Every finding on record at River Pointe Health Campus

Based on record review and interview, the facility failed to ensure accurate physicians orders were in the Electronic Medication Administration Record (EMAR), skin assessments were documented as done for one of 3 residents reviewed for hospice. (Resident B) Finding includes: On 5/18/26 at 9:58 a.m., Resident B's clinical record was reviewed. Diagnoses included but were not limited to, chronic systolic (congestive) heart failure, type 2 diabetes mellitus with diabetic neuropathy. Resident B admitted to the facility on [DATE], discharged on 5/16/26.Care plans were reviewed and included but were not limited to:At risk for skin breakdown r/t (related to) generalized weakness, impaired mobility, incontinence. Interventions included but were not limited to:Conduct weekly skin assessment. Pay particular attention to bony prominences, initiated 1/21/25, goal target date 6/28/26. Resident requires hospice care r/t congestive heart failure, date initiated 1/21/25.Physicians orders were reviewed for March, April, May 2026. Orders included but were not limited to:Order set WC (wound care) (Left lateral foot): Cleanse wounds with wound cleanser or normal saline, pat dry, apply skin prep to per-wound, apply collagen and cover with foam dressing. PRN (as needed) if dislodged or soiled. Frequency- Once a day -PRN. special instructions- Change PRN when dressing becomes dislodged or soiled, order date 1/6/26, discontinue date 5/2/26. Order set WC- Observe (Left lateral foot) dressing to open area(s) every shift for draining on dressing and dislodgement. Frequency- Three times a day, order date 1/6/26, discontinue date 5/2/26. The following dates had signatures documented that the dressing was observed in March , April, May, 2026:March - 1-31April- 1- 30May- 1 Wound notes were reviewed and indicated the wound to Resident B's left lateral foot was healed on 2/3/26.The clinical record did not contain documentation that weekly skin assessments were done by nursing staff in 2026. On 5/19/26 at 9:04 a.m., the Assistant Director Of Nursing (ADON) indicated she did not find any weekly skin assessments by the facility on Resident B, typically skin assessments are done by nursing staff. On 5/19/26 at 1:44 p.m., the Executive Director provided the current policy on weekly skin observations with a revised date of 5/14/25. The policy included but was not limited to: The purpose of this policy is to: To monitor the effectiveness of intervention for pressure reduction, identify areas of skin impairments in the early development stage and implement other preventative and/or treatment measures as indicated .1. A full body observation shall be completed weekly by the licensed nurse. 2. Upon admission the admitting nurse shall include as part of the admission orders a weekly skin observation. The order shall read: Weekly skin assessment completed. New treatments and notifications completed for any new areas noted. The date the observation should be completed shall be assigned by the DHS( Director Of Health Services) or designee and indicated by the corresponding date on the treatment administration record,(TAR). 3.The nurse completing the weekly skin check shall indicate the weekly skin assessment is complete .On 5/19/26 at 1:46 p.m., the Executive Director indicated the facility does not have a policy on documentation, they follow the nursing standard of care. This citation relates to Intake 2984172. 410 IAC (Indiana Administrative Code) 3.1-50(a)(1) 410 IAC (Indiana Administrative Code) 3.1-50(a)(2)

Based on observation, record review, and interview, the facility failed to ensure there was a periodic review with a resident and resident representative regarding decisions of any advance directives and its provisions as preferences may change time in 1 of 1 random observation for advance directives. (Resident 48) Finding includes: On 6/17/25 at 11:42 A.M.,during a random observation of the Dashboard (Resident Information Tab) for the Electronic Health Record (EHR) the resident was observed to be a full code. On 6/18/25 at 10:40 A.M.,during a random observation of the Dashboard for the Electronic Health Record (EHR) the resident was observed to be a full code On 6/18/25 at 10:40 A.M., Resident 48's clinical record was reviewed. Diagnoses included, but were not limited to, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side and aphasia. The most Current Quarterly Review dated 5/15/25 indicated that Resident 48 was severely cognitively impaired. The resident needed substantial assist for eating, and was totally dependent for toileting, dressing, and transferring. Current physician orders indicated that the resident was a full code dated 3/17/25. The most recent care plan for Advanced Directives indicated that the following interventions included, but were not limited to, resident was full code. advanced directives were to be updated quarterly and PRN (As Needed), and honor resident's right to change advance directives at anytime, this was dated 3/1/25 with a review and revision on 5/29/25. Resident 48 record's indicated there was a new code status was declared on 5/11/25 of Do Not Resuscitate (DNR). This was scanned into the Electric Health Record (EHR) 5/27/25. During an interview on 6/19/25 at 9:05 A.M., Registered Nurse (RN) 22 indicated that Advance Directives are reviewed every 6 months and PRN along with the Dashboard. She indicated it should have been changed. On 6/23/25 at 9:45 A.M., the Regional Clinical Support Nurse provided a current policy Guidelines for Advanced Directives revised 9/26/24. The policy indicated .the purpose of the policy was to ensure facility staff obtains and follows resident's advanced directives regarding end-of-life care .a member of the Interdisciplinary Team (IDT) will review and/or update quarterly and PRN thereafter . 3.1-4(l)(5)

Based on observation, record review, and interview, the facility failed to ensure infection control practices were followed for 1 of 1 resident reviewed for care. The staff failed to wear personal protective equipment, wash hands, and ensuring a resident's catheter bag was not touching the ground during a random observation of wound care. (Resident 15) Finding includes: During an observation on 6/19/25 at 11:32 A.M., Registered Nurse (RN) 24 and (Licensed Practical Nurse) LPN 21 were observed performing wound care for Resident 15. RN 24 and LPN 21 performed hand hygiene and donned a gown and gloves. Resident 15 was observed sitting in the middle of his room in his wheelchair with his catheter bag attached to the bottom of his wheelchair. The catheter bag and tubing were observed touching the floor. LPN 21 pushed Resident 15 in his wheelchair into the bathroom. The catheter bag and tubing dragged the floor. RN 24 attached the catheter bag to the toilet roll holder. Resident 15 stood up using the assistive railing next to the toilet. LPN 21 and RN 24 removed the resident's pants and brief. LPN 21 cleaned Resident 15's bottom with a wet washcloth, dried the area with a towel, removed her gloves, performed hand hygiene, and put on a new pair of gloves. LPN 21 applied cream to the resident's coccyx. Resident 15 indicated that he felt weak and could not stand for much longer. LPN 21 removed her gloves and performed hand hygiene. LPN 21 did not put on another pair of gloves. LPN 21 used her bare hands to put a brief on Resident 15 and pull up his pants. LPN 21 and RN 24 helped Resident 15 to sit down in his wheelchair. LPN 21 collected the dirty wet washcloths and trash using her bare hands and placed them in the trash bag. LPN 21 performed hand hygiene. RN 24 unhooked the catheter bag from the toilet roll holder and reattached it to the bottom of the wheelchair. The catheter tubing was observed touching the floor. At that time, Resident 15 indicated the tip of his penis burned. LPN 21 pushed Resident 15 in his wheelchair from the bathroom into the middle of his room. The catheter tubing dragged the floor. On 6/18/25 at 1:07 P.M., Resident 15's clinical record was reviewed. Resident 15 was admitted on [DATE]. Diagnoses included, but were not limited to, chronic kidney disease. The most recent admission Minimum Data Set (MDS) Assessment, dated 5/12/25, indicated Resident 15 was cognitively intact, required substantial assistance (staff do more than half of the work) for toileting, and had a catheter. Physician orders included, but were not limited to: Staff to use enhanced barrier precautions, wearing a gown and gloves at minimum during high-contact care activities; Start date 6/6/25. Change catheter bag PRN base on clinical indications such as infection, obstruction, or when the closed system is compromised; Start date 6/6/25. Current care plans included, but were not limited to: Resident requires enhanced barrier precautions (EBP) during high-contact care related to presence of: Indwelling catheter, wounds; Start date 5/8/25. During an interview with RN 24 on 6/20/25 at 9:26 A.M., she indicated catheter bags and tubing should be off of the floor, and staff should be wearing gloves during any care or contact with a resident. On 6/23/25 at 9:31 A.M., the Regional Support Nurse provided a policy titled Preserving Dignity with Indwelling Catheter, dated 12/16/24, that indicated Urinary drainage bags and catheter tubing should be kept from touching the floor surface. On 6/17/25 at 10:45 A.M., the Administrator provided a policy titled Infection Prevention and Control General Guidelines, dated 7/13/20, that indicated Hands should be washed between direct contact with any resident, after doing cleaning tasks, after using the bathroom or any other task that provides opportunity for infection. Gloves should be worn when coming in to contact with blood or body secretions. 3.1-18(b)

Based on observation, interview, and record review, the facility failed to ensure proper storage of medications for 1 of 2 medication carts observed and 2 of 2 medication storage rooms observed. Loose pills were observed in a medication cart, a medication refrigerator was observed propped open with a temperature out of range, and medication refrigerator temperature logs were not filled out completely. (300 Hall Medication Cart, 300 Hall Medication Storage Room, 400 Hall Medication Storage Room) Findings include: 1. On 6/7/24 at 9:38 A.M., the 300 Medication Cart was observed with the following loose pills: 1 oblong yellow pill with marking 151 1 white round pill with marking D5 1 clear gel capsule with no markings 1 round yellow pill with marking RP101 3 round yellow pills with marking G127 1 round white pill with marking GC422 4 round brown pills with marking 08075 1 round pink pill with marking RP101 2 round white pills with no marking 1 oblong cream pill with marking J75 1 oblong white pill with marking KCM20 1 oblong lavender pill with no marking 1 round white pill with marking 502 1 round pink pill with marking 20 on one side and CUP/N on the other side 1 round peach pill with marking 1717 1 round red pill with no marking 2 blue half pills with no marking 1 round white pill with marking RX52B 1 round pink pill with marking L26 1 off-white capsule with no marking 1 white capsule with marking 216 1 oblong white pill with marking VF on one side and 41 on the other side 1 round white pill with marking 500 At that time, Registered Nurse (RN) 21 indicated nursing staff was responsible for cleaning the medication carts. 2. On 6/7/24 at 9:52 A.M., the 400 Hall Medication Storage Room was observed. The medication refrigerator was observed cracked open and the temperature reading on the inside of the refrigerator was 54 degrees Fahrenheit. At that time, a sign was observed posted on the outside of the refrigerator that indicated temperatures should be kept between 36 and 46 degrees Fahrenheit. The temperature log at that time was observed to be not filled out from June 1st through the 4th. On 6/7/24 at 2:00 P.M., the 400 Hall Medication Storage Room was observed with the medication refrigerator reading 34 degrees Fahrenheit. RN 9 indicated the temperature was too low and adjusted it. 3. On 6/7/24 at 10:02 A.M., the 300 Hall Medication Storage Room was observed. The most recent temperature log that was posted was dated May 2024 and lacked temperatures on 5/28/24, 5/29/24, and 5/30/24. A current month temperature log was not posted. At that time, the Unit Manager indicated there should have been a temperature log for June posted and would look for it and provide it. The June temperature log was not provided. The following medications were observed sitting on a shelf in the 300 Hall Medication Storage Room cabinet: 1 bottle of bisacodyl 5mg with no label and expiration date of 5/23 1 bottle of glucose tabs with no date or label 1 bottle of escitalopram 5mg, belonging to Resident 10 1 bottle of amlodipine 10mg, belonging to Resident 10 4 bottles of glimepiride 4mg, belonging to Resident 10 2 bottles of PreserVision AREDS with no label At that time, the Unit Manager indicated Resident 10 had come to that unit from the Assisted Living side of the facility and had probably brought those medications with her. She indicated the medications should have been disposed of, and any nurse that observed them in the medication storage room could have done it. On 6/10/24 at 11:21 A.M., the Administrator provided a current Medication Storage in the Facility policy, dated 11/18, that indicated Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier . Medications and biologicals are stored at their appropriate temperatures and humidity according to the United States Pharmacopeia guidelines for temperature ranges . Medications requiring refrigeration are kept in a refrigerator at temperatures between 2 C (36 F) and 8 C (46 F) . The Facility should maintain a temperature log in the storage area to record temperature at least once a day. On 6/11/24 at 1:17 P.M., the Director of Nursing (DON) provided a current Disposal of Medications and Medication-Related Supplies policy, dated 11/18, that indicated Discontinued medications and medications left in the facility after a resident's discharge, which do not qualify for return to the pharmacy for credit, should be destroyed, given to the appropriate family member/responsible party, or returned to the pharmacy for destruction where permitted by regulations. 3.1-25(m) 3.1-25(o)

Based on interview and record review, the facility failed to ensure education was provided prior to administering flu vaccines for 5 of 5 residents reviewed for vaccines. (Resident 27, Resident 12, Resident 12, Resident 29, Resident 30) Findings include: On 6/10/24 at 8:41 A.M., resident vaccine information was reviewed for the following residents: 1. Resident 27 received a flu vaccine on 10/4/23. The clinical record lacked information about education provided to the resident and/or resident representative prior to administering the vaccine. 2. Resident 13 received a flu vaccine on 10/4/23. The clinical record lacked information about education provided to the resident and/or resident representative prior to administering the vaccine. 3. Resident 12 received a flu vaccine on 10/4/23. The clinical record lacked information about education provided to the resident and/or resident representative prior to administering the vaccine. 4. Resident 29 received a flu vaccine on 10/4/23. The clinical record lacked information about education provided to the resident and/or resident representative prior to administering the vaccine. 5. Resident 30 received a flu vaccine on 10/4/23. The clinical record lacked information about education provided to the resident and/or resident representative prior to administering the vaccine. On 6/12/24 at 10:37 A.M., the Director of Nursing (DON) indicated she had administered the flu vaccines this season and was unaware that education for the flu vaccine was needed annually prior to administration. On 6/7/24 at 2:00 P.M., the Administrator provided a current Influenza Immunization policy, dated 4/12/17, that indicated Each resident/responsible party will be provided annually with information regarding the risk and benefits of influenza vaccine and receive the immunization per their request, unless medically contraindicated. 3.1-13(a)

Based on observation, interview, and record review, the facility failed to ensure dignity was respected for 2 of 2 random observations. (Resident 24, Resident 31) Findings include: 1. On 6/7/24 at 12:08 P.M., RN (Registered Nurse) 21 was observed in the dining room assisting Resident 24 to eat lunch. RN 21 was standing. On 6/11/24 at 10:42 A.M., Resident 24's clinical record was reviewed. Diagnoses included, but was not limited to, Parkinson's disease. The most current Quarterly MDS (Minimum Data Set) Assessment, dated 5/29/24, indicated Resident 24 was rarely or never understood and dependent on staff to eat. On 6/12/24 at 9:27 A.M., the DON (Director of Nursing) indicated that staff should sit to assist residents to eat if they required constant assistance. 2. On 6/11/24 at 11:24 A.M., Resident 31 was observed sitting on the toilet with his pants around his ankles. The doors to the bathroom and the hallway were open. Two CNAs (Certified Nurse Aide) were assisting Resident 31 to use the toilet. On 6/12/24 at 8:17 A.M., Resident 31's clinical record was reviewed. Diagnosis included, but was not limited to, Parkinson's disease. The most current Quarterly MDS Assessment, dated 5/4/24, indicated Resident 31 was rarely or never understood and required substantial to maximal assistance of staff (staff does more than half) for toileting On 6/12/24 at 9:27 A.M., the DON indicated staff should provide privacy while assisting a resident to use the toilet. Staff should close one or both doors. On 6/13/24 at 10:34 A.M., the Regional Support Nurse provided a current Resident Rights Guidelines policy, revised on 5/11/17, that indicated Our residents have a right to .privacy .be treated fairly, courteously and with respect by all staff. 3.1-3(a)

Based on observation, interview, and record review, the facility failed to ensure a resident that required assistance with transferring and moving had an order, evaluation, and care plan for the self administration of medication based on 1 of 1 residents reviewed for self-administration of medications. Finding includes: On 6/10/24 at 11:30 A.M., a bottle of Refresh brand eye drops and a bottle of Orajel oral pain analgesic were observed on the bedside tray of Resident 15. On 6/10/24 at 2:24 P.M., a bottle of Refresh brand eye drops were observed on the bedside tray of Resident 15. On 6/11/24 at 2:00 P.M., Resident 15's clinical record was reviewed. Diagnoses included, but were not limited to, chronic obstructive pulmonary disease with (acute) exacerbation, emphysema unspecified, and acute and chronic respiratory failure. The current Admission MDS (Minimum Data Set) Assessment, dated 5/16/24, indicated Resident 15 was cognitively intact and needed supervision for transferring and moving. Current physician orders lacked an order for eye drops, oral analgesic, and self-administration of medication. On 6/13/24 at 8:50, the Regional Support Nurse provided a copy of Resident 15's Self-Administration of Medication Assessment completed on 6/7/24. The assessment indicated the resident could self-medicate nebulizer treatments, pills after nurse set up, inhaler, and (medication) antacid after nurse set up. The inhaler could be kept at bedside and all others were to be kept at the nurse's station until set up. During an interview on 6/13/24 at 10:07 A.M., the DON (Director of Nursing) indicated a resident was expected to have a care plan and an order if the resident self-medicated. During an interview on 6/13/24 at 10:25 A.M., the DON indicated there was no care plan for self-administration of medication for Resident 15. On 6/13/24 at 10:20 A.M., the DON provided a current Guidelines for the Self-Administration of Medications policy, dated 12/31/23. The policy indicated . the results of the assessment will be presented to the physician for evaluation and an order for self-medication. The order should include the type of medications the resident is able to self-medicate . 3.1-11(a)

Based on observation, interview, and record review, the facility failed to notify the attending physician for 1 of 1 residents reviewed for skin conditions. The physician was not notified of new skin tears and orders for wound care were not obtained. (Resident 31) Finding includes: On 6/7/24 9:54 A.M., Resident 31 was observed to have two dressings on his left arm. On 6/10/24 at 12:54 P.M., a family member indicated Resident 31 had skin tears on his left arm due to shearing from the wheelchair. On 6/12/24 at 8:17 A.M., Resident 31's clinical record was reviewed. Diagnoses included, but were not limited to, Parkinson's disease and Alzheimer's disease. The most current Quarterly MDS (Minimum Data Set) Assessment, dated 5/4/24, indicated Resident 31 was rarely or never understood, required substantial to maximal assistance (staff does more than half) for transfers, and did not have any skin conditions or issues. The clinical record lacked physician orders, care plans, assessments, and an Event form related to the two wounds on Resident 31's left arm. On 6/12/24 at 8:59 A.M., the Wound Nurse indicated Resident 31 had two skin tears on his left arm that she found during a skin assessment on 6/3/24. When she found them, they had steri-strips on them and she changed the dressing at that time to a foam border. She was unsure how he got the skin tears and who applied the steri-strips. She monitored the skin tears and changed the dressings every 5 days. At that time, she was unable to find orders related to the skin tears on the resident's left arm. She indicated she must have forgotten to put an event into the chart and had been monitoring the skin tears on her own. On 6/13/24 at 8:50 A.M., the Regional Support Nurse provided a current Comprehensive Care Plan Guideline policy, dated 5/22/18, that indicated Acute problems that arise with the resident and are expected to be resolved within a short time frame will be addressed on the Event form specific for that problem. On 6/13/24 at 9:20 A.M., the Regional Support Nurse provided a current Bruise, Rash, Lesion, Skin Tear, Laceration Assessment Guidelines policy, dated 5/10/16, that indicated Complete one event for each Skin Tear/Laceration. On 6/13/24 at 10:34 A.M., the Regional Support Nurse provided a Notification of Change in Condition policy, dated 5/10/16, that indicated The resident's representative/provider should be notified of change in condition or diagnostic testing results in a timely manner . Documentation of notification or notification attempts should be recorded in the resident's electronic health record. On 6/13/24 at 10:38 A.M., the Regional Support Nurse indicated a timely manner would be within the shift. 3.1-5(a)(3)

Based on observation, interview, and record review, the facility failed to develop and implement care plans for 1 of 2 residents reviewed for ADLs (Activities of Daily Living) and 1 random observation. (Resident 31, Resident 15) Findings include: 1. On 6/10/24 at 12:54 P.M., a family member indicated staff transferred Resident 31 by grasping on to his shoulders which caused the resident pain. A gait belt was used while the resident was at home, but staff do not use the gait belt at the facility. On 6/11/24 at 11:24 A.M., Resident 31 was observed sitting on the toilet with CNA (Certified Nurse Aide) 3 and CNA 5 assisting him. The resident did not have a gait belt around his torso. At that time, the CNAs could not locate the gait belt and asked, where's the gait belt. The CNAs located a gait belt and transferred the resident from the toilet to his wheelchair. At that time, a family member indicated Oh. They are using the gait belt this time. On 6/12/24 at 8:17 A.M., Resident 31's clinical record was reviewed. Diagnoses included, but were not limited to, Parkinson's disease and Alzheimer's disease. The most current Quarterly MDS (Minimum Data Set) Assessment, dated 5/4/24, indicated Resident 31 was rarely or never understood and required substantial to maximal assistance (staff does more than half) with toilet transfers. A decline in functional status care plan, dated 10/17/23, indicated Resident 31 required assistance of 2 for transfers. Current physician's orders included, but were not limited to, the following: Activity: Assist x 2 for transfers, dated 10/17/23 A nursing progress note, dated 5/21/24 at 12:19 P.M., indicated that family noted bruising on the resident's bilateral upper arms that were reddish purple in color which might have happened during 2 person transfers. Hospice was made aware of the bruising and staff were encouraged to use a gait belt with transfers. On 6/12/24 at 9:27 A.M., the DON (Director of Nursing) indicated if a resident required assistance of 2 staff for transfers, a gait belt should be used. 46758 2. On 6/10/24 at 11:30 A.M., a bottle of (Name of medication) eye drops and a bottle of (Name of medication) oral analgesic was observed on the bedside tray of Resident 15. On 6/10/24 at 2:24 P.M., a bottle of (Name of medication) eye drops was observed on the bedside tray of Resident 15. On 6/11/24 at 2:00 P.M., Resident 15's clinical record was reviewed. Diagnoses included, but were not limited to, chronic obstructive pulmonary disease with (acute) exacerbation, emphysema unspecified, and acute and chronic respiratory failure. The current Admission MDS (Minimum Data Set) Assessment, dated 5/16/24, indicated Resident 15 was cognitively intact and needed supervision for transferring and moving. The clinical record lacked orders and a care plan for self-administration of medication. On 6/13/24 at 8:50, the Regional Support Nurse provided a copy of Resident 15's Self-Administration of Medication Assessment completed on 6/7/24. During an interview on 6/13/24 at 10:07 A.M., the DON (Director of Nursing) indicated a resident was expected to have a care plan and an order if resident self-medicated. During an interview on 6/13/24 at 10:25 A.M., the DON indicated there was no care plan for self-administration of medication for Resident 15. On 6/12/24 at 9:52 A.M., the DON provided a Caregiver New Hire Checklist, dated 3/22/23, that indicated all CNAs were trained on the use of gait belts upon hire to the facility. On 6/12/24 at 9:52 A.M., the DON provided a current Guidelines for Gait Belt Use policy, dated 5/10/17, that indicated If a resident requires more than limited assists and does not require a lift, a gait belt may be used with transfers. On 6/13/24 at 8:50 A.M., the Regional Support Nurse provided a current Comprehensive Care Plan Guideline policy, dated 5/22/18, that indicated Care plan interventions should be reflective of risk area(s) or disease processes that impact the individual resident . Comprehensive care plans need to remain accurate and current. On 6/13/24 at 10:20 A.M., the DON provided a current policy Guidelines for the Self-Administration of Medications dated 12/31/23. The policy indicated there should be a .Self- Medication plan of care initiated and updated as indicated . 3.1-35(a) 3.1-35(b)(2)

Based on observation and interview, the facility failed to ensure staff were following proper infection control protocols during 3 of 3 random observations. Staff were not changing gloves after performing care and were entering and exiting Enhanced Barrier Protection (EBP) rooms without donning and doffing Proper Protective Equipment (PPE). (Resident room [ROOM NUMBER]-unit, Resident 31, Resident 19) Findings include: 1. On 6/12/24 at 8:50 A.M., during a random observation of toileting, CNA (Certified Nurse's Aide) 25 was observed touching a resident's clothes without changing gloves after performing care. 48147 2. On 6/11/24 at 11:24 A.M., CNA (Certified Nurse Aide) 3 and CNA 5 were observed assisting Resident 31 to use the toilet. CNA 3 and CNA 5 had on gloves. The resident was assisted to stand. CNA 3 wiped the resident's buttocks with toilet paper and pulled up his pants. At that time, CNA 3 did not change her gloves. CNA 3 retrieved the resident's wheelchair from outside the bathroom. CNA 3 and CNA 5 transferred the resident to his wheelchair. CNA 3 cleaned up the bathroom and emptied the trash and then removed her gloves. On 6/12/24 at 11:37 A.M., the DON (Director of Nursing) indicated staff should change their gloves after cleaning a resident and between dirty and clean tasks. 38770 3. On 6/14/24 at 9:30 A.M., Certified Nurse Aide (CNA) 3 and CNA 5 were observed to enter Resident 19's room. At that time, a sign on the outside of the door indicated the resident was on enhanced barrier precautions (EBP) and required staff to put on a gown and gloves when providing care and making direct contact with the resident. Resident 19 indicated to both CNAs that he wanted to be adjusted in the bed. CNA 3 and CNA 5 were observed from the hall to assist the resident to adjust in the bed without putting on gloves or a gown. After the aides left the room, Resident 19 indicated the aides did not put on a gown or gloves when providing care for him. On 6/10/24 at 1:57 P.M., Resident 19's clinical record was reviewed. Diagnosis included, but was not limited to, obstructive uropathy and renal insufficiency. The most recent Quarterly MDS (Minimum Data Set) Assessment, dated 4/29/24, indicated a mild cognitive impairment, substantial to maximal assistance with bed mobility, and no behaviors or rejection of care. Current physician orders included, but were not limited to: Staff to use enhanced barrier precautions, wearing a gown and gloves at minimum during high-contact care activities (related to urinary catheter), dated 4/3/24. A current enhanced barrier precautions care plan, dated 4/1/24, indicated EBP was required during high-contact care related to presence of an indwelling catheter. On 6/11/24 at 1:06 P.M., the Director of Nursing (DON) provided a current EBP policy, dated 4/1/24, that indicated Personal Protective Equipment (PPE) should be used even if blood and body fluid exposure is not anticipated . At minimum, staff shall wear gloves and gowns during high-contact care activities. On 6/13/24 at 10:20 A.M., the DON (Director of Nursing) provided a current Standard Precautions Guidelines policy revised on 12/31/23. The policy indicated .Standard precautions include a group of infection prevention practices that apply to all patients, regardless of suspected or confirmed infection status, in any setting in which healthcare is delivered .standard precaution include but are not limited to hand hygiene, .the proper use of PPE (example gloves, gown,) .in addition to proper hand hygiene, it is important for staff to use appropriate protective equipment as a barrier to exposure to any body fluids (whether known to be infected or not) . 3.1-18(b) 3.1-18(j) 3.1-18(l)

Based on interview and record review, the facility failed to notify the residents representative for 1 of 3 falls reviewed. A resident's representative was not notified of a fall until the next day. ( Resident B) Finding includes: On 2/26/27 at 9:43 a.m., Resident B's clinical record was reviewed. Diagnoses included, but were not limited to, fracture of unspecified part of neck of left femur, subsequent encounter for closed fracture with routine healing (primary, admission), unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance. An Admission MDS (Minimum Data Set) assessment dated [DATE], indicated Resident B's cognition was moderately impaired, toileting dependent, sit to stand substantial. Resident B no longer resided at the facility. Care plans were reviewed and included, but were not limited to Resident is at risk for falling r/t fall history, impaired mobility . start date 11/29/23. Progress notes were reviewed and included, but were not limited to: 1/9/24 at 11:15 p.m., pt had call light on, staff entered room and pt was sliding off bed holding onto call light in his attempt to bo (sic) to the bathroom by himself. ROM (range of motion) normal all extremities. Assisted per 2 to toilet then to bed. Neurochecks initiated. Encouraged pt to call for help when transferring. 1/9/24 at 11:53 p.m., MD notified of fall. A progress note dated 1/10/24 at 12:11 a.m., included but was not limited to: Pain severity and location : How does Resident rate their pain from 1-10 2 Resident describes pain as:: Aching Does resident display non-verbal signs of pain ? Yes Non-verbal signs of pain: Facial grimaces/winces-furrowed brow, narrowed eyes, clenched teeth, tightened lips, jaw drop/distorted expressions. What alleviated pain ?: Medication, rest Teaching and Training provided :: Fall prevention and safety management. Exacerbation of symptoms, when to call the physician . The EMAR (Electronic Medication Administration Record) was reviewed for 1/9/24-1/10/24 and included, but was not limited to: hydrocodone -acetaminophen (pain medication) 7.5-325 mg amount to administer 1 tablet oral every 6 hours prn (as needed ) was given at 1:37 a.m., on 1/10/24, pain location butt, pain scale 4. 1/10/24 at 7:20 a.m., Was called to room [ROOM NUMBER]. Resident was in w/c. PT was here to take down for therapy. Resident slump in w/c. Color was pale pulse was not present. Got resident in bed and applied o2 and V/s were taken. Pupils were pinpoint. Son [name ] was notified and return called to keep resident comfortable and he would be here. Not to send resident out. [name] daughter arrived before [name]. Staff was monitor v/s and keeping family informed. 1/10/24 at 3:05 p.m., Residents family at bedside et requesting resident be sent out to [name of hospital] ED (emergency department) for eval et trt (treat) re: c/o strong pains with Lt. femur. Called Dr.[name] office et. received order to send to to [name of hospital] ED for eval et trt. re: c/o pains with Lt. Femur upon any movement or touch. Called [name ] for transportation to [name of hospital ] ED. On 2/27/24 at 9:11 a.m.,, the DON indicated the nurse on duty when Resident B fell was going to call the family and inform them of the fall in the morning because it was late at night and no injuries were found, he became unresponsive in the morning and the son was called, she thought the son's wife came in first. On 2/27/24 at 11:02 a.m., the DON provided the current policy on fall management program guidelines with an effective date of 5/31/17 and a review date of 12/31/23. The policy included, but was not limited to, .3. The attending physician or medical director in the absence of the attending physician and the responsible party should be notified . This citation relates to Complaint IN00428144. 3.1-5(a)(1)

Based on observation, interview, and record review, the facility failed to follow the plan of care for 1 of 3 residents reviewed for falls. A resident was assisted by one staff instead of two to transfer. (Resident C) Finding includes: On 2/26/24 at 11:28 a.m., Resident C's clinical record was reviewed. Diagnoses included, but were not limited to, Parkinson's disease, Alzheimer's disease, repeated falls. A Quarterly MDS (Minimum Data Set) assessment dated [DATE], indicated Resident C's cognition was impaired, toileting hygiene dependent, sit to stand substantial/maximal assist, chair/bed to chair : the ability to transfer to and from bed to a chair (or wheelchair) substantial/maximal assist. Care plans were reviewed and included, but were not limited to: Profile care guide: Goal : To communicate resident care needs. Approaches included, but were not limited to: Transfers: assist x 2, start date 10/17/23. Current physicians orders for February 2024 were reviewed and include, but were not limited to: , Activity: assist x 2 for transfers, start date 10/17/23. Progress notes were reviewed and included, but were not limited to: 2/3/24 at 12:06 a.m., [recorded as late entry on 2/3/24 12:07 a.m.], resident was assisted to floor after loosing (sic) his balance around 2130 on 2/2/24, poa (power of attorney) and md made aware. no injures noted or reported. 2/3/24 at 7:47 p.m., continues monitoring for assisted fall. no injures noted. denies pain or discomfort. VS WNL. will continue to monitor. 2/5/24 at 9:40 a.m., IDT : Resident being assisted transferred from wheelchair to toilet seat. Wheelchair footrest fell forward onto residents ankle causing resident to lose balance. Resident was assisted by staff member onto floor. No injuries noted. Vitals WNL. MD and family aware. Root cause: loosening of footrest on wheelchair. Intervention: assess wheelchair and notify hospice of any adjustments needed. 2/14/24 at 6:18 p.m., CAR: Resident placed in CAR (Comprehensive Assessment Review) monitoring for recent assisted fall when Broda chair footrest engaged forward bumping resident leg causing him to lose balance. Hospice to have Broda chair evaluated to assure footrests engage properly. Continues to transfer with assist of one. Propelled per staff and family. Plan of care monitored for effectiveness. The CAR note did not include the use of two assist for transfer as identified on the current care plan. On 2/27/24 at 9:12 a.m., the DON indicated the profile care guide on the care plans, is communication for the CNA's on residents needs. On 2/27/24 at 9:28 a.m., Resident C was observed to be transferred from his Broda chair to bed by CNA 1 and CNA 2. CNA 1 and CNA 2 indicated Resident C was a two assist for all transfers. On 2/27/24 at 10:41 a.m., the DON indicated CNA 3 was transferring Resident C by herself when he was lowered to the bathroom floor, fall interventions are on the resident care assist profile on the kiosk. On 2/27/24 at 11:02 a.m., the DON provided the current policy for comprehensive care plan guidelines with an effective date of 5/22/18. The policy included, but was not limited to: Purpose : To ensure appropriateness of services and communication that will meet the resident's needs, severity/stability of conditions, impairment, disability, or disease in accordance with state and federal guidelines .4. Pertinent care plan approaches are communicated to the nursing staff per the 24-hour CRCA (Certified Resident Care Associate/ Certified Nurse Aide) assignment or the care tracker profile dependent on campus preference . On 2/27/24 at 11:02 a.m., the DON provided the current policy on fall management guidelines with an effective date of 5/31/17 and a review date of 12/31/23. The policy include, but was not limited to: .b. care plan interventions should be implemented that address the resident's risk factors . This citation relates to Complaint IN00428144. 3.1-35(a)

Based on interview and record review, the facility failed to ensure a resident was free from misappropriation of their property for 1 of 4 residents reviewed for misappropriation. Narcotics were unaccounted for. (Resident B) Finding includes: On 5/17/23 at 10:00 A.M., facility reported incident reports were reviewed. An incident report dated 5/4/23 indicated Facility unable to locate Norco 7.5/325 mg [milligram] [a narcotic pain medication] belonging to resident [resident name]. Facility immediately initiated investigation. Resident [resident name] had no adverse affects noted due to having current supply of pain medication . On 5/18/23 at 7:30 A.M., Resident B's clinical record was reviewed. Resident B was admitted [DATE]. Diagnosis included, but were not limited to, multiple rib fractures. The most recent admission MDS (minimum data set) Assessment, dated 4/20/23, indicated Resident B was cognitively intact, and received scheduled and PRN (as needed) pain medication. Physician orders included, but were not limited to: hydrocodone-acetaminophen (Norco, a narcotic pain medication) 7.5-325 mg 1 tablet every 4 hours PRN, dated 4/14/23. Lidocaine adhesive patch (pain patch) 4%, 1 patch to right ribs once a day, dated 4/24/23 Resident B's electronic MAR (medication administration record) from 4/14/23 (admitted ) through 5/18/23 indicated the following dates Norco was administered: 4/15/23 (1 dose) 4/16/23 (1 dose) 4/17/23 (1 dose) 4/22/23 (1 dose) 4/23/23 (1 dose) 4/27/23 (1 dose) 4/28/23 (1 dose) 4/29/23 (1 dose) 5/5/23 (1 dose) 5/8/23 (1 dose) On 5/18/23 at 8:04 A.M., the narcotic binder on the 600 Hall (Resident B's hall) was reviewed from April and May 2023. The binder indicated one empty medication card was removed from the medication card for Resident B on 5/9/23 that had contained Norco 7.5 mg. The card tracking sheet lacked information that any narcotic had been added to the medication cart at any time during Resident B's residency at the facility. The narcotic count sheets were reviewed from 4/29/23 through 5/18/23 and indicated the following dates and times a narcotic count was not completed by staff at change of shift: 4/29/23 at 2:00 P.M. 4/30/23 at 2:00 P.M. and lacked other documentation until 6:00 A.M. the following morning 5/1/23 unreadable after 6:00 P.M. 5/2/23 at 10:00 P.M. 5/3/23 at 10:00 P.M. 5/4/23 at 6:00 P.M. with no signature from incoming nurse at 6:00 A.M. 5/10/23 at 10:00 P.M. 5/11/23 at 10:00 P.M. 5/12/23 at 6:00 P.M. 5/15/23 at 6:00 A.M. 5/16/23 at 10:00 A.M. 5/17/23 at 6:00 P.M. At that time, QMA (Qualified Medication Aide) 5 indicated those were all of the sign-in sheets for staff from April and May 2023. The Controlled Drug Use Record indicated Resident B received Norco on the following dates: 4/20/23 (1 dose) - not indicated on resident's MAR 4/21/23 (1 dose) - not indicated on resident's MAR 4/22/23 (1 dose) 4/23/23 (2 doses) 4/24/23 (2 doses) - not indicated on resident's MAR 4/25/23 (2 doses) - not indicated on resident's MAR 4/26/23 (2 doses) - not indicated on resident's MAR 4/27/23 (1 dose) 4/28/23 (3 doses) 4/29/23 (1 dose) 4/30/23 (1 dose) - not indicated on resident's MAR 5/1/23 (3 doses) - not indicated on resident's MAR 5/2/23 (2 doses) - not indicated on resident's MAR 5/3/23 (2 doses) - not indicated on resident's MAR 5/5/23 (1 dose) 5/6/23 (1 dose) - not indicated on resident's MAR 5/8/23 (2 doses) 5/9/23 (3 doses) - not indicated on resident's MAR 5/10/23 (3 doses) - not indicated on resident's MAR 5/11/23 (2 doses) - not indicated on resident's MAR 5/13/23 (1 dose) - not indicated on resident's MAR 5/14/23 (2 doses) - not indicated on resident's MAR 5/16/23 (2 doses) - not indicated on resident's MAR 5/17/23 (3 doses) - not indicated on resident's MAR On 5/18/23 at 9:37 A.M., a police report, dated 5/5/23, was reviewed and indicated on 5/4/23 a medication (hydrocodone 7.5-325 mg) quantity 30 was lost from the facility belonging to Resident B. During an interview on 5/18/23 at 7:54 A.M., Resident B indicated was in the facility due to broken ribs and pain. Resident B indicated while in the facility, had received pain pills and a pain patch. Resident B indicated did not ask for pain pills every day due to having a pain patch that took care of most of the pain. During an interview on 5/18/23 at 7:59 A.M., QMA 5 indicated a count of all narcotic medications should be completed by staff at every shift change, and should be signed off by the off-going staff as well as the on-coming staff in the narcotic medication binder located on the medication cart. QMA 5 indicated any time a resident was given a narcotic pain medication, the staff administering the medication should be signing off on the narcotic binder as well as the resident's electronic MAR that it was given. QMA 5 indicated when a new narcotic medication was received or when a medication was finished, staff should write it on the back of the sign sheet in the narcotic binder. During an interview on 5/18/23 at 8:22 A.M., the Director of Nursing (DON) indicated while making rounds on 5/5/23, the QMA on the 600 Hall requested assistance with medications. While the QMA was going through the narcotic binder, a folded paper came out of it. Upon review, the folded paper was a narcotic count sheet for Norco belonging to Resident B. At that time, the DON began a search for the medication card that would have come with the narcotic count sheet, but it could not be located. The DON indicated all other medication carts and medication storage rooms were searched, then the Administrator was notified when the medications could not be located. The DON indicated there was documentation that the medication was delivered from the pharmacy on 4/23/23, and all staff that had the medication cart keys were interviewed but no one recalled the medications being in the building that day. The DON indicated drug testing was completed for all staff that had access to the medication cart keys with all negative results and a police report was initiated. The DON indicated she thought a staff member might have dropped the missing medication card into the medsafe (a locked medication container) but had no way of looking inside to be sure. During an interview on 5/18/23 at 9:10 A.M., the DON indicated prior to 4/20/23, Resident B's medications came from the med bank because the pharmacy had not sent her medications cards yet, and all medications that were given could be viewed on the med bank documentation. At that time, the DON indicated staff was supposed to sign off on narcotic medications given in the resident's electronic MAR as well as in the binder, but sometimes the nurses were not very good at signing off for medications given in the resident's MAR. The med bank documentation for Resident B indicated Norco was administered once on 4/14/23 and once on 4/15/23. During an interview on 5/18/23 at 9:52 A.M., the Lead Pharmacist indicated when delivering narcotic pain medications, the receiving staff at the facility would sign off that they were received and keep a copy, as well as the delivery driver. The delivery driver would also sign in their own electronic system that it was delivered. At that time, she indicated RN (Registered Nurse) 7 was the staff member that signed off on receiving the medication for Resident B on 4/23/23. During an interview on 5/18/23 at 12:30 P.M., the DON indicated RN 7 was on the 600 Hall (Resident B's hall) at the time Resident B's medication went missing, and signed for the medication the day it was delivered early that morning. She indicated she had spoken with RN 7 about the medication missing, and RN 7 did not recall what had been done with the medication. On 5/18/23 at 9:37 A.M., a current abuse, neglect, and exploitation policy, reviewed 12/31/22, indicated [Company name] has developed and implemented processes, which strive to ensure the prevention and reporting of suspected or alleged resident abuse and neglect . [company name] as implemented processes in an effort to provide a comfortable and safe environment . and to be free from abuse, neglect, exploitation, and misappropriation of property. 3.1-28(a)

Based on observation, interview, and record review, the facility failed to ensure residents received services in the facility with reasonable accommodation of resident needs for 4 of 5 residents reviewed for activities of daily living. Call lights were observed out of reach for residents. (Resident 11, Resident 35, Resident 12, Resident 48 ) Findings include: 1. On 3/13/23 at 10:19 A.M., Resident 11 was observed laying in bed with the call light hanging to the floor on the left side of the bed not within reach of the resident. On 3/20/23 at 8:45 A.M., Resident 11 was observed sitting in their recliner eating breakfast and the call light was on the bed not within reach of the resident. On 3/20/23 at 9:50 A.M., Resident 11's clinical record was reviewed. Resident 11 was admitted on [DATE]. Diagnoses included, but were not limited to, traumatic subdural hemorrhage with loss of consciousness of unspecified duration, unspecified dementia without behaviors, dysphagia, and anxiety disorder. The most recent admission MDS (Minimum Data Set) Assessment, dated 1/10/23, indicated Resident 11 was cognitively intact, an extensive assist of 1 (one) staff for bed mobility and toileting, and limited assist of 1 (one) staff for transfers. A current risk for falls care plan, dated 1/17/23, included, but was not limited to, the following intervention: Keep call light within reach, initiated 1/17/23 2. On 3/13/23 at 11:14 P.M., Resident 12 was observed sitting in their wheelchair eating breakfast at the table and the call light was on the bed not within reach of the resident. On 3/20/23 at 8:53 A.M., Resident 12 was observed sitting up in a chair eating breakfast. The call light was not within reach of the resident. On 3/16/23 at 8:53 A.M., Resident 12's clinical record was reviewed. Resident 12 was admitted on [DATE]. Diagnoses included, but were not limited to, Parkinson's disease, diabetes mellitus type II, and cellulitis of left lower limb. The most current admission MDS Assessment, dated 2/27/23, indicated resident was cognitively intact and was an extensive assist of 1 (one) staff member for transferring. A current risk for falls care plan, dated 3/15/23, included, but was not limited to, the following intervention: Keep call light in reach, initiated 3/15/23 3. On 3/13/23 at 10:00 A.M., Resident 35 was observed sitting in their wheelchair on the left side of the bed. The call light was on the right side of the bed not within reach of the resident. On 3/20/23 at 8:40 A.M., Resident 35 was observed sitting in the recliner waiting for breakfast and the call light was not within reach of the resident. On 3/20/23 at 9:22 A.M., Resident 35's clinical record was reviewed. Resident 35 was admitted on [DATE]. Diagnoses included, but were not limited to, pneumonia, dementia without behaviors, and history of falling. The most recent admission MDS Assessment, dated 2/15/23, indicated Resident 35 was moderately cognitively impaired and an extensive assist of 2 (two) staff for bed mobility, transfers, and toileting. A current risk for falls care plan, dated 3/20/23, included but was not limited to, the following intervention: Keep call light within reach, initiated 3/20/23 During an interview on 3/20/23 at 8:40 A.M., Resident 35 and family representative both said Resident 35 used the call light. During an interview on 3/20/23 at 8:50 A.M., CNA 14 indicated Resident 11, Resident 12, and Resident 35 would use the call light. At that time, they also indicated that before they leave the resident's room, they would make sure the call light, bedside table, and water were within reach of the resident. 46819 4. On 3/14/23 at 9:57 A.M. Resident 48 was observed in her wheelchair, sitting about 4 feet away from the recliner in her room. The call device was observed in the crack between the seat and the arm of the recliner. During an interview with the resident at this time, she said she did not know where her call device was and she said she could not see it. During an interview on 3/20/23 at 9:00 A.M., LPN 16 indicated that resident uses her call light. On 3/17/23 at 1:54 P.M. Resident 48's records were reviewed. Diagnoses included, but were not limited to, COVID on 12/11/23, Unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, history of falling, cognitive communication deficit. The most recent quarterly MDS assessment dated [DATE] indicated resident has severe cognitive impairment, has adequate vision, and requires extensive assistance of two personnel for bed mobility, limited assistance of one personnel for transfers, supervision and assistance of one personnel for eating, and limited assistance of two personnel for toileting. Current physician orders lacked an order to keep call light within reach of resident. The care plan lacked intervention for keeping call light within reach of resident. A current Call Light policy, dated 5/11/16, was provided by Clinical Support 29 on 3/20/23 at 11:00 A.M., and indicated . 2. Ensure the call light is plugged in securely to the outlet and in reach of the resident . 13. If nothing else is needed, return the call light to within reach of the resident 3.1-3(v)(1)

Based on observation, interview, and record review, the facility failed to ensure residents that were self administering medications were assessed for capability to self administer medications for 3 of 3 residents observed with medications in their rooms. (Resident 30, Resident 12, Resident 161) Findings include: 1. On 3/16/23 at 6:32 A.M., QMA (Qualified Medication Aide) 9 was observed to administer medications for Resident 30 in the 300 Hall by the nurses station. QMA 9 indicated Resident 30's eye drops could not be found in the medication cart. QMA 21 ( who was present at that time) indicated the eye drops were probably in Resident 30's room in his hearing aid case, as that was where he kept them. QMA 21 went to Resident 30's room, came out with eye drops, and handed them to QMA 9 who then administered the eye drops to Resident 30. At that time, QMA 9 indicated although Resident 30 kept his eye drops in his room, he did not have an order to do so. On 3/16/23 at 11:32 A.M., Resident 30's clinical record was reviewed. Diagnosis included, but were not limited to, dry eyes. The most recent quarterly MDS (minimum data set) Assessment, dated 2/14/23, indicated Resident 30 was cognitively intact, vision impaired, and wore corrective lenses. Current physician orders included, but were not limited to: GenTeal Tears Moderate (artificial tear drops) 0.1-0.3-0.2 %; one drop each eye for dry eyes, once a day between 6:00 and 10:00 A.M., dated 1/13/23 The clinical record lacked an order for self administration of medications. The clinical record lacked a care plan related to self administration of medications. The clinical record lacked a self administration of medication assessment. During an interview on 3/17/23 at 10:37 A.M., Clinical Support 43 indicated Resident 30 did not have an assessment for self administration of medications, and was not supposed to have any medications in his room. 46416 2. On 3/13/23 at 11:46 A.M., Resident 12 was observed sitting in his wheelchair eating breakfast at the table in his room. At that time, a box with a prescription label indicating diclofenac sodium 1% topical gel (gel prescribed to rub on joints to relieve pain from arthritis) was observed laying on his bedside table and the resident indicated that he used it and staff were aware he had it at bedside. On 3/16/23 at 8:53 A.M., Resident 12's clinical record was reviewed. Diagnoses included, but were not limited to, Parkinson's disease, diabetes mellitus type II, and cellulitis of left lower limb. The most current admission MDS Assessment, dated 2/27/23, indicated resident was cognitively intact and was an extensive assist of 1 (one) staff member for transferring. Resident 12's clinical record lacked physician's orders for diclofenac sodium 1% gel and self administering medications, a self administering medications care plan, and a self administering medication assessment. On 3/17/23 at 9:28 A.M., Resident 12 was observed in his room with the same box of diclofenac sodium 1% topical gel on his bedside table. The prescription label indicated fill date was 1/30/23. At that time, Resident 12 indicated that staff was aware that he used it when he needed it. During an interview on 3/17/23 at 10:35 A.M., RN (Registered Nurse) 23 indicated she was not aware of diclofenac gel at Resident 12's bedside. At that time, she indicated she didn't think he had an order for it, was not sure where he got it, and he was not able to self administer medications. On 3/20/23 at 9:55 A.M., RN 18 indicated she was not sure what Resident 12 used the diclofenac gel for but it was usually prescribed to use topically (on surface of body) for pain. She further indicated the staff found the box in his drawer after they were made aware he had it at bedside and it had been removed. 3. On 3/14/23 at 9:30 A.M., Resident 161 was observed sitting in her room with a medicine cup containing 6 (six) pills, a small cup of applesauce with a spoon, and a small cup of water on the bedside table. At that time, the resident indicated that the nurse brought this medication into the room and left it there for the resident to take on their own. On 3/14/23 at 10:15 A.M., Resident 161's clinical record was reviewed. The resident was admitted on [DATE]. Diagnoses included, but were not limited to, anxiety disorder, low back pain, history of falling, and weakness. The current admission MDS was still in progress. Resident 161's clinical record lacked physician's orders for self administering medications, a self administering medications care plan, and a self administering medication assessment. On 3/14/23 at 9:45 A.M., all care plans and all physician's orders were requested, but the DON (Director of Nursing) indicated the staff was working to get physician's orders and care plans in place for the resident to self administer medications but they were not completed at this time. During an interview on 3/14/23 at 10:04 A.M., QMA (Qualified Medication Aide) 21 indicated Resident 161 came from assisted living and the nurse was able to leave medications at bedside for the resident to take on her own. During an interview on 3/14/23 10:10 A.M., LPN (Licensed Practical Nurse) 25 indicated Resident 161 could administer their medications because she came from assisted living and was only on skilled for rehab after her fall. During an interview on 3/17/23 at 10:35 A.M., RN 23 indicated before residents could self administer medications, the resident had to have a physician's order and a self administering of medication assessment completed. On 3/17/23 at 10:41 A.M., a current Guidelines for Self-Administration of Medications policy, reviewed 12/31/22, indicated Residents requesting to self- medicate or has self-medication as a part of their plan of care shall be assessed using the observation [company name] Self Administration of Medication within the electronic health record. Results of the assessment will be presented to the physician for evaluation and an order for self-medication . A Self-Medication plan of care will be initiated and updated as indicated 3.1-11(a)

Based on observation, interview, and record review, the facility failed to ensure resident privacy was maintained for 2 of 4 residents observed for medication administration, and 2 random observations. A resident's shirt was raised in the hall to apply a pain patch, the privacy curtain and door were not shut during care, and a computer screen was left up with resident information visible. (Resident 30, Resident 52) Findings include: 1. On 3/16/23 at 6:32 A.M., QMA (Qualified Medication Aide) 9 was observed to administer medications for Resident 30 in the hall by the nurses station. QMA 9 obtained a pain patch from the medication cart, raised Resident 30's shirt, and applied the patch to his back. At that time, another resident was observed within view of Resident 30, sitting in a wheelchair. On 3/16/23 at 11:45 A.M., Resident 30 was observed in his room with his shirt off while Hospice staff 22 was massaging his back. The privacy curtain and door were open, leaving Resident 30 visible from the hallway. 2. On 3/17/23 at 10:50 A.M., a computer screen with resident information visible from the hall was observed unattended on the 600 Hall. Resident 52's information, including, but not limited to, age, date of birth, admitted , room number, address, phone number, picture, continuity of care document, and emergency contact information, were visible on the computer screen. The computer screen was continuously observed until 10:58 A.M., when RN (Registered Nurse) 5 entered the area and locked it. During that time, therapy staff, maintenance, and a housekeeper walked by the computer screen. During an interview on 3/17/23 at 1:04 P.M., LPN (Licensed Practical Nurse) 25 indicated when applying a pain patch to a resident, staff should do so in the resident's room to maintain privacy. LPN 25 further indicated when walking away from a computer, staff should put a lock on the screen to hide the resident information. During an interview on 3/17/23 at 1:08 P.M., CNA (Certified Nurse Aide) 27 indicated resident privacy curtains and doors should be closed when providing any type of care to provide privacy for that resident. On 3/17/23 at 2:05 P.M., a current Preparation and General Guidelines policy, revised 11/18, was provided and indicated [during administration of medications] privacy is maintained at all times for all resident information (e.g., MAR (medication administration record]) when not in use On 3/17/23 at 2:05 P.M., a current Resident Rights policy, dated 11/28/16, was provided and indicated The resident has a right to personal privacy and confidentiality of his or her personal and medical records . Personal privacy includes accommodations, medical treatment, written and telephone communications, personal care, visits, and meetings of family and resident groups 3.1-3(o) 3.1-3(p)(2)

Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan to meet a resident's medical and nursing needs that were identified in the comprehensive assessment for 1 of 3 residents reviewed for respiratory care and 2 of 3 residents reviewed for antibiotic use. Resident's clinical record lacked a care plan and interventions for infection, IV (intravenous) site care, and antibiotic use. The resident's interventions on care plans were not being followed. (Resident 12, Resident 22, Resident 38) Findings include: 1. On 3/13/23 at 11:46 A.M., Resident 12 was observed sitting in their wheelchair eating breakfast at the table in their room. At that time, an IV line with a dressing dated 3/9/23 was observed in his right arm. The resident stated that they had an infection of the right ankle, were getting antibiotics by IV, and was using a wound VAC (therapeutic technique used to help heal wounds). On 3/16/23 at 8:53 A.M., Resident 12's clinical record was reviewed. Diagnoses included, but were not limited to, Parkinson's disease, diabetes mellitus type II, and cellulitis of left lower limb. The most current admission MDS (Minimum Data Set) Assessment, dated 2/27/23, indicated resident was cognitively intact and was an extensive assist of 1 (one) staff member for transferring. Current physician's orders included, but were not limited to the following: cefazolin (antibiotic) 2 (two) g (grams)/10 mL (milliliters) NaCl (sodium chloride) 0.9% IV push every 8 hours for cellulitis of left lower limb, started 2/22/23 Monitor IV site for signs and symptoms of infiltration twice a day, start date 2/23/23 Negative pressure dressing to left foot intact twice a day, start date 2/22/23 125 mmHG (millimeters of mercury) continuous therapy to left lower extremity wound twice a day, start date 2/26/23 Negative pressure dressing (wound vac) place today and begin changes three times weekly per podiatry on Mondays, Wednesdays, and Fridays, start date 3/13/23 The clinical record lacked a current care plan with interventions given to care for the resident's wound. 2. On 3/13/23 at 10:11 A.M., Resident 38 was observed sitting in his wheelchair with an IV dressing dated 3/12/23 in his left arm that he indicated was used to get antibiotics for the infection he had in his right knee. On 3/16/23 at 1:00 P.M., Resident 38's clinical record was reviewed. Diagnoses included, but were not limited to, infection and inflammatory reaction due to internal right knee prosthesis, sepsis, and diabetes mellitus type II. The most recent admission MDS Assessment, dated 2/6/23, indicated that the resident was cognitively intact and an extensive assist of 2 (two) staff for bed mobility, transfers, and toileting. Current physician's orders included, but were not limited to, the following: Monitor IV site for signs and symptoms of infiltration every shift, start date 2/3/23 Vancomycin (antibiotic) 1.5 g in 500 mL of Na Cl 0.9% IV every 12 hours, start date 3/13/23 Aztreonam (antibiotic) 2 g injection three times a day, started 3/14/23 The clinical record lacked a care plan with interventions given to care for the resident's infection. During an interview on 3/17/23 at 10:51 A.M., the MDS coordinator indicated she would expect a care plan and interventions to be developed for residents related to IV, antibiotics, and infections. During an interview on 3/20/23 at 11:20 A.M., Clinical Support 50 indicated that nursing staff should open an infection event that will stay open until chronic and this is used as the care plan. During an interview on 3/20/23 at 11:25 A.M. QMA (Qualified Medication Aide) 14 indicated if the resident has a care plan, it should be located under care plans in (computer program) or staff can refer to physician's orders for interventions. During an interview on 3/20/23 at 11:30 A.M., RN (Registered Nurse) 18 indicated nursing staff should open an event for infections when the problem arises. At that time, they indicated the event is not updated but staff go over it in the morning meeting and if the MDS Coordinator thinks there should be a care plan, they will put one in the clinical record under care plans and list the interventions there. 3. On 3/14/23 at 8:15 A.M., Resident 22 was observed laying in bed with their nasal cannula shifted to the right and not left in left nostril. The flow rate on the oxygen concentrator was set at 4 LPM (liters per minute)and at that time, the resident indicated she does not adjust the setting. On 3/14/23 at 8:36 A.M., staff took ice water in to Resident 22 but did not adjust nasal cannula tubing. On 3/16/23 at 8:30 A.M., Resident 22 was observed laying awake in bed with the nasal cannula tubing wrapped around her body. The flow rate on the oxygen concentrator was set at 3 LPM. On 3/15/23 at 9:12 A.M., Resident 22's clinical record was reviewed. Diagnoses included, but were not limited to, COPD (chronic obstructive pulmonary disease), dementia, and anxiety. The most recent admission MDS Assessment, dated 1/30/23, indicated the resident was moderately cognitively intact and a limited assist of 1 (one) staff for bed mobility, transfers, and toileting. Current physician's orders included, but were not limited to the following: Oxygen at 2 LPM per nasal cannula continuous, start date 2/7/23 A current anxiety care plan, dated 1/30/23 included, but was not limited to, the following intervention: Oxygen per orders, initiated 1/30/23 During an interview on 3/17/23 at 10:35 A.M., RN 23 indicated that the resident's oxygen flow rate was set incorrectly to almost 3 LPM so she adjusted rate back to 2 LPM earlier that morning. During an interview on 3/20/23 at 11:15 A.M., Clinical Support 29 indicated there was not a policy for following the plan of care for residents, but each residents care plan should have follow the plan of care at the end of the interventions and they would expect staff to do so. A current Comprehensive Care Plan policy, dated 5/22/2018, was provided by Clinical Support 29 on 3/20/23 at 11:00 A.M., and indicated . b. care plan interventions should be reflective of risk area(s) or disease processes that impact the individual resident . c. should new identified areas of concern arise during the resident's stay, they should be addressed on the care plan . 6. Comprehensive care plans need to remain accurate and current. a. New interventions will be added and updated during or directly following CCM (morning staff meeting) b. Newly recognized problems will have a care plan developed and added after CCM meeting. 3.1-35(a) 3.1-35(b)(1) 3.1-35(d)(1)

Based on observation, interview, and record review, the facility failed to ensure a safe, functional, and comfortable environment for 3 of 16 resident rooms observed for water temperatures. Water temperatures were above 120 degrees Fahrenheit. (room [ROOM NUMBER], 308, 314) Findings include: On 3/13/23 at 11:40 A.M., hot water was observed in the following rooms on the 300 Hall: room [ROOM NUMBER]: water temperature in the bathroom sink was 122.3 degrees Fahrenheit. At that time, the only resident in room [ROOM NUMBER] indicated he got up on his own and used the bathroom. room [ROOM NUMBER]: water temperature in the bathroom sink was 123.1 degrees Fahrenheit. room [ROOM NUMBER]: water temperature in the bathroom sink was 123.2 degrees Fahrenheit. On 3/14/23 at 10:40 A.M., the rooms that had temperatures higher than 120 degrees Fahrenheit were observed with the Maintenance Supervisor with the following temperatures: room [ROOM NUMBER]: 119.4 degrees Fahrenheit. room [ROOM NUMBER]: 118.5 degrees Fahrenheit. room [ROOM NUMBER]: 122.5 degrees Fahrenheit. At that time, the Maintenance Supervisor indicated the automatic water heater had been set to 150 degrees Fahrenheit, and 2 (two) days prior had been lowered to 140 degrees Fahrenheit. He indicated he had noticed the water temperatures getting high, and had contacted the water heater company for assistance lowering the temperatures. He further indicated the tank holding the water was still hot, and would notice a decrease in water temperatures once that water was gone out of the tank. On 3/14/23 at 12:45 P.M., water temperature logs were provided from 1/2023 through 3/2023. The following days were recorded higher than 120 degrees Fahrenheit: 2/8/23: 123 (400 Hall), 122 (600 Hall) 2/9/23: 121 (300 Hall), 122 (400 Hall), 122 (600 Hall) 2/10/23: 123 (400 Hall), 123 (600 Hall) The logs lacked a temperature reading for 2/11/23 and 2/12/23 2/13/23: 122 (400 Hall), 123 (600 Hall) 2/14/23: 121 (300 Hall), 122 (400 Hall), 122 (600 Hall) 2/15/23: 121 (300 Hall), 122 (400 Hall), 122 (600 Hall) 2/16/23: 121 (300 Hall), 122 (400 Hall), 123 (600 Hall) 2/17/23: 121 (400 Hall), 121 (600 Hall) The logs lacked a temperature reading for 2/18/23 and 2/19/23 2/20/23: 121 (300 Hall), 121 (400 Hall), 121 (600 Hall) 2/21/23: 121 (300 Hall), 122 (600 Hall) 2/22/23: 121 (300 Hall), 121 (400 Hall), 122 (600 Hall) 2/23/23: 122 (600 Hall) 2/24/23: 121 (400 Hall) The logs lacked a temperature reading for 2/25/23 and 2/26/23 2/28/23: 121 (600 Hall) 3/2/23: 121 (600 Hall) 3/3/23: 121 (600 Hall) On 3/17/23 at 1:00 P.M., a communication document was provided from the water heater company. The document listed services they had provided for the facility since 1/2023. The services included: 2/27/23: 2 (two) tankless water heaters were installed in the kitchen 1/9/23 and 1/30/23: Serviced leaking tankless water heater and replaced valve in wing 400 3/9/23: Installed new circulating pump in kitchen Nothing was provided regarding the 300 hall. On 3/15/23 at 10:27 A.M., a current Water Temperature Testing policy, revised 8/20/18, indicated [when recording water temperatures] Note any discrepancies . Adjust water heater settings as required . Patient room temperatures are specified by state requirements . Indiana 100 [degrees] - 120 [degrees] 3.1-19(h)

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program during the COVID-19 crisis for 2 of 2 residents observed. Hand hygiene was not performed, staff was double gloved when performing resident care, and a resident was not offered a facial covering during personal care. (Resident 36, Resident 42) Findings include: 1. On 1/4/21 at 9:25 a.m., CNA 1 and CNA 2 were observed donning PPE to enter Resident 36's room. Resident 36 was on contact and droplet precautions which indicated gown, glove, mask, and a face shield should be worn when entering the resident's room. Resident 36 was observed to be sitting on the commode with a large amount of stool on the bathroom floor. CNA 1 was observed to obtain wipes from CNA 2 and clean the stool off of the floor. After cleaning the floor, CNA 1 was observed to change her gloves. No hand hygiene was observed. CNA 2 removed the resident's soiled brief and placed the brief into the trash can. CNA 2 changed her gloves. No hand hygiene was performed. CNA 1 obtained a clean brief, open the brief and place it on the resident. CNA 2 obtained the resident's wheelchair and placed it in the bathroom. CNA 1 placed a gait belt around the resident and assisted the resident to stand. CNA 2 provided pericare (washing of the groin and buttocks). CNA 1 assisted the resident into his wheelchair. CNA 2 removed the gait belt, obtained the trash, removed her PPE and exited the resident's room. CNA 2 sanitized her hands. CNA 1 assisted the resident with eating his breakfast. CNA 1 did not perform hand hygiene. Resident 36 did not have a mask on nor was the resident offered a mask to wear. The care observation lasted longer than 15 minutes while the resident was unmasked and less than six feet from the two CNAs who assisted the resident. On 1/4/21 at 9:56 a.m., CNA 1 indicated hand hygiene should be performed prior to donning gloves and after removing gloves. Gloves should be changed and hand hygiene performed if the gloves become soiled and after cleaning stool off the floor. On 1/4/21 at 12:20 p.m., CNA 1 indicated the resident did not apply a mask as the resident had been eating prior to being taken to the bathroom and was in a hurry when he was taken to the bathroom. The resident had a mask at his bedside. CNA 1 indicated she should have offered a mask to the resident prior to assisting the resident off of the commode and providing pericare. 2. On 1/4/21 at 9:41 a.m., LPN 1 was observed donning PPE to enter Resident 42's room. LPN 1 was observed to drop her ink pen onto the floor, pick the ink pen up, and enter the resident's room. Glove change or hand hygiene was not performed prior to contact with the resident. LPN 1 was observed to place Resident 42's medication and cup of water onto the resident's over bed table, obtain the pulse oximeter from the automatic vital sign machine and place the oximeter onto the resident's finger. LPN 1 indicated the machine was not working correctly and removed and replaced the oximeter several times before indicating she had obtained the reading from the resident. LPN 1 removed her gloves and performed hand hygiene prior to administering the resident's medication. On 1/4/2021 at 9:52 a.m., LPN 1 indicated hand hygiene should be performed prior to donning gloves, when changing gloves, and after touching inanimate objects or picking anything up off the floor. On 1/4/21 at 9:10 a.m., the Administrator indicated all residents were on contact/droplet precautions with all units being yellow zones except for the 600 unit which was the COVID positive unit. On 1/4/21 at 1:50 p.m., the Director of Nursing (DON) indicated she had spoken with CNA 1 regarding glove use and hand hygiene during care. The DON indicated CNA 1 had told her she had double gloved prior to cleaning floor. The DON stated CNA 1 told her they double gloved all the time at the hospital. The DON indicated CNA 1 had previously worked at a hospital. On 1/4/21 at 2:00 p.m., the Administrator (Adm) and DON stated they did not understand why the staff could not double glove and they felt as though they were being penalized for being overly cautious and, furthermore, wanted to know where in the regulations it stated you should not double glove. Both indicated that best nursing practice did not allow for staff to double glove but did not understand why hospitals get by with it and they were being penalized. The DON requested to know where it was located in the nursing practice manual to not double glove with resident care. The current facility policy, Guideline for Handwashing/Hand Hygiene, revision date 3/12/20, provided by the Administrator on 1/4/21 at 4:02 p.m., included, but was not limited to, Health Care Workers shall use hand hygiene at times such as: After removing gloves worn per Standard Precautions for direct contact with excretions or secretions, mucous membranes, specimens, resident equipment, grossly soiled linen, etc. The facility lacked documentation of a policy for double gloving. The facility lacked documentation of a policy for mask use by the resident. 3.1-18(b) 3.1-18(l)

Based on record review and interview, the facility failed to follow the guidance for Covid 19 testing including obtaining physicians orders for resident testing and failed to update their policy regarding the need to obtain physician orders [REDACTED]. The facility lacked physician orders [REDACTED]. (Resident 36, Resident 42) Findings include: On 1/4/20 at 9:15 a.m., the Administrator indicated the facility performed COVID-19 testing for all staff and residents twice a week on Mondays and Thursdays. 1. The clinical record for Resident 36 was reviewed on 1/4/21 at 10:26 a.m. Resident 36 had tested negative for COVID-19 on 12/3/20, 12/10/20, 12/14/20, 12/17/20, 12/27/20, and 12/29/20. The clinical record lacked documentation of a physician's orders [REDACTED]. 2. The clinical record for Resident 42 was reviewed on 1/4/21 at 12:10 p.m. Resident 42 had tested negative for COVID-19 on 12/3/20, 12/10/20, 12/14/20, 12/17/20, 12/27/20, and 12/29/20. The clinical record lacked documentation of a physician's orders [REDACTED]. On 1/4/21 at 1:10 p.m., the Administrator indicated the residents should have a physician's orders [REDACTED]. On 1/4/21 at 1:49 p.m., the Director of Nursing (DON) provided a physician's orders [REDACTED]. The order received date and start date was 1/4/2021. On 1/4/21 at 1:49 p.m., the DON provided a physician's orders [REDACTED]. The order received date and start date was 1/4/2021. The current facility policy, Guidelines for Physician Services, effective date 5/11/16, provided by the Administrator on 1/4/21 at 4:03 p.m., included, but was not limited to, Physician orders [REDACTED]. 3.1-18(b)(5)

Based on observation, interview, and record review, the facility failed to ensure residents were free from accidents for 2 of 3 residents reviewed for falls. Assistance and fall interventions were not in place, which resulted in a resident receiving a femur fracture and subsequent surgical intervention, and a resident receiving a skin tear and hematoma. (Resident 37, Resident 253) Findings include: 1. On 4/22/19 at 10:55 a.m., Resident 37 was observed in a wheelchair in her room. Resident 37 was attempting to get out of her wheelchair unassisted. The resident had white socks without treads on the bottom were observed on and no leg rests were observed on the wheelchair. The call light was wrapped on the arm of the wheelchair, but the resident was unable to locate the call light when asked. The clinical record for Resident 37 was reviewed on 4/24/19 at 2:00 p.m. [DIAGNOSES REDACTED]. An admission MDS (Minimum Data Set) assessment, dated 1/9/19, indicated the resident had moderate cognitive impairment. The MDS indicated the resident required the assistance of 2 persons for transfers, and assistance of 2 persons for toileting. The MDS assessment indicated mobility devices included a wheelchair and a walker. A care plan, start date 1/14/19, indicated the resident was at risk for falls. Interventions included, but were not limited to, the following: Assure the floor is free of liquids and foreign objects, dated 1/14/19. Encourage/assist resident to assume a standing position slowly, dated 1/14/19. Keep call light in reach, dated 1/14/19. Keep personal items and frequently used items within reach, dated 1/14/19. Provide nonskid footwear, dated 1/14/19. Staff to assist resident with transfers as needed, dated 1/14/19. Encourage use of call light, dated 2/11/19. A progress note, dated 3/7/19 at 1:40 p.m., indicated the following: Resident noted on floor beside bed lying on left side. Resident was noted bare footed and floor was dry, Room was clutter free and room was well lit. Call light was not with in reach at this time. PROM (Passive Range of Motion) performed and complains of left hip pain with no evidence of internal/external rotation noted. No complaints of pain with palpation of hip. When asked resident what happened, resident stated, I was trying to get over there. Assisted resident to bed with assist of 3. Noted small skin tear to left inner lower leg measuring 2 cm x 1 cm (centimeter). No other injury noted. Son walked in room and was notified of fall and nurse will get orders for left hip x-ray and order for skin tear treatment. Verbalized understanding. Reminded resident to use call light when needing to get up out of bed. A progress note, dated 3/7/19 at 6:41 p.m., indicated the facility received the radiology report of the left hip. The report indicated an intertrochanteric fracture. A progress note, dated 3/7/19 at 10:17 p.m., indicated the ambulance arrived and spent over 20 (twenty) minutes in the resident's room prior to departing for the hospital. The note indicated the EMS (Emergency Medical Service) started an IV (intravenous) and administered IV pain medication prior to placing the resident on the transportation cart as the resident was in so much pain. The note indicated the nurse was notified the resident would be going to the trauma hospital, as the hospital the family had requested would send the resident to the trauma hospital and the EMS staff felt this would save the resident another traumatic ambulance ride. An event report, dated 3/7/19 at 2:25 p.m., indicated the resident had transferred herself and the fall was unwitnessed. The report indicated the resident had cognitive or memory impairment that affected her safety and judgement, had difficulty following directions, required assistance to ambulate safely, required the use of an assistive device, and refused to comply with safety measures such as call light use, alarms, appliances, etc. The report indicated a new measure to prevent reoccurrence included bed alarm, advanced call light system. An IDT (Intradepartmental Team) note, dated 3/8/19 at 9:17 a.m., Resident was noted to be on floor beside bed lying on left side. Root Cause: resident reports, I was just trying to get over there. Self transferring. Injury: Skin tear measuring 2 cm x 1 cm to left leg. Complaining of pain to left hip. X-ray revealed a fracture. She was subsequently sent out to the hospital and is scheduled for surgery today. On 4/25/19 at 2:40 p.m., the Corporate Consultant indicated care plans should be individualized. She indicated the resident's care plan had not been followed. On 4/29/19 at 8:33 a.m., the Regional Consultant indicated the resident had fallen out of bed. She indicated the facility had interventions in place, but the resident had been in bed and therefore did not have nonskid footwear on. 2. On 4/22/19 at 9:09 a.m., Resident 253 was observed to be sitting in a Broda chair with a brace to her right shoulder, a compression glove to her right hand, and her right hand resting on a pillow. Resident 253 indicated she had received a fall since entering the facility. The clinical record for Resident 253 was reviewed on 4/15/19 at 10:46 a.m. [DIAGNOSES REDACTED]. An admission MDS (Minimum Data Set) assessment, dated 4/11/19, indicated the resident had slight cognitive impairment. A baseline care plan, dated 4/5/19, indicated the resident was at risk for falls. Interventions included, but were not limited to, the following: Therapy evaluate and treat. Keep call light within reach and encourage use of it. Assist resident with transfers/mobility as needed. A progress note, dated 4/8/19 at 3:30 a.m., indicated the resident was noted to be lying on the floor on her right side next to her bed, facing the window. The note indicated the resident had regular socks (socks without treads) on and no lights were on, except the bathroom light. The resident was transferred into bed using the Hoyer lift (a mechanical lift). The note indicated the resident had received an abrasion to her right elbow measuring 0.8 cm (centimeters) x 0.3 cm and a half-dollar size hematoma to her head. The resident's right hand was [MEDICAL CONDITION] and the resident had scattered bruising to her bilateral upper and lower extremities. Interventions at the time of the fall included, education to the staff. On 4/25/19 at 2:40 p.m., Corporate Consultant indicated the care plan needed to be individualized. She indicated the care plan did not provide interventions related to the resident fall risk. The current facility policy, effective date, 5/31/17, review date 5/22/18, and obtained from the Regional Consultant on 4/29/19 at 10:00 a.m., indicated the facility would strive to maintain a hazard free environment. The definition of a fall would be considered an unintentionally coming to a rest on the ground, floor, or other lower level, but not as a result of an overwhelming external force . A fall without injury is still a fall. Unless there is evidence suggesting otherwise, when a resident is found on the floor, a fall is considered to have occurred. 3.1-45(a)

Based on record review, observation, and interview, the facility failed to ensure residents, who admitted with no pressure ulcers, did not develop a pressure related skin injury for 1 of 3 residents reviewed. This deficient practice resulted in Resident 37 developing a Suspected Deep Tissue Injury (SDTI) (purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of under-lying soft tissue from pressure and/or shear) to her right heel. (Resident 37) Findings include: On 3/20/18 at 10:20 a.m., the clinical record for Resident 37 was reviewed. The record indicated Resident 37 admitted from the hospital on [DATE] at 2:20 p.m., and had been hospitalized with stroke-like symptoms. The progress notes indicated Resident 37 was alert x 1 (to person) and able to answer questions appropriately. The admission assessment, dated 2/24/18, indicated no [MEDICAL CONDITION] to bilateral lower extremities, had limitations to range of motion to bilateral lower extremities, was chair fast, completely immobile, and to turn and reposition for comfort with care. The Admission MDS (Minimal Data Set) dated 3/2/18 indicated Resident 37 had a Stage 1 pressure ulcer, was receiving pressure ulcer care, had severe cognitive impairment, dependence on 2 staff members for extensive assistance with bed mobility, transfer, dressing, toilet use, and personal hygiene, and had impairment to functional range of motion on upper and lower on both sides. Progress note, dated 2/27/18 at 10:27 a.m., indicated a dark red 3.5 cm (centimeter) pressure area to right heel, MD and family notified of area . staff educated on need to float heels and protect area while up in chair. Weekly Wound Assessment, dated 2/28/18 at 11:00 a.m., indicated Resident 37 was found to have a stage one pressure area on right heel, skin prep would be used and would wear pressure relieving boots while in bed on BLE (Bilateral Lower Extremities) to prevent further skin breakdown. Progress note, dated 3/18/18 at 2:29 p.m., indicated Resident 37 continued to have a Stage I (one) red heel on her right foot, took Med Pass (dietary supplement) 60 ml (milliliters) BID (twice daily), and the Registered Dietician evaled (evaluated) and recommendations were being followed. Progress note, dated 3/20/18 at 7:27 a.m., the Weekly Wound Assessment indicated the pressure area on Resident 37 had healed. Small line of dry skin remains along edge of where area was, and wound continue to apply skin prep and use pressure relieving boots in bed to prevent further breakdown. The Care plan indicated: At risk for skin breakdown R/T: Impaired mobility, bowel and bladder incontinence, [MEDICAL CONDITIONS]. Start date 2/28/19, revised 3/20/18 Interventions included: pressure relieving boots to BLE (bilateral lower extremities) when in bed (dated 3/20/18), avoid shearing skin during positioning, turning, and transferring (dated 2/28/18), conduct weekly skin assessment, pay particular attention to bony prominences (sic) (dated 2/28/18), encourage and assist to turn and reposition for comfort and as needed (dated 2/28/18), keep linens clean and dry (dated 2/28/18), keep resident as clean and dry as possible, minimize skin exposure to moisture (dated 2/28/18), pressure reducing cushion to chair (2/28/18), pressure reducing mattress to bed (2/28/18), use lifting device as needed for bed, mobility (e.g. lift sheet, etc.)(dated 2/28/18), and use moisture barrier product to perineal area as need (dated 2/28/18). A resolved care plan dated 2/28/18 and discontinued on 3/20/18, indicated Resident 37 has a pressure ulcer to right heel, and further indicated right heel wound healed. Interventions lacked pressure reduction prevention for lower extremities prior to development of skin impairment. On 3/21/18 at 9:26 a.m., Resident 37 was observed to be sitting up in her high back wheelchair next to her bed with eyes closed, feet resting on padded foot pedals, wearing socks. RN 1 requested and assisted CNA 2 and CNA 3 to transfer Resident 37 to bed per mechanical lift. RN 1 removed the sock from Resident 37's right foot and an irregular non draining open area was observed on the inner heel surface approximately dime size, with small amount of maroon discoloration beside irregular area with defined edge. Outer wound area was observed to be dry and scaly. RN 1 indicated Resident 37 wore pressure relieving boots while in bed and boots were applied. On 3/21/18 at 9:42 a.m., the Wound Nurse indicated Resident 37's heel didn't look like that yesterday. She further indicated Resident 37 had had a stroke, had been in the hospital, and had been back a day or two when the area was found. The facility had put a padded foot rest in place, after the area, which had been red and soft, had been found. The Wound Nurse then obtained measurements of the skinless area which measured 1.8 cm (centimeters) w (wide) by 0.8 cm l (long) and indicated she would class the area as a DTI (deep tissue injury), and applied skin prep to the right heel. On 3/21/18 at 10:04 a.m., CNA 3 indicated if a new skin area was found, they would tell the nurse and charted it in the facility system. On 3/21/18 at 1:05 p.m., the Wound Nurse entered a progress note that indicated, but not limited to, a 3 cm (centimeter) x (by) 3 cm area of dry skin that remained on resident heel as noted yesterday had started to peel away revealing a 1.8 cm x 0.8 cm discolored area that was not visible with the dry skin intact. There is an area of 1 cm x 0.8 cm that was completely exposed and was a dark red/purple area. There was an additional 0.8 cm x 0.8 cm that was not yet exposed and extends off of this area to under the remaining dry skin in which faint discoloration is visible. On 3/22/18 at 8:05 a.m., the Administrator provided the current facility policy, Guidelines for Pressure Prevention, revised date 5/10/17. The Policy indicated, but was not limited to, position body with pillows and other devices, protect elbows and float heels as needed, and elevate heels off the bed-avoid use of heel protectors. 3.1-40(a)(1)

Based on observation, interview, and record review, the facility failed to ensure residents were free from accidents for 2 of 3 residents reviewed for falls. Assistance and assistive devices were not in place and assessments were not completed upon a fall which resulted in a resident receiving a subarachnoid hemorrhage and a resident receiving a fractured hip. (Resident A, Resident B) Findings include: 1. During an observation on 1/17/17 at 1:15 p.m., Resident A was observed to be lying in bed with the left side of her face discolored. Resident A indicated she had fallen recently and had a small brain bleed. During an observation on 1/23/16 at 11:05 a.m., Resident A was observed to be sitting in a chair at the foot of her bed in her room. The call light was on the siderail of the bed out of reach of the resident and the resident was not wearing non-skid footwear. On 1/18/17 at 9:20 a.m., LPN #1 indicated Resident A had a recent fall and received a small cerebral hemorrhage. LPN #1 indicated the resident had been in the hospital for a few days but had recently returned to the facility. The clinical record for Resident A was reviewed on 1/19/17 at 10:28 a.m. Resident A had [DIAGNOSES REDACTED]. A quarterly MDS (Minimum Data Set) assessment, dated 12/26/16, indicated Resident A had a BIMS (Brief Interview for Mental Status) assessment of 11, which indicated moderate cognitive impairment. A Risk for Fall care plan, dated 12/5/16, indicated the following interventions: Give verbal reminders not to ambulate/transfers without assist . Call light within reach. Keep personal items and frequently used items within reach. Progress notes indicated the following: 1/12/17 at 8:50 p.m., (Recorded as late entry on 1/13/17 at 7:47 a.m.), This nurse was going down the hall to pass meds close to the resident's room, As I reached hallway in front of resident's door noted resident falling forward hitting side of forehead on dresser. This nurse immediately called for help to resident's room while bending down to check on resident that was lying on the floor and rolling on back as this nurse got to resident's aide. CRCA (certified resident care assistant) obtained ice and towel to place on forehead. Resident alert to self unsure of what she was doing at time of fall and thinks she is at the hospital reoriented to place see vs (vital signs) at this time. 1/13/17 at 10:40 a.m.: IDT (Interdisciplinary Team) review: At 8:50 p.m., on 1/12/17, resident was ambulating in her room without her rollator walker and lost her balance falling forward into her dresser. Resident was sent to ER (emergency room ) and admitted to hospital with hematoma to forehead and small subarachnoid hemorrhage. Root Cause: Resident lost balance while ambulating without walker. New Intervention: Upon return to campus will initiate a bed alarm and have PT (physical therapy) evaluate resident. Upon readmission to the facility on [DATE]/16, Resident A had a [DIAGNOSES REDACTED]. A bed alarm was placed on the resident's bed at that time and the resident was to be up with a rolling walker and assist of 1 (one) person. Resident A had a physician's orders [REDACTED]. During an interview on 1/24/17 at 10:15 a.m., the Senior Clinical Consultant and Administrator #1 indicated the facility needed to chart when an incident occurred. The Senior Clinical Consultant indicated the facility did a fall assessment on a resident upon admission. The Regional Consultant further indicated the resident should have used her rollator for ambulation. 2. On 1/18/17 at 9:52 a.m., Resident B was observed to be sitting in a wheelchair in her room. Resident B had a sitter at the bedside. The clinical record for Resident B was reviewed on 1/23/17 at 9:18 a.m. Resident B had [DIAGNOSES REDACTED]. A significant change MDS (Minimum Data Set) assessment, dated 12/8/16. indicated Resident B had a BIMS (Brief Interview for Mental Status) score of 7 (seven), which indicated moderate cognitive impairment. The MDS indicated the resident had a fall prior to entering the facility. A Potential for Falls care plan included, but was not limited to, the following: 11/17/16: Non-skid footwear. 11/17/16: Apply brakes on wheelchair before transfers, assist me with all transfers. 11/17/16: Call light within reach 11/17/16: Monitor for side effects of medications Progress notes indicated the following: 11/27/16 at 1120: At 2320 (11:20 p.m.) resident noted in floor in bathroom door way, side laying on left side, upon elbow calling for help. Stated she was coming out of bathroom and fell . Resident complaining of left hip and leg pain, notified MD. New order received to send to (name of hospital) for eval (evaluation) and treat. AMR (name of ambulance service) and family notified. 11/28/16 at 12:04 a.m.: 2350 (11:50 p.m.) AMR (ambulance service) here to transport to St Mary's (name of hospital). Report called to ER (emergency room ) nurse. 11/28/16 at 10:04 a.m., IDT review: (Late entry on 11/29/16 at 1:12 p.m.): reviewed events of the fall and that resident was found in the doorway of the bathroom lying on her left side, Resident non-compliant with care plan to be up with 1 assist. Resident does have history of unsteady gait and balance. The hospital [DIAGNOSES REDACTED]. Resident B could be transferred to the wheelchair with the assist of 1 (one) person. The clinical record lacked documentation of any assistance or assistive devices used by the resident prior to the fall. The fall resulted in the resident obtaining a fractured femur. During an interview on 1/24/17 at 10:15 a.m., the Senior Clinical Support Consultant indicated the resident did not have a fall assessment completed when the resident fell . The Senior Clinical Support Consultant further indicated any interventions used should be documented in the progress notes or on the event report. A policy, revised 5/10/10 and obtained from Administrator #1 on 1/26/17 at 8:45 a.m., included, but were not limited to, efforts would be made toward minimizing or preventing injury. This Federal tag relates to Complaint IN 939. 3.1-45(a)(2)

Based on record review and interview, the facility failed to ensure residents admitted without pressure ulcers did not develop unstageable ulcers for 2 of 4 residents reviewed for pressure ulcers in a sample of 4 who met the criteria for pressure ulcers. Resident # 20's heel wound worsened and required transfer to the hospital. (Resident #20 and Resident #88) Findings include: 1. The closed of Resident #20 was reviewed on 6/21/12 at 3:00 p.m. The resident was admitted to the facility on [DATE]. The Nursing Admission Data Collection form of 04/17/12 did not indicate a skin condition concern regarding the resident's left heel. A Skin Impairment Circumstance investigation, dated 04/30/12, documented a left heel pressure area, Stage 1 with possible deep tissue injury. The Pressure/Stasis/Arterial/Diabetic Ulcer form indicated the area was not present on admission and measured 3.0 X 3.0 and the depth was unable to be determined. A physician's orders [REDACTED]. The left heel was measured again on 05/01/12 and the measurements recorded on the Pressure Ulcer form were the same as 04/30/12. A Nurses note, dated, 05/05/12, indicated the resident had an area to the left heel with red bed and slough and a new order for [MEDICATION NAME] (a specialty dressing) every three days and as needed. A physician's orders [REDACTED]. On 05/08/12, the Pressure Ulcer Assessment indicated the heel wound measurement was 2.2 cm (centimeters) X 2.0 cm and unstageable. A physician's orders [REDACTED]. A nurses note, dated 5/11/12 at 12:00 p.m., indicated the left lower extremity dressing was removed and there was severe discoloration with multiple new bruises and wounds. A nurses note, dated 5/11/12, with no time indicated Resident #20 had an acute change to the left foot and a new order was received to send Resident #20 to the emergency room . A doctors order, dated 5/11/12, indicated Resident #20 was to be sent to the emergency room . A Minimum Data Set Assessment (MDS), dated [DATE], coded the resident as being at risk for developing pressure ulcers but did not have any pressure areas coded at the time. A care plan for skin condition, updated 6/1/12, identified the resident as at risk for skin areas on lower extremities due to disease process such as: history of [MEDICAL CONDITION] and wound infection. The interventions included but were not limited to assess skin status and prevent pressure to areas. A care plan titled potential alteration in skin integrity, dated 4/30/12 and reviewed 6/1/12, indicated interventions including but not limited to Z flow to float left heel, no shoes, wear non skid socks, monitor effectiveness of pressure relieving devices. A treatment record for April documented the Z-flow was being used on 4/30/12 only, and skin prep to the left heel had been done. A treatment sheet for May indicated there was an order, dated 4/30/12, for Z-flow to the heels, but there was no documentation on the treatment sheet that this had been done. The treatment record indicated an order to float heels in bed, dated 5/11/12, and was documented starting 5/12/12. In an interview with the DoN (Director of Nursing) on 6/21/12 at 3:45 p.m., she indicated Resident #20's pressure ulcer to the left heel was found on 4/30/12 and was being caused by pressure from Resident #20's shoe. She indicated there was no documentation of floating the heels prior to 4/30/12 and the documentation of using the Z-flow or floating the heels from 5/1/12 until 5/12/12 had not been done. 2. The closed record of Resident #88 was reviewed on 6/22/12 at 11:19 a.m. The resident was admitted to the facility on [DATE]. The Nursing Admission Assessment Data Collection form of 1/28/12 did not indicate a skin condition concern regarding the resident's left heel. The February 2012 treatment sheet indicated weekly skin assessments were performed for Resident #88 on 02/07/12, 02/14/12, and 02/21/12. Each of these assessments indicated an existing area of impairment. A care plan titled potential for alteration in skin integrity, dated 2/8/12, indicated Resident #88 was at risk due to immobility and diabetes. The interventions included but were not limited to assess skin for changes, turn and reposition every 2 hours, pressure reducing mattress and heels off bed. The Pressure/Stasis/Arterial/Diabetic Ulcer form, dated 02/22/12, indicated the area was not present on admission and measured 3.5 cm X 4.5 cm and the depth was unable to be determined. The form indicated the treatment was Skin Prep every shift, float heels, no shoes, and gripper socks when out of bed. The form indicated on 2/28/12, the wound was black in color, staged as "E" (unstageable)measured 3.5 cm X 5.0 cm and the treatment was Skin Prep, float heels, low air loss mattress, and no shoes. The form indicated on 3/6/12, the wound was unstageable and measured 2.5 cm X 3.5 cm. A doctor's order, dated 2/22/12, indicated Resident #88 was to have Skin Prep to left heel every shift and as needed, no shoes, wear gripper non skid socks in bed and float heels in bed. The treatment sheets for February and March indicated Resident #88 was to have heels floated in bed, no shoes until healed, wear gripper non skid socks. The February 2012 and March 2012 treatment sheets lacked any documentation of heels being floated, no shoes, or gripper nonskid socks. In an interview with the CRCA (Certified Resident Care Associate) preceptor on 6/22/12 at 10:30 a.m., she indicated there was not a place on the activities of daily living kiosk computer to document heels being floated. The Pressure Prevention Guideline was provided by the HFA (Health Facilities Administrator) on 6/26/12 at 12:00 p.m., and indicated the facility would "elevate heels off the bed-avoid use of 'heel protectors' and protect elbows and float heels as needed... Purpose... provide measures that will promote and maintain good skin integrity" on residents with potential and or actual impairment or skin integrity. 3.1-40(a)(1) 3.1-40(a)(2)

Based on record review and interview, the facility failed to ensure it was free of significant medication errors, for 1 of 1 supplemental sample resident reviewed for medications, in the supplemental sample of 9, in that the new admission was ordered to receive [MEDICATION NAME] (diuretic) once a day and received it three times a day, resulting in a low potassium level, and then received less than the ordered potassium for two days. (Resident #62) Finding includes: Resident #62's clinical record was reviewed on 5/16/11 at 10:50 a.m. The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medication orders from the hospital included, but were not limited to, "[MEDICATION NAME], 40 mg (diuretic) po (by mouth) 1 (one) tab po daily." Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]"[MEDICATION NAME] 40 mg p.o. T.I.D. (three times a day) before meals." The medication had been documented as given three times a day on 5/11, 5/12, 5/13, 5/14, 5/15, and once thus far on 5/16/11. physician's orders [REDACTED]. A lab report indicated the resident's potassium level was 2.8 on 5/13/11, with normal ranges being 3.5-5.4. A follow-up potassium level, on 5/16/11, was noted to be 2.6. The error in transcription was reviewed with the physician's Nurse Practitioner, on 5/16/11 at 10:55 a.m. She indicated the [MEDICATION NAME] being given more frequently than ordered would account for the low potassium level, and indicated she was unaware of the error. The Director of Nursing indicated, on 5/16/11 at 11:00 a.m., she would need to review the orders and the MAR. At 11:30 a.m., she indicated it did appear there was an error, however, she pointed out the Nurse Practitioner had seen the resident on 5/12 and 5/13/11 and indicated to continue the same orders, including the [MEDICATION NAME] 40 mg three times a day. According to the Lippincott Manual of Nursing Practice Handbook, third edition, hypokalemia (low potassium levels) can be caused by diuretic therapy. Signs and symptoms of hypokalemia included weakness, lethargy, anorexia, abdominal distention, decreased bowel sounds, and muscle tenderness. The manual indicated hypokalemia resulted more quickly with loop diuretic therapy, such as [MEDICATION NAME] ([MEDICATION NAME]). The Director of Health Services was interviewed on 5/16/11 at 3:00 p.m. She indicated the procedure for reviewing new admission orders [REDACTED]. In this case, she indicated there were 4 new admissions that date. LPN #2 took the orders off of the admission orders [REDACTED]. RN #2 was supposed to review the orders for accuracy an additional time. The Director of Health Services indicated RN #2 noted that LPN #3 had reviewed them and LPN #3 was a nurse manager, so she did not follow through with her review, since a nurse manager had already reviewed them. She indicated they were in the process of looking at the process and where it broke down. The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED].o. twice a day was started on 5/14 in the morning. the MAR indicated [REDACTED]. Review of the medication provided from the pharmacy indicated it was delivered on 5/13/11. There were 30 tablets delivered of 20 meq each. The label indicated two tablets were to be given twice a day. There were 24 tablets left at the time of the review. RN #1 was present and indicated she had given two tablets that morning. Ten (10) tablets should have been missing for 5 doses of 40 meq each. RN #1 then checked the Emergency Drug Kit (EDK). No doses of potassium had been signed out for Resident #62. This information was reviewed with the Director of Health Services (DoHS) on 5/16/11 at 3:00 p.m. She indicated the back up pharmacy could have provided some doses and she would check. At 3:45 p.m., she reported they could find no further evidence of additional medication being provided, so he must have gotten half the potassium dose over the weekend, i.e. 20 meq twice a day instead of 40 meq twice a day. 3.1-25(b)(9) 3.1-48(c)(2)

Based on interview and record review, the facility failed to ensure a resident with a [DIAGNOSES REDACTED]. Resident F Findings include: 1. On 2/22/11 at 9:50 A.M., the Director of Nursing provided the current facility policy on "Medication Orders," dated 2/1/10. The policy included: "Medications are administered only upon the clear, complete, and signed order of a person lawfully authorized to prescribe...Medication orders specify the following: a. Name of medication, b. Strength of medication, where indicated, c. Dose and dosage form, d. Time or frequency of administration...f. Quantity or duration (length) of therapy...B. Any dose or order that appears inappropriate considering the resident's age, condition...or [DIAGNOSES REDACTED].[REDACTED]. If the label and MAR indicated [REDACTED]." 2. The closed clinical record of Resident F was reviewed on 2/21/11 at 2:25 P.M. [DIAGNOSES REDACTED]. A physician's orders [REDACTED].@ 1600 (4:00 P.M.)" "[MEDICATION NAME] 40 mg po Q AM (every morning)," and "[MEDICATION NAME] 25 mg tablet give 1 tablet orally every day." An additional physician's orders [REDACTED]. PT/INR on Sunday 11-28-10." The November 2010 MAR indicated [REDACTED]." The MAR indicated [REDACTED]. A physician's orders [REDACTED]. (Recheck) PT/INR 12/6/10." A "Medication Error Circumstance, Assessment and Intervention" form, dated 12/1/10, indicated, "Date of error 11-21-10...Nature of error: Medication not given...Injury/describe: wt. gain...Prevention Update, Nursing education, Nursing counseling...." The form did not indicate the name of the medication that was not given. A "Medication Error Circumstance, Assessment and Intervention" form, dated 12/1/10, indicated, "Date of error 11-26-10...Location error found yellow copy of order...Nature of error: no current order for [MEDICATION NAME] was available 11-28, (and) 11-29, Lab not transcribed (and) was missed...Treatment required: (Yes) Lab...Prevention Update, Nursing education, Nursing counseling...." A physician's orders [REDACTED].@ 1600. Follow up CXR (chest x-ray) on 12-3-10." A Physician's progress note, dated 12/3/10, indicated, "...Her weight has increased - weight today is 204 pounds. She has not received her [MEDICATION NAME] dose since November 21, 2010. Staff report it was discontinued from the MAR indicated [REDACTED]. I also told her heart (sic) is not doing good and she voiced understanding...Treatment: 1. [MEDICAL CONDITION] Tablet ([MEDICATION NAME]), 40 MG, Orally, 1 tablet q am; 1/2 tablet in pm, Once a day, CXR (chest x-ray) and labs have been ordered. 2. [MEDICAL CONDITION] or embolism (blood clot) of distal lower extremity, Continue [MEDICATION NAME] tablet...." Nurse's Notes include the following notations: 12/7/10 (untimed): "Residents (sic) wt this AM 202.6 (up) from 199.6 yesterday, 3-4+ [MEDICAL CONDITION] to Bilat (lower) ext. (extremities)...(Physician) notified...." A physician's orders [REDACTED]." 12/15/10 at 10:45 P.M.: "N/O (new order) rec'd to (increase) [MEDICATION NAME] to 10 mg PO daily D/T (due to) heart failure...." 12/22/10 at 7:00 A.M.: "Aide told nurse pt. (patient) had SOB (shortness of breath). Difficult breathing...0805 (8:05 A.M.) N.O. (new orders) to send to (name of hospital)...." The resident's November 2010 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]"Order (changed) 11/21/10." New orders for [MEDICATION NAME] were not documented after 11/21. The resident's December 2010 MAR indicated [MEDICATION NAME] 25 mg (one) BID, Upon rising, HS (at bedtime)." The HS entry was not initialed as given on 12/7, 12/8, or 12/9. On 2/22/11 at 8:50 A.M., during interview with the DON, she indicated the nurse who wrote "order (changed)" on the [MEDICATION NAME] orders, was interviewed, and indicated he did not know why he wrote that on the MAR. He indicated he had not received any order. The DON indicated they could not find any other residents who may have received that order. The DON indicated the resident did not receive the [MEDICATION NAME] until it was discovered on 12/1/10, due to the resident's weight gain. The DON indicated the [MEDICATION NAME] error happened due to the nurse not transcribing the PT/INR lab order to the TAR, and the nursing staff "knew not to give the [MEDICATION NAME] unless they knew what the PT/INR values were." The DON indicated the resident missed 2 doses of [MEDICATION NAME]. On 2/23/11 at 10:40 A.M., during interview with the DON, she indicated she did not know why the resident had not received her bedtime dose of [MEDICATION NAME] on 12/7, 12/8, or 12/9. On 2/23/11 at 12:10 P.M., during interview with the DON, she reviewed the record of Resident F, and indicated, "It actually looks as if she didn't miss her [MEDICATION NAME] but 1 night, but the lab was missed." The DON indicated the record looked as if the physician was actually notified on 11/30/10, and then ordered the PT/INR for every other day, and so the lab was obtained on 12/3/10. The DON indicated it was not clear in the documentation regarding when the physician was notified of the medication error or how many doses of the [MEDICATION NAME] were missed. This federal tag relates to Complaint IN 610. 3.1-25(b)(9)