.m., included, but was not limited to, the following: Procedure .1. Verify physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 3.1-47(a)(6)

Based on observation, interview and record review, the facility failed to ensure menus were followed for 4 of 4 residents with pureed diets reviewed for following menus. (Residents 72, 9, 45 and 7). Finding include: A current, undated, facility document titled, Week-At-A-Glance, which was provided by the Administrator on 6/13/22 at 10:00 a.m. indicated the following: Wednesday Lunch: Herb Lemon Chicken Au Gratin Potatoes Key West Vegetables Cherry Cobbler Bread Lemonade Coffee Margarine. Review of the 6/15/22, facility Diet Guide Sheet (menu portion size guide), which was provided by the Administrator in 6/15/22 at 1:13 p.m., indicated the following:Pureed diets- 2 ounces of pureed bread. During a 6/15/22 (Wednesday) 12:17 p.m. to 12:45 p.m. lunch meal observation, the following concerns were identified: a. During an observation on 6/15/22 at 12:19 p.m., Resident 72 was served a pureed meal which lacked pureed bread. b. During an interview on 6/15/22 at 12:22 p.m., Dietary Aide 4, who was serving the meals on the secured dementia unit, indicated she did not know if there was pureed bread on the steam table. She indicated she was serving either pureed potatoes or pureed bread and she didn't know which she was serving. c. During an interview on 6/15/22 at 12:23 p.m., the Dietary Manager indicated the pureed bread had not been prepared in error. It was currently being prepared and would be served. d. During an observation and interview on 6/15/22 at 12:33 p.m., CNA 8 indicated Resident 72 had never been served any additional item after she was served her initial tray. The CNA indicated the resident was now done eating. No pureed bread was observed on the tray or in an additional bowl. e. During an observation on 6/15/22 at 12:41 p.m., Resident 9 had been served a pureed meal with no pureed bread being served. At this time, the resident had left the dining room indicating their meal was complete. f. During an observation on 6/15/22 at 12:41 p.m., Resident 7 had been served a pureed meal with no pureed bread being served. At this time, the resident had left the dining room indicating their meal was complete. g. During an observation on 6/15/22 at 12:42 p.m., Resident 45 had been served a pureed meal with no pureed bread being served. At this time, the resident had left the dining room indicating their meal was complete. h. During an observation and interview on 6/15/22 at 12:43 p.m., with the Administrator and Dietary Manager. Both individuals looked at the meal trays and indicated Residents 9, 45, and 7 had not been served the pureed bread as the menu indicated. Both indicated the residents who were served meal trays prior to the pureed bread being placed on the serving line should have been served their bread when it came to the serving line. Both indicated an error had been made. 1. Resident 72's clinical record was reviewed on 6//16/22 at 12:28 p.m. Current diagnoses included, but were not limited to, diabetes mellitus, Feeding difficulties- unspecified, dementia, and dysphasia. The resident had a current, 4/21/22, order for a pureed diet. The resident had a current, 5/19/22, care plan problem need regarding a risk for weight loss related to dementia. An approach to this problem was to serve a diet as ordered. The resident had a 5/10/22, Quarterly, Minimum Data Set (MDS) assessment which indicated the resident was rarely or never understood, required extensive assistance to eat, and required a mechanical altered diet. 2. Resident 9 clinical record was reviewed on 6/16/22 at 12:49 p.m. Current diagnoses included, but were not limited to, Alzheimer's disease, anxiety, and dysphasia. The resident had a current, 11/1/21, order for a pureed diet. The resident had a current, 6/2/22, care plan problem need regarding nutritional risk do to dysphasia. An approach to this problem was diet as ordered. The resident had a current, 5/2/22, Quarterly, MDS assessment which indicated the resident was rarely or never understood, required extensive assistance to eat, and required a mechanical altered diet. 3. Resident 45 clinical record was reviewed on 6/16/22 at 11:56 a.m Current diagnoses included, but were not limited to, dementia, diabetes mellitus, and anxiety. The resident had a current, 4/14/22, order for a pureed diet. The resident had a current, 2/16/22, care plan problem need regarding nutritional risk do to recurring a pureed diet. An approach to this problem was diet as ordered. The resident had a current, 4/11/22, Annual, MDS assessment which indicated the resident was rarely or never understood, required extensive assistance to eat, and required a mechanical altered diet. 4. Resident 7 clinical record was reviewed on 6/16/22 at 11:36 a.m Current diagnoses included, but were not limited to, dementia, and dysphasia. The resident had a current, 11/1/21, order for a pureed diet. The resident had a current, 3/18/22, care plan problem need regarding a risk for weight loss. An approach to this problem was diet as ordered. The resident had a current, 6/3/22, Quarterly, MDS assessment which indicated the resident was severely cognitively impaired, required extensive assistance to eat, and required a mechanical altered diet. A current, 2012, facility policy, titled Meal Service, which was provided by the Administrator on 6/17/2022 at 10:42 a.m., indicated the following: Policy: Tray set-up for meal service is consistent. .7. Trays are monitored for accuracy by the 'checker'. 3.1-20(i)(1)

Based on observations, record reviews and interviews, the facility failed to ensure services were provided to maintain the dignity of 2 out of 10 cognitively impaired residents during a meal observation. (Resident C and Resident D) Findings include: 1. The clinical record for Resident C was reviewed on 10/20/2021 at 1:35 p.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The most recent Quarterly Minimum Data Set (MDS) assessment, dated 8/2/2021, was reviewed on 10/20/2021 at 1:35 p.m. The MDS indicated Resident C was severely cognitively impaired and required extensive assistance of one person for eating. During a meal time observation on 10/18/2021 from 4:32 p.m. to 6:06 p.m., Resident C's tray was delivered at 5:20 p.m. The resident did not received assistance until 5:45 p.m. During that time the resident made no attempt to feed herself. Review of a current CNA (Certified Nursing Assistant) assignment sheet provided by the Unit Manager on 10/20/2021 at 11:58, indicated the resident required assistance with meals. 2. The clinical record for Resident D was reviewed on 10/20/2021 at 9:45 a.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The most recent Annual MDS assessment, dated 9/24/2021, was reviewed on 10/20/2021 at 9:45 a.m. The MDS indicated Resident D was severely cognitively impaired, required extensive assistance of one person for eating and was ordered a mechanically altered diet (pureed). Review of a current CNA assignment sheet, provided by the Unit Manager on 10/20/2021 at 11:58, indicated the resident required assistance with meals. During a meal time observation on 10/18/2021 from 4:32 p.m. to 6:06 p.m., Resident D's tray was delivered at 5:23 p.m. The resident did not receive assistance until 5:38 p.m. During that time the resident made no attempt to feed herself. During an interview on 10/18/2021 at 6:00 p.m., CNA 1 indicated it was not appropriate to sit a tray in front of a resident that requires assistance and not provide assistance to them right away. During an interview on 10/18/2021 at 6:04 p.m., CNA 2 indicated the normal procedure was to sit and provide assistance when the tray was passed. During an interview on 10/18/2021 at 6:06 p.m., CNA 3 indicated if staff passed a tray to a resident that required assistance, the staff member should sit down and feed them so their food does not get cold. During an interview on 10/20/2021 at 11:47 a.m., The MDS Coordinator indicated the meaning of extensive assistance was staff gave physical assistance. Staff may try to give verbal support at first but then will provide the resident with physical assistance, actually lift the utensil to the mouth. During an interview on 10/20/201 at 12:12 p.m., the Executive Director indicated the facility did not have a specific policy that addressed assisting residents with meals in a timely manner. The ED indicated CNA's were taught during their training to provide assistance timely to residents who required such assistance. This Federal tag relates to Complaint IN 907 3.1-3(t)

Based on, interview and record review, the facility failed to ensure a resident on an antipsychotic medication had documented behaviors of a failed gradual dose reduction, prior to increasing the antipsychotic medication dose for 1 of 3 residents reviewed for medication usage (Resident B). Findings include: The clinical record for Resident B was reviewed on 3/15/21 at 10:34 a.m. [DIAGNOSES REDACTED]. A quarterly Minimum Data Set (MDS) assessment, dated 11/25/20, indicated the resident was cognitively intact. The resident did not have any hallucinations or delusions at the time of the assessment and had mild depression. A health care plan, dated 1/16/17 and revised 2/22/21, indicated the resident had a [DIAGNOSES REDACTED]. Interventions included, but were not limited to, monitor resident for targeted behaviors and new or worsening behaviors will be monitored. A social service progress note, dated 12/21/20 at 11:51 a.m., indicated the resident had no abnormal behavioral expressions during Assessment Reference Date (ARD) of the MDS assessment. A progress note, dated 1/2/21 at 1:54 a.m., indicated the resident was cooperative with staff. A psychiatric progress note, dated 2/3/21, indicated the resident stated she was frequently confused about things such as the time of day or whether her behavior was socially appropriate. The note indicated the resident struggled with gauging the intensity of other's reactions. It was unclear if it was due to dementia or depression. A social service progress note, dated 2/5/21 at 2:40 p.m., indicated the emergency contact was notified of a reduction in [MEDICATION NAME] from 100 mg to 75 mg. The original order for [MEDICATION NAME] 100 mg was dated 8/14/20. Progress notes indicated the following: 2/8/21 at 11:12 a.m., the resident had no adverse effects to the reduction of [MEDICATION NAME]. 2/9/21 at 11:44 a.m., no adverse effects or behaviors from [MEDICATION NAME] reduction. 2/11/21 at 10:14 p.m., resident slid out of chair and laid on the floor. No injuries were noted. 2/12/21 at 3:31 a.m., no adverse reaction due to Gradual Dose Reduction (GDR) of [MEDICATION NAME]. 2/13/21 at 3:30 a.m., no adverse reaction noted from fast fall and no change from GDR of [MEDICATION NAME]. 2/15/21 at 11:30 a.m., no change in behavior, resident calm and pleasant with care and staff. 2/17/21 at 1:00 a.m., no adverse reaction noted due to GDR of [MEDICATION NAME], resident is cooperative with care and medications. 2/17/21 at 2:41 p.m., no adverse effects noted at this time. 2/18/21 at 7:47 p.m., head to toe assessment completed. Resident had been participating in normal day to day activities with no signs or symptoms of distress. Affect is flat per usual. 2/19/21 at 12:59 a.m., resident showed no adverse effects or behaviors due to GDR of [MEDICATION NAME]. 2/20/21 at 4:21 a.m., Urinalysis (UA) with Culture and Sensitivity (C&S) if indicated. Urinary catheterization obtained 60 mL cloudy, amber urine with odor. 2/21/21 at 4:02 p.m., Bactrim DS (antibiotic used to treat urinary tract infections) ordered. Review of a self-reported incident to the Indiana Department of Health, on 2/18/21 at 8:01 p.m., indicated Resident B voiced concern that a staff member was providing rough care during a shower. The allegation was investigated and found to be unsubstantiated. A social service progress note, dated 2/22/21 at 5:18 p.m., indicated the resident scored 12 on the Brief Interview for Mental Status (BIMS) assessment. The resident was calm in mood and showed no signs or symptoms of distress in mood or behavior\. A nursing note, dated 2/23/21 at 2:34 a.m., indicated the resident was alert and oriented and able to voice wants and needs. She had a complaint with medications and care from staff. The resident was non-compliant with oxygen and continued to remove throughout the night. An email, provided by the Director of Nursing (DON) on 3/15/221 at 2:45 p.m., indicated the Social Service Director (SSD) sent an email to the Nurse Practitioner (NP) on 2/23/21 at 2:39 p.m. The email indicated (name of resident) has made several false allegations about staff in the past few days. Each of these allegations were investigated and found to be false. Staff say .history of false accusations and we believe this her making these accusations again could be an effect of the [MEDICATION NAME] GDR Can we increase her [MEDICATION NAME] to the previous dose and consider this a failed GDR? The NP indicated it would be fine to increase the [MEDICATION NAME] dose. A current physician's orders [REDACTED]. A social service progress note, dated 2/23/21 at 4:21 p.m., indicated she attempted to notify the emergency contact for Resident B related to the failed GDR of [MEDICATION NAME]. The medication was increased from 75 mg to 100 mg. Review of the behavior management administration record from 2/1/21 through 2/28/21, Resident B was receiving antipsychotic therapy for the targeted behaviors: a. Thoughts of shopping trips she did not go on. b. False allegation related to care not being provided. c. Throwing baked goods at roommate who she thought was hungry. d. Picking at skin and smearing blood on the wall. e. Voiding and defecating in clothing and refusal of care. f. Refusal of weights, treatments and medications. g. Climbing under her bed for candy wrappers. The behavior history failed to show any documented behaviors during time period in February. During an interview with the SSD on 3/15/21 at 2:34 p.m. with the DON present, the SSD indicated the psych note done on 2/3/21 indicated no real behaviors, but the NP kept the dose at 100 mg. She then called on 2/5/21 and requested a GDR for the [MEDICATION NAME]. The DON indicated she was off during the self-reported incident, but the Inter-Disciplinary Team (IDT) felt since the resident made these allegation they needed to increase the [MEDICATION NAME]. The DON indicated the only behavior she saw was on 2/11/21 when the resident sat herself on the floor. She considered that a behavior with her, but that would not be the case with all residents. The DON indicated there were no other documented behaviors prior to the increase in [MEDICATION NAME]. On 3/15/21 at 3:37 p.m., the Administrator indicated Resident B did have a [DIAGNOSES REDACTED]. A psych note indicated she was not doing as well and felt people were upset with her and she was also on a reportable. It did not sound like staff did a very good job documenting her behaviors. Review of a current facility policy, dated October 2013 titled Behavior management program, which was provided by the Administrator on 3/15/21 at 3:46 p.m., indicated the following: Policy statement CarDon communities provide services It is CarDon's policy that each community will have a behavior program that: identifies, monitors, manages and disseminates .least invasive approach based on the individual resident affected. Our goal is to provide the highest level of functioning .Reduction Residents who are admitted The medication management observation in Matrix should be used as a guide when narratively documenting medication reduction meetings by the IDT. After the first year, a tapering should be attempted annually unless clinically contraindicated. 3.1-48(a)(3) 3.1-48(a)(4)

Based on observation, record review, and interview, the facility failed to identify and assess skin issues when a resident readmitted with two pressure wounds for 1 of 3 residents reviewed for pressure ulcers (Resident D). Findings include: Resident D's clinical record was reviewed on 2/26/21 at 9:26 a.m. She was re-admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. A current care plan indicated she was at risk for skin breakdown related to incontinence. Interventions included, but were not limited to, monitor skin for signs of skin breakdown. Review of a supplemental admission assessment, with an observation date of 2/18/21 at 7:37 p.m. and a date recorded of 2/19/21 at 3:47 a.m., indicated the resident needed assistance to reposition, her skin was exposed to moisture, and she did not have a history of pressure ulcers or other skin conditions. Review of an admission observation, with an observation date of 2/18/21 at 7:55 p.m. and a date recorded of 2/19/21 at 3:55 a.m., indicated the resident's skin was warm, dry, normal color, and skin turgor was normal. The assessments did not indicate any wounds to her left or right buttocks. A progress note, dated 2/19/21 at 4:38 a.m., indicated the resident had arrived via ambulance from a local hospital and was total care with ADL's (Activities of Daily Living). A wound management assessment, with a date/time observed of 2/19/21 at 3:17 p.m. and a created date/time of 2/25/21 at 3:18 p.m., indicated an unstageable wound, (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), to the left buttock, measured 1.0 X 1.0 centimeters (cm) with a depth of 0.1 cm. The tissue type was listed as slough (dead tissue). A wound management assessment, with a date/time observed of 2/19/21 at 3:20 p.m. and a created date/time of 2/25/21 at 3:21 p.m., indicated a Stage 2 pressure wound, (partial-thickness loss of skin with exposed dermis), measured 1.2 X 1 cm with a depth of 0.1 cm. A physician order, dated 2/25/21, indicated to cleanse right and left buttock with normal saline, pat dry, apply Allevyn (an absorbent foam dressing) daily and as needed for soilage. During an interview, on 2/26/21 at 1:27 p.m., the Corporate Nurse indicated she would look into why skin issues present on re-admission were not indicated in progress notes or on wound assessment until 2/25/21. A progress note, dated 2/19/21 at 12:21 p.m. and recorded as a late entry on 2/26/21 at 2:27 p.m., indicated an area to her right and left buttock was noted during care and bandage was applied. The note did not include an assessment of either wound. During an interview, on 2/26/21 at 1:54 p.m., the DON indicated the resident readmitted with right and left buttock wounds, one was an unstageable wound and the other was a stage 2. She indicated she had been suspended on 2/18/21, pending an investigation and had not returned to work until 2/25/21, she had received the wound measurements from the admitting nurse and had completed the wound assessment on 2/25/21. She did not know why someone else had not completed the wound assessments in her absence. During an interview, on 2/26/21 at 1:44 p.m., Resident D indicated she had a couple of wounds on her bottom that were being treated. During phone interview, on 2/26/21 at 2:13 p.m., LPN 5 indicated she was the admitting nurse, the resident had two coccyx wounds, she thought she had included the wounds on the admission assessment. During a wound observation, on 2/26/21 at 2:52 p.m., the DON measured the wound on the resident's right buttock. The area measured 1.5 X 2.1 cm with a depth of 0.1 cm. measurement of the wound the her left buttock was not done, the resident was waiting to have an x-ray of her right knee, and turning her onto her right side to observe the area on the left buttock was not to be done until the results of the X-ray were known. Review of a current facility policy, titled WOUND MANAGEMENT POLICY, dated 2/1/2019 and provided the Corporate Nurse on 2/26/21 at 3:21 p.m., indicated POLICY STATEMENT CarDon and Associates, Inc. is committed to providing quality care to our residents by implementing clinical guidance and best practices for management of wounds and other skin conditions throughout a resident's stay in our CarDon communities 3.1-40(a)(2)

Based on observation and interview, the facility failed to discontinue communal dining associated with a global pandemic of an infectious disease, in 1 of 2 dining rooms observed (Cherished Memories). Findings include: During a tour of the Cherished Memories unit, on 4/16/20 and accompanied by Nurse 7, the residents were sitting in the dining room for lunch. The square-shaped tables, with a capacity for four residents at a table, had three and four residents sitting at each table, 26 residents in total were in the dining room. She indicated the residents received their meals in the dining room, the residents were not socially distanced with at least six feet between them, if a resident coughed or sneezed at the table, and other residents sitting at that same table could be affected by respiratory droplets expelled during a cough or sneeze. The Administrator arrived on the unit during this meal time, he indicated they had previously tried serving residents in their room but the residents enjoyed the social interactions during meals in the dining room, he indicated he was aware of the guidance issued from the the Indiana State Department of Health (ISDH) to cancel all group activities and communal dining, and was aware that residents could be positive for the COVID-19 virus without showing any signs or symptoms. The campus had five residents that had been transferred to the hospital, all of the residents had been tested for [MEDICAL CONDITION] at the hospital, four residents tested positive for [MEDICAL CONDITION], one had passed away, and one resident's test results were pending. There was one employee that had tested positive for [MEDICAL CONDITION] and one employee's test results were pending. This Federal Tag relates to complaint IN 689. 3.1-18(a)

Based on record review and interview, the facility failed to ensure a resident was referred to the State-designated authority for a Level II preadmission screening and resident review (PASRR) when newly diagnosed with [REDACTED]. (Resident 19) Findings include: The clinical record for Resident 19 was reviewed on 2/26/20 at 12:41 p.m. [DIAGNOSES REDACTED]. The PASRR Level I was completed on 1/6/17. A review of the Level I indicated the resident had no known or suspected mental health [DIAGNOSES REDACTED]. It also indicated that if changes occur or new information refutes these findings, a new screen must be submitted. Review of the resident's Quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated active [DIAGNOSES REDACTED]. During an interview on 2/27/20 at 10:24 a.m., the Administrator indicated the facility had identified an issue with the Level II PASRR assessments and had performed a facility-wide audit since 1/8/20, but had missed identifying Resident 19's need for a Level II. During an interview on 2/27/20 at 11:48 a.m., the Corporate Consultant indicated the facility had no specific corporate policy regarding PASRR evaluations. The facility used the recommendations indicated by ASCEND (a company that performs PASRR assessment).

Based on observation, interview and record review, the facility failed to implement a comprehensive care plan that addressed treatment and interventions of an acute condition for 2 of 6 residents who were reviewed for respiratory conditions. (Residents 21 and 35) Findings include: 1. During an observation and interview on 2/24/2020 at 11:09 a.m., Resident 21 sat in her room with intermittent congested cough. She indicated she had been sick over a week and was not getting any better. On 02/25/20 at 9:30 a.m., Resident 21 was observed in her room with intermittent cough. At 10:31 a.m. resident was observed walking with CNA to dining room, with deep congested sounding cough. The clinical record for Resident 21 was reviewed on 02/25/20 02:41 p.m. The [DIAGNOSES REDACTED]. Current physician orders [REDACTED]. a. [MEDICATION NAME] Sore throat [MEDICATION NAME] 15-3.6mg, one four times a day as needed. Start date 2/17/20. b. [MEDICATION NAME] liquid, 100mg/5ml, give 5 ml every four hours as needed. Start date 2/17/20, for pharyngitis. c. [MEDICATION NAME] DM tablets, extended release 30-600mg, twice a day. Start date 2/24/20 for Acute upper respiratory infection d. [MEDICATION NAME] 100 mg every eight hours. Start date 2/27/20, for cough Nursing notes on 2/24/20 at 3:06 p.m., indicated nasal congestion, moist productive cough with yellow sputum. On 2/25/20 at 6:43 a.m., notes indicated a moist productive cough, yellow sputum and clear nasal drainage. The care plans were reviewed and lacked identification or interventions for cough, pharyngitis or upper respiratory infection. During an interview with RN 6 on 2/28/20 at 8:56 a.m., she indicated she did not find the upper respiratory infection addressed on the care plan and that it should be. 2. During an observation and interview on 2/25/20 at 11:27 a.m., Resident 35 was observed in room with congested sounding cough. She indicated she has been ill several days. The clinical record was reviewed on 02/27/20 at 12:44 p.m. [DIAGNOSES REDACTED]. Current physician orders [REDACTED]. a. [MEDICATION NAME], 5-7.5 mg four times a day. Start date 2/19/20 for cough. b. Cough Syrup (quaifenesin), 100mg/ml give 5 ml four times a day as needed. Start date 2/19/20. c. [MEDICATION NAME]-[MEDICATION NAME] solution for nebulization, 0.5mg-3mg/3ml. One vial every six hours. start date 2/21/20. d. [MEDICATION NAME] tablet, start date 2/20/20 for pleural effusion Nursing notes were reviewed and indicated the following: a. on 2/19/20 at 5:10 p.m., indicated resident complained of cough and congestion. b. On 2/20/20 at 1:32 p.m. indicated orders were received for labs and chest x-ray and at 7:14 p.m, [MEDICATION NAME] (antibiotic) was started due to pneumonia. The care plans were reviewed and lacked identification or interventions for pneumonia, cough or use of antibiotic. During an interview with CNA 7 on 02/28/20 at 09:34 a.m. she indicated Resident 35 had stayed in her room for several days but was feeling better and coming out now. During an interview with RN 6 on 02/28/20 at 09:03 a.m., she indicated there was not a care plan for the upper respiratory infection and they should have one. A current facility policy, revised December 2016, titled Care Plans, Comprehensive Person-Centered, provided by Corporate Consultant on 2/28/20 at 3:07 p.m., indicated the following: Policy .measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs . 8. The comprehensive, person-centered care plan will: b. Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. 10. Identifying problem areas and their causes, and developing interventions that are targeted and meaningful . 3.1-35(a)(1)

Based on record review and interview the facility failed to provide urinary catheter care for 1 of 3 residents reviewed for urinary catheters (Resident B). This deficient practice resulted in the resident arriving to the hospital in poor condition with [MEDICAL CONDITION], acute kidney injury, and dehydration. The facility also failed to provide an appropriate rationale for the urinary catheter for 1 of 3 residents reviewed for urinary catheter. Findings include: The clinical record for Resident B was reviewed on 11/15/2018 at 10:10 AM. [DIAGNOSES REDACTED]. Review of a current Quarterly Minimum Data Set (MDS) assessment, dated 10/7/18, indicated Resident B was severely cognitively impaired. The resident required extensive assistance with 2 person assistance for bed mobility, transfers, dressing and personal hygiene. Review of a nursing progress note, dated 9/23/2018 at 6:25 PM, indicated the resident was readmitted to the facility from the hospital post surgery related to a fractured right hip. The resident arrived with an anchored urinary catheter in place. Review of a care plan, dated 9/24/2018, indicated the resident required the indwelling urinary catheter due to a [MEDICAL CONDITION] femur with surgical repair. Interventions included, but were not limited to, provide catheter care per order and as needed; assess the drainage as needed: record the color amount, type and odor. Review of the physician orders, dated 9/24/2018, indicated an order for [REDACTED]. Review of the Medication Administration and Treatment Records for (MONTH) (YEAR) and (MONTH) (YEAR) lacked any documentation the urinary catheter or bag had been changed since the resident readmitted to the facility. The records also indicated urinary catheter care had been documented as provided every shift as ordered. Review of a nursing progress note, dated 10/22/2018 at 12:53 PM, indicated the urinary catheter was to be discontinued, but a new order was received to leave the urinary catheter in place due to wounds on the coccyx. Review of a nursing progress note, dated 10/30/2018 at 11:52 AM, indicated the resident was transported to the hospital due to a decline in condition. Vital signs were documented as follows: blood pressure 101/61, oxygen saturation at 95%, heart rate 95 and respirations 32. No temperature was documented. The previous nursing progress note was dated 10/25/2018. Review of the hospital records indicated on 10/30/2018 at 12:30 PM, the resident arrived with a temperature of 101.1. The resident was admitted to the hospital. [DIAGNOSES REDACTED]. Review of a hospital nursing note, dated 10/30/2018 at 1:03 PM, indicated the following: . There is a foley (sic) catheter in place and draining scant amount of urine, Foley bag and tubing notes sediment and purulent drainage. Catheter insertion site notes dried stool and sediment. During an interview on 11/15/2018 at 10:16 AM, the hospital emergency room nurse indicated she was present when the resident was brought to the hospital. The nurse stated the resident was in terrible condition. The nurse indicated the catheter tubing was adhered to the resident's skin with dried sediment and there had been dried stool noted between the resident's labia. The nurse indicated resident was incontinent upon arrival, however not all of the stool was fresh and the resident appeared as if she had not had catheter care for quite some time. During an interview on 11/15/2018 at 12:24 PM, the Director of Nursing (DON) indicated she had not seen the resident prior to her discharge. The DON indicated she had fed and provided care to the resident the evening prior to discharge and had noted a decline in the resident's condition. The DON also indicated she did not document the care or observations in the clinical record. During an interview on 11/15/2018 at 3:20 PM, the DON indicated the rationale for leaving the urinary catheter in place on 10/22/2018 was because the resident was showing a significant decline and increased pain. They felt the resident was near death and did not want the resident to develop a gapping hole. Review of a current policy dated (MONTH) (YEAR), titled Activities of Daily Living (ADL), Supporting indicated the following: Policy Statement . Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene. This policy was provided by the Corporate Consultant on 11/15/208 at 2:9 PM. Review of a current undated procedure titled Procedure #33: Bed Bath/Perineal Care indicated the following: .Catheter Care: 22. If resident has catheter, check for leakage, secretions or irritation. Gently wipe four inches of catheter from meatus out. 23. Wipe from front to back and from center of perineum to thighs. If washcloth is visibly soiled, change cloths. For females: Separate labia. Wash urethral area first. Wash between and outside labia in downward [MEDICAL CONDITION], alternating from side to side and moving outward to thighs. Use different part of washcloth for each stroke. This procedure was provided by the DON on 11/15/2018 at 2:10 PM This Federal tag relates to Complaints IN 175 and IN 900. 3.1-41(a)(1) 3.1-41(a)(2)

Based on interview and record review, the facility failed to prevent abuse by a staff member for 2 of 6 residents reviewed for abuse. This deficient practice resulted in Resident D being placed in a Broda chair as a restraint for approximately 4 hours and Resident J being tearful after medication administration with LPN 7. (Resident D and Resident J) This deficient practice had the potential to affect 56 residents who lived on the North Hall of 86 who resided in the facility. The immediate jeopardy began on 1/31/18 when LPN 7 placed Resident D in a Broda chair, tilted it back as LPN 7 slept at the nurses' station. This nurse also forcefully administered medication to a resident. The Administrator was notified of the immediate jeopardy on 2/21/18 at 1:20 p.m. Findings include: 1. The clinical record for Resident D was reviewed on 2/19/18 at 5:38 p.m. [DIAGNOSES REDACTED]. Resident D was admitted to the facility on [DATE]. A 14-day Minimum Data Set (MDS) assessment, dated 1/30/18, indicated the resident was severely cognitively impaired. He required extensive assistance with 2 person assistance for bed mobility, transfers, walking, dressing and hygiene. The resident used a wheelchair as his mobility device. A current health care plan, dated 1/22/18, indicated the resident exhibited wandering behaviors. Interventions included, but were not limited to, provide a magazine or book, walk the facility with the resident or join an activity. On 1/24/18 at 1:00 a.m., the resident was observed to have been exit seeking on the North Hall. Review of the staff schedule for 1/30/18, LPN 7 was assigned to the North Hall from 2:00 p.m. until 6:00 a.m. on 1/31/18. Review of an Indiana State Department of Health reportable, dated 1/31/18 at 8:40 a.m., indicated Resident D was placed in a geri chair in a reclined position. A staff member was concerned the resident would not be able to get up on his own. The incident was immediately reported to the Administrator. LPN 7 was suspended pending an investigation. Review of the facility investigation indicated the following: A statement, dated 2/1/18, by CNA 10, indicated she was told by LPN 7 to get a Broda chair (a reclining chair on wheels) from another hall. She asked the nurse if a resident needed an order and the nurse stated It doesn't matter, he won't stay still. CNA 10 went to find a Broda chair on another hall and when she returned, LPN 7 had already retrieved one. CNA 10 indicated she did help move Resident D into the Broda chair because she did not want LPN 7 to transfer him herself. A statement provided by CNA 8, dated 2/1/18, indicated when she arrived, she noticed Resident D seated in a Broda chair. She indicated she picked up his gown and covered him up immediately. The statement indicated LPN 7 continued to say You're going to want to keep him there. Another nurse directed CNA 8 to remove Resident D and move him into his wheelchair. A statement by CNA 9, dated 2/1/18, indicated she arrived at the facility at 6:00 a.m. She indicated Resident D had a gown on the floor beside him. He was seated in a Broda chair and it had been leaned back. She asked LPN 7 why Resident D was in the Broda chair and LPN 7 stated He was too much last night. She indicated the other unit came to the North Hall unit looking for the Broda chair. A statement by LPN 4, indicated when he arrived to work, he saw Resident D lying back in the broda and asked LPN 7 what he was doing there. LPN 7 indicated I couldn't do anything with him, so I put him there to keep him off the floor. LPN 4 stated to LPN 7 that she could not really just put him there and LPN 7 stated well I did. During review of the video surveillance of (MONTH) 31, (YEAR) starting at 2:06 a.m., along with the Administrator, Director of Nursing and Corporate Nurse, Resided D was seen seated in his wheelchair at the nurses' station while LPN 7 was sleeping at the nurses station. At 2:08 a.m., CNA 10 brought a Broda chair to the North Hall and LPN 7 was waking up and stretching. At 2:32 a.m., Resident D was moved from his wheelchair into the Broda chair by CNA 10 and LPN 7. CNA 10 reclined the Broda chair completely back and placed a sheet over him. Resident D continued to be restless throughout the morning, continued to kick off his sheet and attempted to remove his gown. At 4:46 a.m., CNA 10 removed Resident D's brief while he was tilted back in the Broda chair. At 5:05 a.m., Resident D appeared to only have socks on his feet and no other clothing item covered him. Resident D remained at the nurses' station. At 5:55 a.m., CNA 10 and CNA 8 removed Resident D from the view of the video and he returned at 6:03 a.m. wearing a shirt and jeans. At 6:05 a.m., Resident D was transferred from the Broda Chair to his wheelchair. An employee communication form, dated 2/2/18, indicated LPN 7 was terminated for Failure to ensure resident safety, sleeping on clock on unit. Confidential interviews for staff were completed. Exact times and dates withheld to maintain anonymity. Employee 1 indicated LPN 7 was the worst nurse ever by being mean and rude to the residents and the residents would refuse for LPN 7 to give them their medication. Employee 1 indicated he/she wrote up several grievance forms, as did therapy. Employee 1 indicated that did not seem to work, so they just started calling the Administrator directly. Employee 2 indicated LPN 7 left Resident D naked and they had it on camera. He/She stated it was reported by a day shift nurse The Administrator and Director of Nursing (DON) were aware of the concerns with LPN 7. He/She thought the nurses' were passing along the information, but felt it stopped with the Administrator and Director of Nursing (DON). Employee 3 indicated LPN 7 did not treat residents in a good way by not giving the residents their pain medication and the residents would have to repeatedly ask her for it. He/She thought management was aware that LPN 7 was abusive. Employee 3 indicated staff often refused to work with LPN 7. Employee 4 indicated he/she often heard complaints of LPN 7 not giving residents their pain medication. Employee 5 indicated the complaints had been going on for some time and the complaints went up the chain, but staff thought nothing was being done. Employee 6 indicated he/she heard a lot of complaints about LPN 7 withholding pain medication. LPN 7 should have been gone a long time ago. He/She heard LPN 7 say if they are going to laugh and joke with me, I am not giving them their pain medicine. Employee 7 indicated staff often filled out grievance forms and to his/her knowledge, the Administrator had not spoken to any of them. Employee 8 indicated when staff mentioned anything to the Administrator, he told them to go to nursing. Employee 9 indicated when he/she arrived to work on 1/31/18, Resident D's genitals were visible and the chair was tipped back. On 2/19/18 at 8:27 a.m., the Administrator indicated for the last couple of months, things were not working well with LPN 7. He indicated she had a problem administering medications timely. During an interview on 2/20/18 at 9:46 a.m., the DON indicated early in (YEAR), LPN 7 was not getting the flow of day shift and she moved her to night shift. She did bring her in and talk to her, but felt she was not teachable. On 2/20/18 at 10:27 a.m., LPN 9 indicated when he arrived to work, Resident D only had a T-shirt on and no brief and there was a sheet on the floor. He indicated Resident D was reclined in the chair. He instructed the aides to take him to his room, clean him up and put him in his wheelchair. During an interview on 2/21/18 at 9:48 a.m., the DON indicated LPN 7 told CNA 10 to go and get a Broda chair. CNA 10 did help transfer Resident D into the Broda chair. LPN 7 did not provide a written statement and although the DON had viewed the video surveillance, she was unable to provide the time Resident D was placed in the Broda chair. During a telephone interview on 2/22/18 at 11:49 a.m., LPN 3 indicated she did remember the night when Resident D was in the Broda chair. She was told her image was seen on the video moving Resident D to the side so she could weigh another resident. She indicated she was unfamiliar with the resident and if he was usually in a Broda chair. She did not report the incident to the Administrator. Review of LPN 7's employee record, indicated she signed an acknowledgement of policies on 12/7/16. The policies included, but were not limited to, abuse prevention, code of conduct, and reporting a reasonable suspicion of a crime against a resident. LPN 7 also signed a general orientation checklist on 12/7/16, indicating she had received sufficient education and training for abuse, neglect and resident rights. On 12/7/16, LPN 7 signed an affirmation statement indicating she agreed to abide by the code of conduct. On 2/22/18 at 12:24 p.m., the Corporate Administrator indicated CNA 10 had been terminated that day for her contributions to the abusive conduct During a telephone interview on 2/22/18 at 3:22 p.m., LPN 7 indicated it was the CNA who suggested to put Resident D in the Broda chair. She had complained to management before that Resident D needed one on one observation because he would often wander into other resident rooms. LPN 7 indicated she would often put her head down because she had a headache. LPN 7 indicated she would occasionally document that she had administered medication on her shift, but because she was busy, the day shift nurse would then give the medication. She gave no explanation as to why as the nurse in charge, she would allow Resident D to be placed in the Broda chair. 2. The clinical record for Resident J was reviewed on 2/20/18 at 9:26 a.m. [DIAGNOSES REDACTED]. During an interview on 2/21/18 at 10:54 a.m., Resident J indicated she received two doses of her medications one night. She indicated she was unsure of the date, but stated the nurse brought her a second dose of crushed medications and told her to take it. The nurse was forceful and the resident was tearful and very scared. The medicine cup had her blood pressure medications in it. She told CNA 6 about the incident. An Admission Minimum Data Set (MDS) assessment, dated 1/19/18, indicated Resident J was cognitively intact. During an interview on 2/19/18 at 9:26 p.m., CNA 6 indicated she came to work at 10:00 p.m. on 1/30/2018 and worked until 6:00 a.m. on 1/31/18. During her shift, she saw LPN 7 coming out of Resident J's room. When she made her way back to Resident J's room, she was crying and said the nurse made her take her medications again. The resident said she told the nurse she had already taken them. The resident was afraid and did not want her to leave her. CNA 6 indicated she notified the charge nurse, LPN 5, that Resident J stated she had taken her medication twice. LPN 5 told her to report it. During a telephone interview on 2/20/18 at 11:41 a.m., LPN 5 indicated CNA 6 did tell her that Resident J supposedly took her medication twice. She did not go and assess the resident, but called the unit manger that evening at home. On 2/21/18 at 11:13 a.m., Unit Manager 4, DON, Administrator and Corporate Nurse were interviewed. The Corporate Nurse indicated she was told during the day by the therapist that the next door roommate to Resident J was heard saying Resident J received two doses of her medication. They immediately assessed Resident J and spoke to CNA 6, who indicated she did not say anything to the next door roommate about Resident J. On 2/21/18 at 12:31 p.m., the DON indicated she had spoken to LPN 5. LPN 5 went to the North Hall to get something and CNA 6 told her that LPN 7 gave Resident J two doses of medicine. She did not assess her and was unaware the resident was tearful. The DON indicated LPN 5 stated she did call Unit Manager 4 at home. She had interviewed Resident J and the resident denied saying she was scared or tearful, but did state the nurse just stuck it in my mouth. A current facility policy, dated (MONTH) 2014 and revised (MONTH) (YEAR), titled Abuse Policy, provided by the DON on 2/20/18 at 8:50 a.m., indicated the following: It is the policy .to provide each resident with an environment that is free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion .IV. IDENTIFYING & RECOGNIZING SIGNS AND SYMPTOMS OF ABUSE Policy Statement Our facility will not condone any form of resident abuse or neglect. To aid in abuse prevention, all personnel are to report any signs and symptoms of abuse/neglect to their supervisor immediately who will report to the Administrator or authorized designee immediately. .VII. REPORTING ABUSE TO: A. Administrator Policy Statement It is the responsibility of our employees .to immediately report any incident or suspected incident of neglect or abuse .to the Administrator or Designee if the Administrator is unavailable. a. Abuse is defined as the willful infliction of injury; unreasonable confinement; intimidation; punishment with resulting physical harm; pain or mental anguish; or deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. .e. Involuntary seclusion is defined as separation of a resident from other residents or from his or her room A current undated facility policy, titled Use of Restraints, provided by the DON on 2/22/18 at 12:16 p.m., indicated the following: Restraints shall only be used for the safety and well-being of the resident(s) and only after other alternatives have been tried unsuccessfully. Restraints shall only be used to treat the resident's medical symptom(s) and never for discipline or staff convenience, or for the prevention of falls. .3. Examples of devices .geri-chairs An undated, facility policy, titled Licensed Nurse Med Pass Clinical Skills Validation, which was provided by the DON on 2/21/18 at 4:10 p.m., indicated the following: .29. Medication was given within the 60 minutes before or after the time designated unless otherwise directed by the physician . The Immediate Jeopardy (IJ) that began on 1/31/18 was removed on 2/22/18 when interviews with staff confirmed the facility had begun inservicing staff on abuse, restraints and the reporting process. The noncompliance remained at the lower scope and severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy because all employees had not been inserviced. This Federal tag relates to Complaint IN 160. 3.1-27(a)(1)

Based on record review and interview, the facility failed to ensure that staff members who had knowledge of an incident of physical abuse and a resident who was tearful after medication administration on the evening shift, immediately reported those concerns to the facility Administrator for 2 of 6 residents reviewed for abuse (Resident D and Resident J). This deficient practice had the potential to affect 56 residents who lived on the North Hall of 86 who resided in the facility. The immediate jeopardy began on 1/31/18 when LPN 7 placed Resident D in a Broda chair, as a restraint and a resident was forcibly given medication and staff did not immediately report their observations to the Administrator. The Administrator was notified of the immediate jeopardy on 2/21/18 at 1:20 p.m. Findings include: 1. The clinical record for D was reviewed on 2/19/18 at 5:38 p.m. [DIAGNOSES REDACTED]. Resident D was admitted to the facility on [DATE]. A 14-day Minimum Data Set (MDS) assessment, dated 1/30/18, indicated Resident D was severely cognitively impaired. Resident D required extensive assistance with 2 person assistance for bed mobility, transfers, walking, dressing and hygiene. Resident D used a wheelchair as his mobility device. A current health care plan, dated 1/22/18, indicated Resident D exhibited wandering behaviors. Interventions included, but were not limited to, provide a magazine or book, walk the facility with the resident or join an activity. Review of the staff schedule for 1/30/18, LPN 7 was assigned to the North Hall from 2:00 p.m. until 6:00 a.m. on 1/31/18. During review of the video surveillance of (MONTH) 31, (YEAR) starting at 2:06 a.m., along with the Administrator, Director of Nursing and Corporate Nurse, the following was noted: At 3:05 a.m., CNA 2 was seen walking around Resident D as the resident sat in a Broda chair (reclining chair on wheels). At 3:51 a.m., Laundry Aid 10 was seen in the video with her laundry carts near Resident D while he was seated in the Broda chair, leaned back. No other staff person was present. At 4:44 a.m., LPN 3 was seen bringing another resident in a Broda chair to be weighed. She moved Resident D out of the way, then pushed the other resident to be weighed and then left. At 5:29 a.m., CNA 8 walked by Resident D, picked up his sheet that was on the floor and tossed it back over the resident. At 5:30 a.m., CNA 11 walked past Resident D to place her items at the nurses' station. Review of an Indiana State Department of Health reportable, dated 1/31/18 at 8:40 a.m., indicated Resident D was placed in a geri chair in a reclined position. A staff member was concerned the resident would not be able to get up on his own. The report indicated the incident was immediately reported to the Administrator. LPN 7 was suspended pending an investigation. Although this incident started at 2:06 am, no one reported it to the Administrator until the LPN 4 arrived to work on day shift. Review of the facility investigation, a statement, dated 2/1/18, by CNA 10, indicated she was told by LPN 7 to get a Broda chair from another hall. She asked the nurse if a resident needed an order and the nurse stated It doesn't matter, he won't stay still. CNA 10 went to find a Broda chair on another hall and when she returned, LPN 7 had already retrieved one. CNA 10 indicated she did help remove Resident D into the Broda chair because she did not want LPN 7 to transfer him herself. A statement provided by CNA 8, dated 2/1/18, indicated when she arrived, she noticed Resident D seated in a Broda chair. She indicated she picked up his gown and covered him up immediately. The statement indicated LPN 7 continued to say You're going to want to keep him there. Another nurse directed CNA 8 to removed Resident D and move him into his wheelchair. A statement by CNA 9, dated 2/1/18, indicated she arrived at the facility at 6:00 a.m. She indicated Resident D had a gown on the floor beside him. He was seated in a Broda chair and it had been leaned back. She asked LPN 7 why Resident D was in the Broda chair and LPN 7 stated He was too much last night. She indicated the other unit came to the North Hall unit looking for the Broda chair. A statement by LPN 4, indicated when he arrived to work, he saw Resident D lying back in the broda and asked LPN 7 what he was doing there. LPN 7 indicated I couldn't do anything with him, so I put him there to keep him off the floor. LPN 4 stated to LPN 7 that she could not really just put him there and LPN 7 stated well I did. An employee communication form, dated 2/2/18, indicated LPN 7 was terminated for Failure to ensure resident safety, sleeping on clock on unit. On 2/20/18 at 10:27 a.m., LPN 9 indicated when he arrived to work, Resident D only had a T-shirt on and no brief. The sheet was on the floor. He indicated Resident D was reclined in the chair. He instructed the aides to take him to his room, clean him up and put him in his wheelchair. During an interview on 2/21/18 at 9:48 a.m., the DON indicated LPN 7 told CNA 10 to go and get a Broda chair. CNA 10 did help transfer Resident D into the Broda chair. LPN 7 did not provide a written statement and although the DON had viewed the video surveillance, she was unable to provide the time Resident D was placed in the Broda chair. During an interview on 2/22/18 at 12:58 p.m., CNA 8 indicated she questioned where the Broda came from when she saw Resident D. She did not report the incident to the Administrator. On the surveillance video, CNA 8 was seen on the video at 5:28 a.m. tossing a sheet over the resident as he sat in the Broda chair. During a telephone interview on 2/22/18 at 11:49 a.m., LPN 3 indicated she did remember the night when Resident D was in the Broda chair. She was told her image was seen on the video moving Resident D to the side so she could weigh another resident. She was unfamiliar with the resident and if he was usually in a Broda chair or not. She did not report the incident to the Administrator. During a telephone interview on 2/22/18 at 3:22 p.m., LPN 7 indicated it was the CNA who suggested to put Resident D in the Broda chair. She had complained to management before that Resident D needed one on one observation because he would often wander into other resident rooms. LPN 7 indicated she would often put her head down because she had a headache. She occasionally documented that she had administered medication on her shift, but because she was busy, the day shift nurse would then give the medication. She gave no explanation as to why as the nurse in charge, she would allow Resident D to be placed in the Broda chair. 2. The clinical record for Resident J was reviewed on 2/20/18 at 9:26 a.m. [DIAGNOSES REDACTED]. During an interview on 2/21/18 at 10:54 a.m., Resident J indicated she received two doses of her medications one night. She indicated she was unsure of the date, but stated the nurse brought her a second dose of crushed medications and told her to take it. The nurse was forceful, she was tearful and very scared. The medicine cup had her blood pressure medications in it. She told CNA 6 about the incident. An Admission Minimum Data Set (MDS) assessment, dated 1/19/18, indicated Resident J was cognitively intact. During an interview on 2/19/18 at 9:26 p.m., CNA 6 indicated she came to work at 10:00 p.m. on 1/30/2018 and worked until 1/31/18 at 6:00 a.m. During her shift, she saw LPN 7 coming out of Resident J's room. When she made her way back to Resident J's room, she was crying and said the nurse made her take her medications again. The resident said she told the nurse she had already taken them. The resident was afraid and did not want her to leave her. CNA 6 indicated she notified the charge nurse, LPN 5, that Resident J stated she had taken her medication twice. LPN 5 told her to report it. During a telephone interview on 2/20/18 at 11:41 a.m., LPN 5 indicated CNA 6 did tell her that Resident J supposedly took her medication twice. She did not go and assess the resident, but called the unit manger that evening at home. On 2/21/18 at 11:13 a.m., Unit Manager 4, DON, Administrator and Corporate Nurse were interviewed. The Corporate Nurse indicated she was told during the day by the therapist that the next door roommate to Resident J was heard saying Resident J received two doses of her medication. She indicated they immediately assessed Resident J and spoke to CNA 6, who indicated she did not say anything to the next door roommate about Resident J. On 2/21/18 at 12:31 p.m., the DON indicated she had spoken to LPN 5. LPN 5 went to the North Hall to get something and CNA 6 told her that LPN 7 gave Resident J two doses of medicine. She did not assess her and was unaware the resident was tearful. The DON indicated LPN 5 stated she did call Unit Manager 4 at home. She had interviewed Resident J. The resident denied saying she was scared or tearful, but did state the nurse just stuck it in my mouth. A current facility policy, dated (MONTH) 2014 and revised (MONTH) (YEAR), titled Abuse Policy, provided by the DON on 2/20/18 at 8:50 a.m., indicated the following: It is the policy .to provide each resident with an environment that is free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion .IV. IDENTIFYING & RECOGNIZING SIGNS AND SYMPTOMS OF ABUSE Policy Statement Our facility will not condone any form of resident abuse or neglect. To aid in abuse prevention, all personnel are to report any signs and symptoms of abuse/neglect to their supervisor immediately who will report to the Administrator or authorized designee immediately. .VII. REPORTING ABUSE TO: A. Administrator Policy Statement It is the responsibility of our employees .to immediately report any incident or suspected incident of neglect or abuse .to the Administrator or Designee if the Administrator is unavailable. a. Abuse is defined as the willful infliction of injury; unreasonable confinement; intimidation; punishment with resulting physical harm; pain or mental anguish; or deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. .e. Involuntary seclusion is defined as separation of a resident from other residents or from his or her room . The Immediate Jeopardy (IJ) that began on 1/31/18 was removed on 2/22/18 when interviews with staff confirmed the facility had begun inservicing staff on abuse, restraints and the reporting process. The noncompliance remained at the lower scope and severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy because all employees had not been inserviced. This Federal tag relates to Complaint IN 160. 3.1-28(c)

Based on interview and record review, the facility failed to thoroughly investigate allegations of abuse by a staff member (Resident D). This deficient practice allowed Resident D to remain restrained and uncovered for approximately 4 hours. This deficient practice had the potential to affect 56 residents who lived on the North Hall of 86 who resided in the facility. The immediate jeopardy began on 1/31/18 when staff reported allegations of abuse and the facility failed to thoroughly investigate the allegations. The Administrator was notified of the immediate jeopardy on 2/21/18 at 1:20 p.m. Findings include: 1. The clinical record for D was reviewed on 2/19/18 at 5:38 p.m. [DIAGNOSES REDACTED]. Resident D was admitted to the facility on [DATE]. A 14-day Minimum Data Set (MDS) assessment, dated 1/30/18, indicated Resident D was severely cognitively impaired. Resident D required extensive assistance with 2 person assistance for bed mobility, transfers, walking, dressing and hygiene. Resident D used a wheelchair as his mobility device. A current health care plan, dated 1/22/18, indicated Resident D exhibited wandering behaviors. Interventions included, but were not limited to, provide a magazine or book, walk the facility with the resident or join an activity. Review of the staff schedule for 1/30/18, LPN 7 was assigned to the North Hall from 2:00 p.m. until 6:00 a.m. on 1/31/18. Review of an Indiana State Department of Health reportable, dated 1/31/18 at 8:40 a.m., indicated Resident D was placed in a geri chair in a reclined position. A staff member was concerned the resident would not be able to get up on his own. The report stated the incident was immediately reported to the Administrator. LPN 7 was suspended pending an investigation. Review of the facility investigation, a statement, dated 2/1/18, by CNA 10, indicated she was told by LPN 7 to get a Broda chair (reclining chair on wheels) from another hall. She asked the nurse if a resident needed an order and the nurse stated It doesn't matter, he won't stay still. CNA 10 went to find a Broda chair on another hall and when she returned, LPN 7 had already retrieved one. CNA 10 indicated she did help remove Resident D into the Broda chair because she did not want LPN 7 to transfer him herself. During review of the video surveillance of (MONTH) 31, (YEAR) starting at 2:06 a.m., along with the Administrator, Director of Nursing and Corporate Nurse, several staff member were seen in the video during the time Resident D was in the Broda chair. The following was observed: At 2:06 a.m., Resided D was seen sitting in his wheelchair at the nurses' station. At 2:08 a.m., CNA 10 brought a Broda chair to the North Hall. At 2:32 a.m., Resident D was moved from his wheelchair into the Broda chair by CNA 10 and LPN 7. CNA 10 reclines the Broda chair completely back and placed a sheet over him. At 3:05 a.m., CNA 2 was seen walking around Resident D. At 3:51 a.m., Laundry 16 was seen in the video with her laundry carts near Resident D while he was seated in the Broda chair, leaned back. No other staff person was present. At 4:44 a.m., LPN 3 was seen bringing another resident in a Broda chair to be weighed. She moved Resident D out of the way, then pushed the other resident to the scales to weigh and left. At 4:46 a.m., CNA 10 removed Resident D's brief while he was tilted back in the Broda chair. At 5:05 a.m., Resident D appeared to only have socks on his feet and no other clothing item. Resident D remained at the nurses' station. At 5:29 a.m., CNA 8 walked by Resident D, picked up his sheet that was on the floor and tossed it back over the resident. At 5:30 a.m., CNA 9 walked past Resident D to place her items at the nurses' station. At 5:55 a.m., CNA 10 and CNA 8 removed Resident D from the view of the video and he returned at 6:03 a.m. wearing a shirt and jeans. At 6:05 a.m., Resident D was transferred from the Broda Chair to his wheelchair. An employee communication form, dated 2/2/18, indicated LPN 7 was terminated only for Failure to ensure resident safety, sleeping on clock on unit. During an interview on 2/22/18 at 10:40 a.m., the Administrator and Director of Nursing were not aware of the three employees shown in the video. They were not aware the statement provided by CNA 10, which indicated she did not bring the Broda chair to the unit, did not match the video surveillance and that no statements were provided from CNA 2, LPN 3, Laundry Aid 10 related to the allegation. On 2/22/18 at 12:24 p.m., the Corporate Administrator indicated CNA 10 had been terminated today for her contributions to the abusive conduct A current facility policy, dated (MONTH) 2014 and revised (MONTH) (YEAR), titled Abuse Policy, provided by the DON on 2/20/18 at 8:50 a.m., indicated the following: It is the policy .to provide each resident with an environment that is free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion .V. ABUSE INVESTIGATIONS Policy Statement All reports of resident abuse, neglect and injuries of an unknown source shall be immediately and thoroughly investigated by the facility management. 1. Should an incident or suspected incident of resident abuse .will notify the following persons or agencies of such incident when applicable: a. The State licensing/certification agency .7. Employees of this facility who have been accused of resident abuse will be suspended from duty The Immediate Jeopardy (IJ) that began on 1/31/18 was removed on 2/22/18 when interviews with staff confirmed the facility had begun inservicing staff on abuse, restraints and the reporting process. The noncompliance remained at the lower scope and severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy because all employees had not been inserviced. This Federal tag relates to Complaint IN 160. 3.1-28(d)

Based on interview and record review, the facility failed to ensure a resident was transferred with sufficient staff assistance to prevent an accident for 1 of 3 residents reviewed for accidents (Resident B). This deficient practice resulted in a tibial fracture for the resident. The facility also failed to ensure a cognitively impaired resident with elopement risk behavior, received the supervision to prevent elopement from the facility for 1 of 4 residents reviewed for accidents. (Resident C). Findings included: 1. The clinical record for Resident B was reviewed on 10/23/17 at 10:06 a.m. [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS) assessment, dated 8/4/17, indicated Resident B was severely cognitively impaired and required extensive assistance with two person assistance for transfers. Review of a current health care plan, dated 2/15/13 and revised 10/13/17, indicated Resident B required extensive assistance with two staff members for transfer and toileting. Interventions included, but were not limited to, provide assistance for all Activities of Daily Living (ADL) as needed. Another health care plan, dated 10/7/13, indicated Resident B was at risk for falls related to muscle weakness, osteoarthrosis, and osteoporosis. Interventions included, but were not limited to, Two person assist for transfers .Keep res (resident) near nursing station when alert and restless .Assist with ADLs as needed Review of a CNA assignment, provided by Unit Manager 1 on 10/24/17 at 11:50 a.m., indicated Resident B requires extensive assist with two staff members for transfers, and toileting. The sheet indicated Resident B was non-ambulatory and required staff to propel her wheelchair on and off the unit. Review of the Point of Care History (P(NAME)) documentation by CNAs, indicated on 10/1/17 at 5:50 a.m. and 7:49 a.m., Resident B was transferred by 1 person by using a transfer aid (gait belt) and was lifted manually. The P(NAME) documentation indicated on 10/2/17 at 11:28 a.m. and 8:05 p.m., Resident B was transferred by 1 person by using a transfer aid and was lifted manually. The P(NAME) documentation indicated on 10/3/17 at 3:44 a.m. and 9:36 a.m., Resident B was transferred by 1 person by using a transfer aid was lifted manually. Review of a progress note, dated 10/3/17 at 11:27 a.m., indicated Resident B was noted to have swelling in her right lower extremity, below the knee. Resident B's leg was slightly warm to touch, but without redness. The physician was notified and ordered an X-ray and Doppler ultrasound. The X-ray report showed a fracture of the proximal tibia. Resident B was sent to the emergency room for evaluation and treatment. On 10/4/17, Resident B returned to the facility and new orders for a knee immobilizer to be worn during all transfers and any rolling movement. She returned with an order for [REDACTED]. During an interview on 10/24/17 at 1:47 p.m., CNA 1 indicated she found Resident B's swollen leg and notified the nurse. She indicated Resident B was a two person assist for transfers and for the most part, she was transferred by two people. She indicated on occasion, she did transfer Resident B by herself. She indicated on the day she found her swollen leg, she was putting her to bed by herself and was pulling down her pants and Resident B screamed. She indicated she informed the nurse of her findings. Review of a current facility policy, revised 2009, titled Safe Lifting and Movement of Residents, which was provided by the Corporate Nurse on 10/24 /17 at 11:33 a.m., indicated the following: Policy Statement In order to protect the safety and well-being of staff and residents, and to promote quality care, this facility uses appropriate techniques and devices to lift and move residents. Policy Interpretation and Implementation 1. Resident safety, dignity comfort .safe lifting and moving of residents. 2. Manual lifting of residents shall be eliminated when feasible. 3. Nursing staff, in conjunction with .asses individual residents' needs for transfer assistance on an ongoing basis. Staff will document resident transferring and lifting needs in the care plan 2. The clinical record for Resident C was reviewed on 10/23/17 at 2:37 p.m. [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS) assessment, dated 10/7/17, indicated Resident C was severely cognitively impaired. Resident C was independent with ambulation. A Elopement Risk Assessment was completed on 3/15/17 and indicated Resident B wandered aimlessly, stood next to exit doors often and was having a difficult time being in the facility. A health care plan, dated 8/17/16, indicated Resident C was at risk for elopement related to [DIAGNOSES REDACTED] and dementia, requiring a Wander guard. The Wander guard was discontinued on 3/15/17 related to [DIAGNOSES REDACTED]. Review of another health care plan, dated 9/28/17, indicated Resident C required 24 hour care and supervision. Interventions included, but were not limited to, provide activity programs of interest. A health care plan, revised 10/23/17, indicated to check placement of the Wander guard every shift. A progress note, dated 8/2/17 at 12:55 p.m., indicated res (resident) standing by doors of memory care unit .housekeeper opened doors and res burst through, staff able to stop res on south hall A progress note, dated 8/4/17 at 1:27 p.m.,, indicated res has been exit seeking at times today .pushes through memory care doors when other staff and family attempt to come A progress note, dated 8/24/17 at 2:53 p.m., indicated .exit seeking at times A progress note, dated 9/2/17 at 2:13 a.m., indicated .at the entrance way attempting to leave. A progress note, dated 9/15/17 at 12:13 a.m., indicated Resident was found pushing buttons on the lock key pad A progress note, dated 10/10/17 at 7:00 p.m., indicated Resident noted to be missing from unit. Initiated staff search for resident. Resident found walking in parking lot stated I'm going home. The progress note indicated the physician and family were notified and Resident C was placed on 15 minute checks. A Event Report, dated 10/10/17 at 7:20 p.m., indicated Resident C was found at approximately 7:05 p.m. in the parking lot. The intervention measure taken was to place Resident C back on the locked unit on 15 minute checks. Review of a CNA assignment sheet, provided by Corporate Nurse on 10/24/17 at 11:33 a.m., indicated Resident C required supervision for transfers and could be up as desired. There was no information related to Resident C wandering or exit seeking on the unit. On 10/24/17 at 1:37 p.m., Corporate Nurse 3 indicated the interventions in place to prevent wandering was being placed on a locked unit. This Federal tag relates to Complaint IN 566. 3.1-45(a)(2)

Based on interview and record review, the facility failed to immediately initiate Cardiopulmonary Resuscitation (CPR) to a resident who requested a full code status and was found unresponsive. This deficient practice affected 1 of 6 residents reviewed who requested CPR and had the potential to affect 41 of 94 residents in the facility who were considered a full code status and would require CPR. (Resident C) The immediate jeopardy began on [DATE] when the facility staff failed to immediately initiate CPR to a full code resident found unresponsive. The Administrator was notified of the immediate jeopardy on [DATE] at 10:32 a.m. The immediate jeopardy was removed on [DATE], but the non compliance remained at the lower scope and severity level of no actual harm, but potential for minimal harm. Findings include: Resident C's record was reviewed on [DATE] at 11:15 a.m. [DIAGNOSES REDACTED]. Review of the clinical record indicated Resident C had a physician's orders [REDACTED]. Review of the clinical record indicated Resident C had a care plan dated [DATE], indicated the following: Problem Start Date [DATE] Resident has chosen life sustaining measures. Interventions included, but were not limited to, Initiate life sustaining measures as needed. Review of the electronic clinical record indicated Resident C's full code status was present within the green banner located at the top of every page with the resident's name and room number. Review of the nursing progress note, dated [DATE] at 10:10 a.m., indicated Resident C was sitting up in bed awaiting breakfast. A staff member entered the room to deliver his morning medication and was unable to wake the resident. The progress noted indicated the staff member yelled for help from other staff members. The resident's breathes were documented as shallow and the resident was turning blue. CPR was initiated and 911 was called. During an emergency cart observation on [DATE] at 10:58 a.m., an AED was present on the bottom shelf of the emergency cart. During an interview on [DATE] at 12:57 p.m., CNA #9 indicated resident code status was located on the CNA assignment sheet. Review of the CNA assignment sheet lacked any indication of resident code status. During an interview on [DATE] at 1:13 p.m., QMA (Qualified Medication Aide) #7 indicated she found Resident C unresponsive and shook him with no response. She indicated she saw the resident take two breaths then stopped breathing. She left the resident's room , past the nurses station on the North Hall, to call for help and stated she did put on the call light, but she did not initiate CPR. She also indicated she did not know Resident C's code status. She indicated she found LPN #1 two doors past the nursing station and down the north hallway to the main hall way near the therapy room. QMA #7 told LPN #1 she could not wake Resident C. I told her she needed to come to his room because he didn't look good. She indicated it took approximately two minutes for LPN #1 and herself to return to Resident C's room. Resident C was still not breathing and LPN #1 then began chest compressions. She indicated no back board was available and they were unable to remove the foot board from the bed to use as a back board. She indicated another nurse arrived with the emergency cart. The staff were unable to locate the ambu bag for rescue breathing. Resident C was already on 4 liters of oxygen and was left on his oxygen during the chest compressions. She indicated a back board was found and brought into the room after chest compression had already been started. The ambulance arrived 10 minutes later and took over administering the CPR. QMA #7 indicated she had a current BLS (Basic Life Saving) CPR certificate at the time of the incident. A copy of her certificate was provided. QMA #7 indicated they had been unaware there was an AED located in the bottom of the emergency cart. During an interview on [DATE] at 8:46 a.m., LPN #1 indicated she had been in another resident's room when she heard QMA #7 call for help. She found QMA #7 sticking her head out of the door of Resident C's room and was told the resident was not responding. They entered the room and she asked the CNAs if the resident was a full code. She indicated no one was sure of Resident C's code status and she left the room to check. She then told them to call 911 and get the nurse from the other unit and then started chest compressions. When LPN #2 arrived the emergency cart was brought in. (Name of LPN #2) had brought the big oxygen tank and we hooked him up. She indicated rescue breathing could not be provided due to them not being able to find an ambu bag. LPN #1 indicated she did not have a current CPR certification at the time of the incident. During an interview on [DATE] at 9:15 a.m., LPN #2 indicated a CNA told her she was needed, that a resident was coding. She indicated when she arrived with the big oxygen tank the CNA brought in the emergency cart. She indicated LPN #1 was already doing chest compressions with QMA #7, trading back and forth. She indicated they were unable to locate an ambu bag from the emergency cart so they placed a mask on Resident C. She was unable to identify the type of mask used. She also indicated she was unable to attach the oxygen regulator to the oxygen tank and had to hold the oxygen tubing to the oxygen tank it with her hands. She indicated Resident C was not breathing. LPN #2 indicated she did have CPR certification at the time of the incident but did not have a card. She indicated the facility did not have a copy of her CPR certification. She stated the ambulance arrived ten minutes later and took over providing CPR. During an interview on [DATE] at 3:05 p.m., the Corporate Nurse Consultant indicated the facility did not have a system in place to monitor CPR certifications or staff education for the AED (Automated External Defibrillator). Education records for the AED and CPR certifications were requested at this time. No records were made available for staff AED education or code blue training. The facility was able to provide eleven staff members CPR certification at that time. During an interview on [DATE] at 7:50 a.m., the Staffing Coordinator indicated the facility did not have a system in place to monitor scheduling to ensure a CPR certified employee was present for all shifts. Review of a current undated policy titled Cardiopulmonary Resuscitation (CPR) and Basic Life Support (BLS) indicated the following: Purpose The purpose of this procedure is to provide guidelines for the initiation of Cardiopulmonary Resuscitation (CPR)/Basic Life Support (BLS) in victims of sudden [MEDICAL CONDITION]. General Guidelines . 5. Depending on the underlying cause, the chances of surviving SCA (sudden [MEDICAL CONDITION]) may be increased if CPR is initiated immediately upon collapse. 8. The goal of early delivery of CPR is to try to maintain life until the emergency medical response team arrives to deliver Advance Life Support (ALS). 9. If an individual (resident, visitor , or staff) is found unresponsive and not breathing normally, a licensed staff person who is certified in CPR/BLS shall initiate unless: a. It is known that a Do Not Resuscitate (DNR) order that specifically prohibit CPR and or external defibrillation exists for that individual. The immediate jeopardy that began on [DATE] was removed on [DATE] when the facility implemented a systemic plan that included the following actions: provided education for nurses on CPR guidelines and expectations and location of the code status in the medical record and location of needed supplies, reviewed the code status for all residents and implemented a process to identify that a CPR certified staff member would be available each shift. This Federal tag relates to Complaint IN 805 3XXX,[DATE](a)(3)

Based on observation, record review and interview, the facility failed to ensure appropriate equipment was available for staff to respond effectively in an emergent situation nor require nursing staff members to have current CPR (Cardiopulmonary Resuscitation) certification. This deficient practice affected 1 of 3 residents reviewed who requested CPR and had the potential to affect 41 of 94 residents in the facility who were considered a full code status and would require CPR. (Resident C) The immediate jeopardy began on [DATE] when the facility staff failed to immediately initiate CPR to a full code resident found unresponsive. The Administrator was notified of the immediate jeopardy on [DATE] at 10:32 a.m. The immediate jeopardy was removed on [DATE], but the non compliance remained at the lower scope and severity level of no actual harm, but potential for minimal harm. Findings include: Resident C's record was reviewed on [DATE] at 11:15 a.m. [DIAGNOSES REDACTED]. Review of the clinical record indicated Resident C had a physician's orders [REDACTED]. Review of the clinical record indicated Resident C had a care plan dated [DATE], indicating the following: Problem Start Date [DATE] Resident has chosen life sustaining measures. Interventions included, but were not limited to, Initiate life sustaining measures as needed. Review of the nursing progress note, dated [DATE] at 10:10 a.m., indicated Resident C was sitting up in bed awaiting breakfast. A staff member entered the room to deliver his morning medication and was unable to wake the resident. The progress noted indicated the staff member yelled for help from other staff members. The resident's breaths were documented as shallow and the resident was turning blue. CPR was initiated. Paramedics arrived and took over providing CPR to Resident C. The resident was then transported to the hospital where he expired approximately 2 hours later. During an interview on [DATE] at 12:57 p.m., CNA #9 indicated resident code status was located on the CNA assignment sheet. Review of the CNA assignment sheet lacked any indication of resident code status. During an observation on [DATE] at 10:58 a.m., the emergency cart located in the North Hall was found to lack the following equipment per the emergency cart check list the: a. Oxygen E-Cylinder with regulator and wrench b. Suction machine c. Ambu bag d. CPR back board e. Suction machine canister f. Connection tubing for suction machine g. [MEDICATION NAME] suction catheters (2) h. Stethoscope i. Blood Pressure cuff During an observation on [DATE] at 1:50 p.m., the emergency cart located in the South Hall was found to lack the following equipment per the emergency cart check list the:: a. Regulator and wrench for oxygen tank b. Goggles c. Suction machine tubing unopened d. Suction machine canister e. Connection tubing for suction machine The South Hall crash cart was located in the staff locker room and was covered with the staff's personal items such as clothing. During an interview on [DATE] at 1:13 p.m., QMA (Qualified Medication Aide) #7 indicated she found Resident C unresponsive and shook him with no response. She indicated she saw the resident take two breaths then stopped breathing. She left the resident's room , past the nurses station on the North Hall, to call for help and stated she did put on the call light, but she did not initiate CPR. She also indicated she did not know Resident C's code status or where to locate it. She indicated she found LPN #1 two doors past the nursing station and down the north hallway to the main hall way near the therapy room. QMA #7 told LPN #1 she could not wake Resident C. I told her she needed to come to his room because he didn't look good. She indicated it took approximately two minutes for LPN #1 and herself to return to Resident C's room. Resident C was still not breathing and LPN #1 then began chest compressions. She indicated no back board was available and they were unable to remove the foot board from the bed to use as a back board. She indicated another nurse arrived with the emergency cart. The staff were unable to locate the ambu bag for rescue breathing. Resident C was already on 4 liters of oxygen and was left on his oxygen during the chest compressions. She indicated a back board was found and brought into the room after chest compression had already been started. The ambulance arrived 10 minutes later and took over administering the CPR. QMA #7 indicated she had a current BLS (Basic Life Saving) CPR certificate at the time of the incident. A copy of her certificate was provided. QMA #7 indicated they had been unaware there was an AED located in the bottom of the emergency cart. During an interview on [DATE] at 8:46 a.m., LPN #1 indicated she had been in another resident's room when she heard QMA #7 call for help. She found QMA #7 sticking her head out of the door of Resident C's room and was told the resident was not responding. They entered the room and she asked the CNAs if the resident was a full code. She indicated no one was sure of Resident C's code status and she left the room to check. She then told them to call 911 and get the nurse from the other unit and then started chest compressions. When LPN #2 arrived the emergency cart was brought in. She indicated rescue breathing could not be provided due to them not being able to find an ambu bag. LPN #1 indicated she did not have a current CPR certification at the time of the incident. During an interview on [DATE] at 9:15 a.m., LPN #2 indicated a CNA told her she was needed, that a resident was coding. She indicated when she arrived with the big oxygen tank the CNA brought in the emergency cart. She indicated LPN #1 was already doing chest compressions with QMA #7, trading back and forth. She indicated they were unable to locate an ambu bag from the emergency cart so they placed a mask on Resident C. She was unable to identify the type of mask used. She also indicated she was unable to attach the oxygen regulator to the oxygen tank and had to hold the oxygen tubing to the oxygen tank it with her hands. She indicated Resident C was not breathing. LPN #2 indicated she did have CPR certification at the time of the incident but did not have a card. She indicated the facility did not have a copy of her CPR certification. She stated the ambulance arrived ten minutes later and took over providing CPR. Dunging an interview on [DATE] at 1:50 p.m., the DON (Director of Nursing) indicated the emergency carts were to be audited every day by the night shift. Emergency Cart Daily Check List were requested for the two emergency carts in the facility. Review of the Emergency Cart Check List for the North Hall for [DATE] indicated the following: ,[DATE]-,[DATE] no check ,[DATE]-,[DATE] no check [DATE] no check ,[DATE]-,[DATE] no check ,[DATE]-,[DATE] no check [DATE] Emergency Cart Check List for the North Hall indicated the suction machine and lubricant were not present for the entire month. Review of the Emergency Cart Check List for the South Hall for [DATE] indicated the following: ,[DATE]-,[DATE] no check [DATE]/2017 no check [DATE] no check ,[DATE]-,[DATE] no check ,[DATE]-,[DATE] no check Review of a current undated policy titled Cardiopulmonary Resuscitation (CPR) and Basic Life Support (BLS) indicated the following: Purpose The purpose of this procedure is to provide guidelines for the initiation of Cardiopulmonary Resuscitation (CPR)/Basic Life Support (BLS) in victims of sudden [MEDICAL CONDITION]. 3. Maintain equipment and supplies necessary for CPR/BLS in the facility. 4. Provide equipment and supplies necessary for CPR/BLS in the facility at all times. General Guidelines . 5. Depending on the underlying cause, the chances of surviving SCA (sudden [MEDICAL CONDITION]) may be increased if CPR is initiated immediately upon collapse. 8. The goal of early delivery of CPR is to try to maintain life until the emergency medical response team arrives to deliver Advance Life Support (ALS). 9. If an individual (resident, visitor , or staff) is found unresponsive and not breathing normally, a licensed staff person who is certified in CPR/BLS shall initiate unless: a. It is known that a Do Not Resuscitate (DNR) order that specifically prohibit CPR and or external defibrillation exists for that individual. The immediate jeopardy that began on [DATE] was removed on [DATE] when the facility implemented a systemic plan that included the following actions: provided education for nurses on CPR guidelines and expectations and location of the code status in the medical record and location of needed supplies, reviewed the code status for all residents and implemented a process to identify that a CPR certified staff member would be available each shift. This Federal tag relates to Complaint IN 805. 3XXX,[DATE](a)

Based on interview and record review the facility failed to provide appropriate supervision for a cognitively impaired dependent resident resulting in injuries of unknown origin - bilateral femur fractures. This deficient practice affected 1 of 2 residents reviewed for injuries of unknown origin. (Resident B) Findings include: The clinical record for Resident B was reviewed on 10/6/16 at 11:00 a.m. [DIAGNOSES REDACTED]. The most recent Quarterly Minimum Data Set (MDS) assessment, dated 8/18/16, was reviewed on 10/6/16 at 11:00 a.m. The MDS indicated the resident was severely cognitively impaired with a BIMS (Brief Interview for Mental Status Score) of 0. The resident received the following Activities of Daily Living (ADL) assistance; transfer-extensive assist with 2 person physical assist, dressing bathing and hygiene- total assist with 1 person physical assist, eating- extensive assistance with 2 person assist and extensive assist with 2 person physical assist for toilet use. The resident was always incontinent of bowel and bladder, and had no impairments of range of motion in all extremities. Review of the Certified Nursing Assistant (CNA ) Assignment Sheet indicated the resident required the total assist of two for transfers and turns. The CNA Assignment Sheet indicated Resident B was not a fall risk. Review of a quarterly Fall Risk Assessment dated 7/29/2016, indicated the resident had a fall risk score of 12 indicating a high risk for falls. Review of a nursing note, dated 9/30/2016 at 5:58 a.m., indicated Aide reports to nurse that Resident has been aggressive during the night while aide was attempting to provide incontinent care. Resident pinching, swatting at and yelling out, unusual behavior for her. During care Resident noted to have dark purple discoloration noted to bilateral lower extremities, anterior and posterior knees and calves. Some swelling noted to bilateral lower extremities. Areas on legs are where resident is resting in bed, inside both knees where knees lay on each other, left outer calf which is against bed and right inner where legs are together. Resident has more pale appearance noted and seems weaker. MD notified with orders received to obtain CBC, bilateral xrays and dopplers, family notified. Resident B was assessed and found to have a low oxygen saturation level of 80%. The resident was put on 2 liters of oxygen per nasal cannula. Oxygen saturation re-evaluated and found to be 95%. Review of a nursing note, dated 9/30/2016 at 8:43 a.m., indicated Results of xray received, results show old femur fracture and osteoarthritis, lab results show critically low hemoglobin and low hematocrit and red blood count, MD notified of results an gave order to send to ER for evaluation and blood transfusion, call placed to Son (name) who states he would like mother sent to (name of hospital), (name of ambulance) to transport. Transport arrived to take Resident B to the hospital at 9:15 a.m. Review of a Change in Condition assessment, dated 9/30/2016, indicated the resident had purple discoloration and swelling to anterior and posterior lower extremities bilaterally. Review of the bilateral lower extremity xrays, dated 9/30/2016, indicated Modest osteoarthritis of the left knee. Acute fracture distal femur. Modest osteoarthritis of the right knee. Acute fracture distal femur. Review of the facility investigation indicated Resident B was assisted to bed on 9/29/2016 between 7:30 p.m. and 8:00 p.m. Two CNA were present in the room at the time of transfer from wheelchair to the bed. Neither CNA noted anything unusual at that time. Review of a written statement, dated 10/3/2016, LPN #14 indicated at 9:00 p.m., indicated the resident complained of a headache and was given tramadol. LPN #14 indicated at 3:00 a.m., CNA #13 reported the resident's complaint of leg pain and bruising. Review of a written statement, dated 10/3/2016 at 2:00 p.m., indicated the night shift CNA #13 arrived on the unit at 9:20 p.m. and passed ice water and washed wheelchairs during the shift. CNA #13 did not check on Resident B until 1:00 a.m. CNA #13 returned to check on Resident B at 3:30 a.m. CNA #13 indicated the resident was dry at the time, but was changed and repositioned. CNA #13 indicated Resident B was slapping and grabbing at her at that time. During an interview on 10/7/2016 at 11:47 a.m., LPN #9 indicated Friday morning the nurse called me down to the room. I was coming into work. I saw bruising on the back of her (Resident B) legs. Se complained of pain when I moved her legs to get a better look at it, just enough to see it. She didn't scream or anything, just said something like 'that hurt'. The unit manager called the son and the doctor. I was here when (name of imagining company) came in to do the xrays, but I wasn't directly involved with that. The unit manager told me what the results were. The son came in when she was already in the ambulance. I gave him her hearing aide and he got her glasses out of her room. I called the hospital later that day and they told me she had a broken femur. I read the xray reports and realized they said she had 2 broken femurs. LPN #9 indicated the DON called and informed the hospital of the xray results and faxed a copy of the results to the hospital. During an interview on 10/7/2016 at 1:12 p.m., Resident B's roommate indicated she was in her bed the night of 9/30/2016 and did not hear or see anything abnormal related to Resident B's care. The roommate denied Resident B falling or being dropped. Resident B's roommate has a BIMS of 14 out of 15. During an interview on 10/7/2016 at 8:12 a.m., the Director of Nursing (DON) and Administrator indicated during the facility investigation several of the initial statements were contradictory. The Administrator indicated the security video tape was reviewed from the morning of 9/20/2016 to clarify the contradictions and to assess if Resident B could have been injured during her shower. No indications of injury were noted at that time. One staff member was terminated as a result of the investigation. During an interview on 10/7/2016 at 1:12 p.m., the DON indicated the facility investigation could not determine the exact cause of Resident B's bilateral femur fractures. We investigated it and to the best of our ability we determined it must have occurred between when she (Resident B) was put to bed and when the injury was reported on 9/30 (9/30/2016). This Federal tag relates to Complaint IN 756. 3.1-45(a)(2)