Every finding on record at Riverview Village

Based on interview and record review, the facility failed to ensure a resident's (Resident E) plan of care was followed for 1 of 3 residents reviewed for implementation of care plans. Findings include:The clinical record for Resident E was reviewed on 7/6/22 at 10:22 a.m. The resident's diagnoses included, but were not limited to, dementia (cognitive decline) with mood disturbance, epilepsy (chronic brain disorder characterized by recurring, unprovoked seizures) and osteoarthritis. The care plan, dated 7/15/22, indicated the resident was at risk for falls and required two staff member assistance with transfers using a full body mechanical lift. A progress note, dated 6/27/26 at 11:53 a.m., indicated Licensed Practical Nurse (LPN) 4 was called to the resident's room by Certified Nursing Assistant (CNA) 5 due to a fall. CNA 5 reported to LPN 4 that after the resident had been transferred to bed, the resident rolled out of the bed. The clinical record lacked documentation of a second staff member present during the transfer of Resident E. During an interview, on 7/6/26 at 11:31 a.m., CNA 5 indicated on the evening of 6/27/26, she had transferred the resident to bed by herself and did not use the full body mechanical lift during the transfer. During an interview, on 7/6/26 at 11:54 a.m., LPN 4 indicated the resident's care plan was for staff members to use a full body mechanical lift for all transfers. The resident's care plans should have been followed. On 7/7/26 at 2:05 p.m., the Executive Director provided a current copy of the document titled IDT Comprehensive Care Plan Policy dated 10/2025. It included, but was not limited to, Policy.It is the policy of this facility that each resident will have an interdisciplinary comprehensive person-centered care plan.The care plan must include.resident specific interventions based on needs and preferences to promote the resident's highest level of functioning. 410 IAC (Indiana Authorization Code) 16.2-3.1-35(g)(1)

Based on observation, interview and record review, the facility failed to ensure a resident (Resident E) was properly placed in bed to prevent a fall for 1 of 3 residents reviewed for accidents. Findings include:The clinical record for Resident E was reviewed on 7/6/26 at 10:22 a.m. The resident's diagnoses included, but were not limited to, dementia (decline in cognitive abilities, such as memory, thinking and reasoning) and osteoarthritis (degenerative joint disease that results from breakdown of joint cartilage and underlying bone). During an observation, on 7/6/26 at 3:00 p.m., the resident was observed resting in her bed with her eyes open and the call light was in reach. The resident was lying towards the left side with both knees drawn up towards her abdomen. The resident had a large goose egg to the left forehead/temple area with purple bruising. The bed was in a low position with a scoop mattress (specialized therapeutic support surface with a concave, trough-like design. The center was lower than the raised, soft-foam edges, which passively cradles the user. This shape safely centers the sleeper, preventing rolling or falling out of bed) on the bed. The bed was against the wall with the head of the bed was towards the bathroom. The care plan, dated 7/15/22, indicated the resident was at risk for falls. The interventions included, but were not limited to, the following:-Hoyer lift (full body mechanical lift) transfers with 2 staff members,-scoop mattress,-high fall risk,-may align bed along the wall for open floor space,-non-skid footwear The annual MDS (minimum data set) assessment, dated 6/10/26, indicated the resident was dependent (Helper does all the effort. The resident does none of the effort to complete the activity) with rolling to the left and right. A progress note, dated 6/27/26 at 11:53 p.m., indicated CNA 5 called LPN 4 into the resident's room to assess the resident due to a fall. CNA 5 stated that she sat the resident up onto the side of the bed. CNA 5 turned to grab something. When CNA 5 turned back around, the resident rolled off the bed and onto the floor before CNA 5 could stop her. The edited progress note, dated 6/27/26 at 11:53 p.m., revised on 7/1/26 at 11:54 p.m., indicated Licensed Practical Nurse (LPN) 4 was called to Resident E's room by Certified Nursing Assistant (CNA) 5 to assess the resident due to a fall. CNA 5 reported to LPN 4 that the resident rolled out of bed after CNA 5 had transferred the resident to bed. The fall event, dated 6/27/26 at 8:30 p.m., indicated CNA 5 had sat Resident E, in the upward position, on the side of the resident's bed. CNA 5 had tried to reach for something and, as soon as CNA 5 had turned back around, Resident B rolled off the bed and onto the floor. During a telephone interview, on 7/6/26 at 11:31 a.m., CNA 5 indicated on the evening shift on 6/27/26, she transferred the resident to the bed. CNA 5 had the resident lying in her bed. CNA 5 turned around to gather her night clothes and supplies to get the resident ready for bed. CNA 5 had turned around for no more than a minute and heard a noise. When CNA 5 turned around, the resident had rolled out of the bed onto the floor. Resident B could not walk, but she could roll herself in the bed. During an interview, on 7/6/26 at 11:54 a.m., LPN 4 indicated on 6/27/26, the resident had a fall from her bed. When CNA 5 first explained to LPN 4 what had happened, CNA 5 reported that the resident was sitting on the side of the bed. CNA 5 then reported that the resident had been lying in bed. CNA 5 never made it very clear. After LPN 4 read the statement from CNA 5, it made sense to revise her original note. LPN 4 did not provide care to Resident E and was unaware if the resident could roll side to side independently. During an interview, on 7/6/26 at 3:03 p.m., CNA 6 indicated she had been working on the memory care unit for over 2 weeks. Resident B could not move herself in bed nor could she roll side to side without staff assistance. She had never seen the resident roll by herself because her legs drew up when she was in bed. During an interview, on 7/7/26 at 1:42 p.m., CNA 7 indicated, prior to the resident's fall, the resident could not roll herself or roll side to side independently. She had not been able to roll independently for a long time. During an interview, on 7/7/27 at 1:44 p.m., CNA 8 indicated prior to the resident's fall, she could not roll independently in bed and could not roll side to side independently without staff assistance. During an interview, on 7/7/26 at 2:09 p.m., the Executive Director and Director of Nursing indicated after investigation, they could only determine the root cause of the fall to be how and where the resident was placed in the bed. Review of the Fall Management policy included, but was not limited to, Policy.It is the policy.to ensure residents residing withing the community have adequate assistance.related to falls. 410 AIC (Indiana Authorization Code) 16.2-3.1-45(a)(2)

Based on interview and record review, the facility failed to ensure a resident's (Resident E) fall was accurately documented for 1 of 3 residents reviewed for medical records. Findings include:The clinical record for Resident E was reviewed on 7/6/26 at 10:22 a.m. The resident's diagnosis included, but was not limited to, dementia (cognitive decline). A progress note, dated 6/27/26 at 11:53 p.m., indicated CNA 5 called LPN 4 into the resident's room to assess the resident due to a fall. CNA 5 stated that she sat the resident up onto the side of the bed. CNA 5 turned to grab something. When CNA 5 turned back around, the resident rolled off the bed and onto the floor before CNA 5 could stop her. The edited progress note, dated 6/27/26 at 11:53 p.m., revised on 7/1/26 at 11:54 p.m., indicated Licensed Practical Nurse (LPN) 4 was called to Resident E's room by Certified Nursing Assistant (CNA) 5 to assess the resident due to a fall. CNA 5 reported to LPN 4 that the resident rolled out of bed after CNA 5 had transferred the resident to bed. The fall event, dated 6/27/26 at 8:30 p.m., indicated CNA 5 had sat Resident E, in the upward position, on the side of the resident's bed. CNA 5 had tried to reach for something and, as soon as CNA 5 had turned back around, Resident B rolled off the bed and onto the floor. During an interview, on 7/6/26 at 11:54 a.m., LPN 4 indicated on 6/27/26, the resident had a fall from her bed. When CNA 5 first explained to LPN 4 what had happened, CNA 5 reported that the resident was sitting on the side of the bed. CNA 5 then reported that the resident had been lying in bed. CNA 5 never made it very clear. After LPN 4 read the statement from CNA 5, it made sense to revise her original note. LPN 5 had forgotten to revise the fall event. The documentation in fall event was incorrect. On 7/7/26 at 2:09 p.m., the Executive Director provided a current copy of the document titled Documentation Guidelines for Nursing dated 8/25. It included, but was not limited to, Purpose.to accurately document in an organized manner all information related to the resident in the medical record.Fall Event.To be completed by the nurse in charge immediately post-fall. 410 IAC (Indiana Authorization Code) 16.2-3.1-50(a)(2)

Based on interview and record review, the facility failed to ensure residents' (Resident C and Resident F) medication administration accurately reflected the administration of narcotic pain medication for 2 of 3 residents reviewed for medical records. Findings include:1.The clinical record for Resident C was reviewed on 11/20/25 at 11:40 a.m. The resident's diagnoses included, but were not limited to, restless leg syndrome, depression and osteoarthritis. The physician's order, dated 5/19/25, indicated the resident was to receive Tramadol (narcotic pain medication) 50 mg (milligrams) every 6 hours for pain at 8:00 a.m., 2:00 p.m., 8:00 p.m. and 2:00 a.m. Review of the October 2025 and November 2025 controlled substance record indicated the resident received the medication on the following dates and times: 10/03/25 at 8:00 p.m., 10/30/25 at 2:00 a.m., 11/01/25 at 2:00 a.m., 11/05/25 at 8:00 p.m., 11/07/25 at 8:00 p.m., and 11/11/25 at 8:00 a.m. The October 2025 and November 2025 medication administration record lacked documentation that the pain medication was administered. During an interview, on 11/20/25 at 4:12 p.m., Licensed Practical Nurse (LPN) 5 indicated when a narcotic pain medication was administered, the nurse should sign the medication as administered on the controlled substance record and the medication administration record. 2. The clinical record for Resident F was reviewed on 11/20/25 at 1:59 p.m. The resident's diagnoses included, but were not limited to, diabetes and hypertension. The physician's order, dated 10/1/25, indicated the resident was to receive Tramadol 50 mg three times a day for pain at 8:00 a.m., 2:00 p.m. and 8:00 p.m. Review of the October 2025 and November 2025 controlled substance records and medication administration records indicated the following: -On 10/01/25 at 8:00 p.m., the medication was signed out as administered on the controlled substance record but not on the MAR.-On 10/10/25 at 8:00 a.m., the medication was signed out as administered on the controlled substance record but not on the MAR.-On 10/11/25 at 2:00 p.m., the medication was signed out as administered on the MAR but not on the controlled substance record.-On 11/07/25 at 2:00 p.m., the medication was signed out as administered on the MAR but not on the controlled substance record.-On 11/10/25 at 2:00 p.m., the medication was signed out as administered on the MAR but not on the controlled substance record. On 11/20/25 at 4:30 p.m., the Director of Nursing provided a current copy of the document titled Controlled Substances: Storage, Documentation, Inventory and Destruction (Includes Fentanyl Patch Removal and Destruction) dated November 2024. It included, but was not limited to, Policy.It is the policy of this facility that all controlled substances will be.recorded.Documentation.When a controlled substance is administered to a resident, it must be recorded in the residents Medication Administration Record. 3.1-50(a)(2)

Based on observation, record review, and interview, the facility failed to ensure a safe and sanitary environment for 2 of 66 resident rooms reviewed for the environment. (Residents 11 and 17). Findings include: 1. During an observation on 6/19/25 at 1:00 p.m., the following was observed: - Resident 17 was sitting on the side of his bed. He was observed to be disheveled and had a strong foul odor. - The bedside nightstand had approximately 15 Styrofoam cups stacked up. - There were 3 garlic bread sticks laying in the bed. The review of the meal menu indicated the last time the facility had served breadsticks was on 6/16/25. - There were 3 bowls of food like substances in each bowl. - The resident's linens and clothes were observed with stains, food debris, and had a foul odor. - There were 3 Styrofoam containers underneath the resident's bed with food stored in them. The resident became upset when the staff tried to open the containers. - The floor had unknown substances that had dried and stained the floor. - The bedside table had a Styrofoam container that contained breakfast food. It also had dried substances and food debris on it. The foul odor from Resident 17's room could be detected in the hallway approximately 15 to 20 feet before getting to the resident's room. The record for Resident 17 was reviewed on 6/20/25 at 1:21 p.m. The resident's diagnoses included, but were not limited to, dementia, obsessive-compulsive disorder, manic episode, severe psychotic symptoms, and a history of a traumatic brain disorder. The care plan, dated 5/28/21 and revised on 8/9/25, indicated Resident 17 could become combative with staff members when they attempted to clean or free his room from old Styrofoam containers or other items that needed to be removed. The resident would also become combative with staff while they attempted personal care, showers, and changing clothes. The resident had a diagnosis of obsessive-compulsive disorder and hoarding and would keep old food or drinks in the room. The interventions included, but were not limited to, the resident would allow staff to keep his room clean and free of trash without injury. Encourage an activity the resident would enjoy, psychiatric admission as needed, administer medications as ordered, aid the resident in calling his family member to encourage him to allow the staff to clean his room, offer a quiet environment, and provide the resident with personal space to calm himself. The Minimum Data Set (MDS) assessment, dated 5/7/25, indicated the resident was rarely or never understood. The resident required moderate assistance with Activities of Daily Living (ADL's). The nurse's note, dated 8/18/24 at 11:00 a.m., indicated the resident hollered, kicked and smacked at the housekeeper when she was cleaning the resident's side of the room. The resident had been re-directed back to his room and educated he could not hit anyone. The Housekeeper manager and Assistant DON (Director of Nursing) was notified. The nurse's note, dated 9/20/24 at 1:30 p.m., indicated the resident threw items at his roommate earlier in the shift, and when the Certified Nurse Aide (CNA) entered the resident's room, she observed water all over the floor from the resident dumping water cups onto the floor and in the trash can. The nurse's note, dated 3/12/25 at 1:44 a.m., indicated the resident was incontinent and soiled himself. The resident attempted to put back on the soiled underwear. Resident 17 became combative when the nurse attempted to aid with incontinence care. 2. During an observation, on 6/18/25 at 9:30 a.m., Resident 11 was sitting in the common area waiting to go out to smoke. The resident looked disheveled, and his clothes were stained and had food debris. The resident had a foul odor. During an observation, on 6/18/25 at 1:00 p.m., the following was observed: - A Styrofoam cup full of urine was sitting on the windowsill. - A Styrofoam cup had a partial sandwich stuffed down inside the cup. - The resident's linens were stained with a brown and pinkish substance and the linens were wet with urine. - The floor had old soggy bread and food debris on it. - The privacy curtain had been stained with a brown substance and had a foul odor. - The room had an overall foul odor, and the odor had drifted out into the hallway approximately 15 to 20 feet. The record for Resident 11 was reviewed on 6/20/25 at 1:21 p.m. The resident's diagnoses included, but were not limited to, dementia, bipolar disorder, and anxiety. The care plan, dated 6/5/19 and revised on 4/15/25, indicated Resident 11 had a history of hoarding items in the drawers in his room including candy, multiple cans of sodas, sugars and creamers. The interventions included, but were not limited to, the resident would allow staff to aid cleaning out his drawers and keeping items necessary, The Quarterly Minimum Data Set (MDS) assessment, dated 4/22/25, indicated the resident was moderately cognitively impaired. The behavior notes, dated 4/29/25 at 9:44 a.m., indicated the resident was throwing feces in the garbage can. The resident often refused care or would not allow staff to clean his room. The resident frequently left cups of urine or dirty briefs throughout the room. During an interview, on 6/18/25 at 1:00 p.m., RN 2 indicated housekeeping would clean the resident's room every day. The resident would hoard food and when staff tried to remove the food he would charge them. The resident refused to take a shower. During a confidential interview, between 6/18/25 and 6/25/25, Staff 100 indicated the resident would get mad and would charge a staff member when they tried to remove anything from his room. They indicated the smell was so bad it could be smelled by the other residents out in the hallways. They indicated the resident would hoard food and keep it in his bed for days or weeks. The room needed deep cleaned, but that had not been done. The room smelled so bad no one wanted to enter the room, and they would not enter without a mask on. During an interview, on 6/18/25 at 2:30 p.m., the Administer indicated she acknowledged the residents' room was a problem. She indicated the odor was infringing on the other residents' rights, but she was unsure how to fix the problem. During an interview, on 6/24/25 at 10:48 a.m., the Housekeeping Supervisor indicated some of the housekeepers were intimated by the resident and it was difficult for them to clean the resident's room. The residents' rooms were to be cleaned daily. The rooms were divided up and different rooms should be deep cleaned daily. 3.1-19(f)

Based on interview and record review, the facility failed to ensure the safety of a resident (Resident C), upon return from the hospital, from a resident (Resident D) with escalating behaviors, which resulted in Resident C's head injury/concussion without loss of consciousness for 2 of 4 residents reviewed for dementia care. Findings include: 1. The clinical record for Resident D was reviewed on 3/3/25 at 11:15 a.m. The resident's diagnoses included, but were not limited to, dementia with other behavioral disturbance, anxiety, depression, and vascular dementia with agitation. The Behavior Note, dated 10/7/24 at 9:08 p.m., indicated the resident repeatedly attempted to enter the nurse's station. The resident kicked the doors, tried to hit the nurse and asked staff to fight. The interventions were not effective, and the resident would be referred to the psychiatrist. The Behavior Note, dated 10/17/24 at 6:15 a.m., indicated the resident was in the middle of the hall screaming. The staff attempted to help, and the resident threatened to hit staff members. The Progress Note, dated 10/21/24 at 6:52 p.m., indicated the resident had grabbed a butter knife off the table. A staff member asked for the knife and the resident refused to give the knife back. A second staff member asked the resident for the knife because the resident held the knife like he was going to stab someone with it. The nurse attempted to get the knife, and the resident tried to stab the nurse with the knife. The nurse was able to retrieve the knife and calm the resident. The resident was reassured that he was not in harm's way. The resident insisted that he would die and not make it until the morning. On 10/25/24, the resident was seen by the facility nurse practitioner with a new order for risperidone (antipsychotic) 0.25 mg (milligrams) twice daily for physical aggression and agitation. The Behavior Note, dated 10/28/24 at 9:07 p.m., indicated the patient screamed at the nurse and attempted to hit the nurse in the face. The nurse explained to the resident the treatment orders for bandage changes to his right upper extremity. The resident appeared to become more agitated which resulted in his attempt to hit the nurse in the face. The Behavior Note, dated 10/29/24 at 12:28 a.m., indicated the resident had moved the trash can, a walker and a wheelchair in front of the room door, which blocked staff from entering the room. A staff member was able to get into the room through an adjoining bathroom. When asked if everything was ok, the resident responded no and that someone was trying to kill him. The resident was unable to be re-directed and continued to place more things in front of the door to hinder staff entrance. The Care Plan, dated 10/29/24, Indicated the resident may experience paranoia thoughts such as someone trying to kill me. Resident will place personal items such as wheelchair, trash can and walker in front of the door which doesn't allow staff to enter. Resident takes an ordered antipsychotic. The interventions included, but were not limited to, offer snack or drink, resident to see in house psych provider, and staff to ensure residents' room door remained open when not providing care. The Behavior Note, dated 10/29/24 at 12:43 p.m., indicated the resident was found in another resident's room with a plunger in his hand. A staff member attempted to assist the resident back in a chair but the resident became agitated. When other staff members came to assist, the resident became combative and hit a staff member with the plunger. The resident kept swinging the plunger in the air trying to hit everybody with it. The Progress Note, dated 10/30/24 at 1:04 a.m., indicated a staff member found the resident in the bathroom naked with the shower on. The resident was spraying himself outside the shower. The staff member assisted the resident to put new clothes on. The resident appeared very restless and was unable to sleep for more than a few minutes before he was back up. The resident was currently sitting on his roommate's bed, with the bed in the lowest position, and call light in reach. The Psychiatric Nurse Practitioner Note, dated 10/30/24 at 7:38 a.m., indicated the resident was previously started on Risperdal to assist with agitation and paranoia. A new order for Zoloft (antidepressant) 25 mg daily to improve agitation and mood. On 10/30/24 at 5:23 p.m., Resident D's roommate, Resident C, readmitted to the facility from the hospital. The Progress Note, dated 10/30/24 at 10:20 p.m., indicated the nurse heard Resident C yell for help. The nurse tried to enter the resident's room; however, the resident's room door was blocked by a wheelchair. The nurse gained access to the room from the room next door through the shared bathroom. When the nurse walked in the room, Resident D was standing over Resident C and stated, where is my apology? You are trying to kill me! Resident D had a wheelchair foot pedal in his hand hitting Resident C with it. The nurse intervened and immediately removed the wheelchair foot pedal from Resident D. The clinical record lacked documentation of increased safety measures or interventions to ensure Resident D's escalating behaviors were closely monitored upon his roommate's return. During an interview on 3/3/25 at 11:45 a.m., the Director of Nursing indicated on 10/29/24, a care plan was implemented for paranoia with interventions of snack, vital signs, psych to see and ensure room door when not providing care. They did not implement one on one- or 15-minute checks when Resident D's roommate readmitted due to Resident D's behaviors were towards staff. Resident D had not had any negative interaction with any resident. On 3/4/25 at 11:52 p.m., the Executive Director indicated the facility did not have a policy on dementia care, but provided a document titled Behavior Management dated 8/2022. It included, but was not limited to, It is the policy .to provide behavior interventions for residents with problematic or distressing behaviors .Care plans should be initiated for any behavioral expression .Care plan interventions should include individualized and non-pharmacological interventions which address both proactive and responsive interventions 2. The clinical record for Resident C was reviewed on 3/3/25 at 11:37 a.m. The resident's diagnosis included, but was not limited to, dementia with mood disturbance. The Progress Note, dated 10/30/24 at 5:23 p.m., indicated Resident C had returned from the hospital. The Progress Note, dated 10/30/24 at 10:20 p.m., indicated the nurse heard Resident C yell for help. Resident D had a wheelchair foot pedal in his hand hitting Resident C. The nurse assessed Resident C and the resident was bleeding heavily from different spots on his head. The nurse called emergency medical services immediately and Resident C was sent to the emergency department for evaluation. The clinical record lacked documentation of increased safety measures or interventions to ensure the safety of Resident C upon readmission from his roommate's (Resident D) escalated behaviors. The Emergency Department Note, dated 10/31/24 at 12:56 a.m., included, but was not limited to, the patient presented with a head injury. The patient was attached by another resident and hit repeatedly in the head with a wheelchair pedal .Diagnosis .Concussion without loss of consciousness The Past noncompliance began on 10/30/24 at 10:20 p.m. The deficient practice was corrected by 11/10/24 after the facility implemented a systemic plan that included the following actions: The interdisciplinary team was educated on identifying and responding to high risk behaviors (11/5/24); All residents were interviewed to assess for abuse and head to toe skin assessments were completed on non-interviewable residents (11/5/24); All staff were educated on Recognizing and Responding to Behaviors and approaches and interventions to respond to behaviors (11/10/24). 3.1-37

Based on observation, interview and record review, the facility failed to ensure a resident's (Resident F) record accurately reflected the discontinuation of a wanderguard for 1 of 3 residents reviewed for documentation. Findings include: The clinical record for Resident F was reviewed on 3/4/25 at 10:30 a.m. The diagnoses included, but were not limited to, severe dementia with agitation and bipolar. The physician order, dated 12/27/24, indicated the resident had a security bracelet (wanderguard) to the left ankle and to check the placement and function every day shift and night shift. On 3/4/25 at 10:18 a.m., the resident was observed slightly reclined in a broda chair in the dining room. The resident did not have a wanderguard in place. The elopement risk assessment, dated 2/13/25 at 1:45 p.m., indicated the resident resided had a significant change, resided on a secure unit and was not assigned a security bracelet. The progress note, dated 2/14/25 at 10:45 a.m., indicated the interdisciplinary team determined the resident no longer required the use of a wanderguard due to the resident was in a wheelchair and unable to self-propel. Review of the February 2025 and March 2025 treatment administration record indicated between 2/15/25 and 3/4/25, the staff documented the resident had a wanderguard in place and the wanderguard was functioning properly. During an interview on 3/4/25 at 11:21 a.m., the Executive Director indicated the staff were made aware of the discontinuation of the wanderguard and should have discontinued the order. During an interview on 3/4/25 at 11:59 a.m., the Director of Nursing indicated the only policy they had on wanderguards was in the elopement policy. 3.1-50(a)(2)

Based on interview and record review, the facility failed to prevent a significant medication error related to insulin administration for 1 of 3 residents reviewed for medication administration. (Resident B) Findings include: The clinical record for Resident B was reviewed on 8/27/24 at 10:08 a.m. The resident's diagnosis included, but was not limited to, diabetes with hyperglycemia. The care plan, dated 7/24/24, indicated the resident was at risk for hyperglycemia and to administer medication as ordered. The physician's order, dated 7/23/24, indicated the resident was to receive insulin degludec (ultralong-acting insulin) 50 units, subcutaneously every morning at 6:30 a.m. The physician was to be notified of a blood sugar less than 60 or greater than 400. The July 2024 medication administration record indicated on 7/24/24 at 6:30 a.m., Resident B's blood sugar was 390. The July 2024 medication administration lacked documentation that the insulin was administered as ordered by the physician. A notation was documented by RN (Registered Nurse) 4 that the drug item was not available, the resident was new and the medication dose was unavailable. Review of the pharmacy shipment delivery indicated Resident B's insulin arrived at the facility on 7/24/24 at 7:19 a.m. During an interview on 8/27/24 at 10:38 a.m., RN 4 indicated on 7/24/24, the resident's insulin had not arrived at that time and the dosage needed was not in the omnicell (emergency drug kit). She reported to the oncoming nurse, RN 3, the residents blood sugar and RN 3 was going to give the insulin upon arrival. During an interview on 8/27/24 at 10:45 a.m., RN 3 indicated she did not give the insulin because she was not aware that Resident B did not receive his insulin since the blood sugar checks were completed on night shift. During an interview on 8/27/24 at 3:16 a.m., the DON (Director of Nursing) indicated the insulin should have been administered upon arrival to the facility at 7:19 a.m. On 8/27/24 at 2:20 p.m., the DON provided a current copy of the document titled Medication Errors dated 11/02. It included, but was not limited to, Policy .It is the policy of this provider to ensure residents residing in the facility are free of mediation errors . This Citation relates to Complaint IN00440394 3.1-48(c)(1)

Based on observation, record review, and interview, the facility failed to ensure the nursing staff followed procedure during 2 of 3 observations of the administration of insulin related to Quality of Care. (Residents 6 and 18) Findings include: 1. During an observation on 6/12/24 at 10:45 a.m., LPN (Licensed Practical Nurse) 3 prepared the lispro flexpen for administration to Resident 6 by applying the needle. The LPN failed to prime the needle prior to dialing the prescribed dosage of lispro. The LPN dialed the flexpen to 10 units and entered the resident's room and administered the insulin into the resident's abdomen. The LPN indicated the resident's blood sugar was 155 mg/dL (milligrams per deciliter). The record for Resident 6 was reviewed on 6/13/24 at 8:40 a.m. The diagnosis included, but was not limited to, type 2 diabetes mellitus. The physician's order, dated 5/17/23, indicated the staff were to administer 10 units of the lispro flexpen to the resident subcutaneously, three times a day. The Annual MDS (Minimum Data Set) assessment, dated 4/9/24, indicated the resident was cognitively intact. She received 7 injections of insulin in the last 7 days prior to the assessment. The June MAR (Medication Administration Record) indicated the resident had received the lispro three times daily. 2. During an observation on 6/12/24 at 10:46 a.m., LPN 3 prepared the Admelog flexpen for administration to the resident by applying the needle. The LPN dialed the flexpen to 25 units and entered the resident's room and administered the insulin into the resident's abdomen. The LPN failed to prime the needle prior to dialing the prescribed dose of the insulin. The LPN indicated the resident's blood sugar was 144 mg/dL. The record for Resident 18 was reviewed on 6/13/24 at 8:53 a.m. The diagnosis included, but was not limited to, type 2 diabetes mellitus with diabetic neuropathy. The Quarterly MDS assessment, dated 4/18/24, indicated the resident was cognitively intact. She received 7 injections of insulin in the last 7 days prior to the assessment. The physician's order, dated 5/31/24, indicated staff were to administer 25 units of the Admelog SoloStar flexpen to the resident subcutaneously, three times a day. The June MAR indicated the resident received the Admelog three times daily except for low blood sugar or a change in condition. During an interview on 6/14/24 at 9:35 a.m., LPN 3 indicated that during the administration of an insulin flexpen, she should dial up the insulin and administer the insulin in the location the resident chose. She should prime the needle when she placed the needle on the insulin flexpen. She had not done that prior to dialing up the dose of insulin on 6/12/24. She thought about not having done that after she had completed the insulin administrations. The Insulin Pen Administration procedure, reviewed October 2019, included, but was not limited to, . 9. Pull off and remove outer pen needle protective cap and cover. 10. Prime the pen by dialing 2 units. 11. Push the end of the pen to push out the 2 units. (A small drop of insulin should be visible. If insulin does not appear, repeat). 12. Dial desired insulin dosage to be administrated to resident . 3.1-37(a)

Based on observation, record review, and interview, the facility failed to ensure oxygen concentrator filters were placed and maintained for 3 of 9 residents reviewed for respiratory care. (Residents 41,14, and 31) Findings include: 1. During an observation on 6/10/24 at 9:37 a.m., Resident 41's oxygen concentrator filter was 100% lightly covered with a white powdery substance and multiple small chunks of a white substance. During an observation on 6/11/24 at 10:52 a.m., Resident 41's oxygen concentrator filter was 100% lightly covered with a white powdery substance and multiple small chunks of a white substance. The record for Resident 41 was reviewed on 6/12/24 at 11:16 a.m. The diagnoses included, but were not limited to, COPD (chronic obstructive pulmonary disease) and hospice care. The care plan, dated 1/14/21, indicated the resident was at risk for impaired gas exchange related to COPD with shortness of breath while lying flat and at times with physical exertion. The interventions, dated 1/14/21, indicated staff were to administer oxygen as ordered, assess vital signs, and lung sounds as needed, monitor oxygen saturation rates as needed and ordered. The Quarterly MDS (Minimum Data Set) assessment, dated 3/29/24, indicated the resident was severely cognitively impaired. She received oxygen treatments. The care plan, dated 4/11/24 and last revised on 4/26/24, indicated the resident had symptoms of decreased oxygenation related to COPD and wore continuous oxygen. The interventions, dated 4/11/24, included but were not limited to, administer oxygen as ordered, monitor oxygen saturations as ordered, and observe for continued or worsening symptoms of decreased oxygenation. The physician's order, dated 11/26/23, indicated staff were to change the oxygen tubing and humidity, and clean the concentrator and filters on Sundays. The physician's order, dated 11/20/23, indicated staff were to provided oxygen at 2 liters per nasal cannula and to monitor every shift. The nurse's note, dated 7/23/23 at 9:45 a.m., indicated the resident was resting abed with O2 (oxygen) per physician's order with O2 saturation of 98% without any SOA (shortness of air). 2. During an observation on 6/10/24 at 9:18 a.m., Resident 14's bilateral oxygen concentrator filters on the oxygen tank sides were 100% covered with a white powdery substance. A finger test indicated the white powdery substance could be wiped away. During an observation on 6/11/24 at 10:09 a.m., Resident 14's bilateral oxygen concentrator filters were 100% covered with a white powdery substance. RN 4 swiped his finger across the left filter, removing the white powdery substance where his finger swiped. During an interview at this time, RN 4 indicated he didn't even know that oxygen tanks had the filter on both sides like that. The staff should do weekly cleaning of the oxygen concentrator filters. The record for Resident 14 was reviewed on 6/13/24 at 9:21 a.m. The diagnoses included, but were not limited to, COPD (chronic obstructive pulmonary disease) and shortness of breath. The physician's order, dated 3/14/21, indicated staff were to change the oxygen tubing and humidity, and clean the concentrator and filter once a day on Sundays. The nurse's note, dated 12/9/23 at 6:07 p.m., indicated the resident had a nonproductive cough, lung sounds were diminished, but CTA (clear to auscultation). The O2 saturation was 97-98% on O2 per order per NC (nasal cannula). The nurse's note, dated 12/10/23 at 12:40 p.m., indicated the resident's O2 was at 2 liters per NC, continuously with saturations in the high 90's. The lungs had rhonchi of the upper lobes bilaterally and diminished at the bases with no signs or symptoms of respiratory distress at 17 breaths per minute. The care plan, dated 2/5/24 and last revised on 5/23/24, indicated the resident had symptoms of decreased oxygenation related to COPD and utilized 2 liters of oxygen continuously. The interventions, dated 2/5/24, included but were not limited to, administer oxygen as ordered, monitor oxygen saturations as ordered, and observe for continued or worsening symptoms of decreased oxygenation. On 4/15/24 the resident preferred no humidification on her O2 (oxygen). The physician's order, dated 4/25/24, indicated staff were to provide oxygen to the resident at 2 liters per nasal cannula continuously, twice daily. The Quarterly MDS assessment, dated 5/6/24, indicated the resident was cognitively intact. The resident received continuous oxygen treatments. During an interview on 6/11/24 at 10:18 a.m., RN 4 indicated the oxygen concentrator filters should be cleaned. The staff may not have known the filters were there to clean. During an interview on 6/14/24 at 9:28 a.m., LPN (Licensed Practical Nurse) 5 indicated the resident had no issues with breathing, other than just having COPD. They were not allowed to spray aerosols in the resident's room 3. During an observation on 6/10/24 at 9:17 a.m., Resident 31's oxygen concentrator had no filter to the back of the oxygen tank. A slight amount of dust was visible in the louvers. During an observation on 6/11/24 at 8:29 a.m., Resident 31's oxygen concentrator still had no filter. During an observation on 6/11/24 at 10:11 a.m., Resident 31's oxygen concentrator still had no filter. At this time, RN 4 indicated he would have to get on that to obtain a filter for the tank. It may have fallen off and housekeeping swept it up, not knowing what it was. The record for Resident 31 was reviewed on 6/13/24 at 9:33 a.m. The diagnoses included, but were not limited to, COPD, dependence on supplemental oxygen, and seasonal allergic rhinitis. The physician's order, dated 3/1/23, indicated staff were to change the oxygen tubing, humidity and clean the concentrator and filters on Sundays. The physician's order, dated 5/1/23, indicated staff were to administer oxygen at 2 liters per nasal cannula to the resident. The Quarterly MDS assessment, dated 2/24/24, indicated the resident was cognitively intact. The resident received oxygen treatments. The care plan, dated 4/11/24 and last revised on 5/28/24, indicated the resident had symptoms of decreased oxygenation related to COPD and she wore continuous oxygen. The interventions, dated 4/11/24, included but was not limited to, administer oxygen as ordered, monitor oxygen saturations as ordered, and observe the resident for continued or worsening symptoms of decreased oxygenation. On 4/22/24 the resident preferred no humidification on the O2. During an interview on 6/11/24 at 10:22 a.m., the DON (Director of Nursing) indicated cleaning the filter would result in better output of the oxygen and cleaner air. The current Oxygen Concentrator policy included, but was not limited to, . 1) DO NOT operate the oxygen concentrator without the filter or with a dirty filter . Daily Maintenance . 3) Clean the air inlet filter PRN [as needed] and weekly . b. Grasp filter and pull out. c. Wash the filter in warm sudsy water and rinse thoroughly. d. Dry filter by removing excess water with a lint free towel. e. Replace filter and turn the power on. 3.1-47(a)(6)

Based on interview and record review, the facility failed to implement a treatment, upon admission, for a resident (Resident D) with wounds for 1 of 3 residents reviewed for treatment and services for pressure ulcers. Findings include: The clinical record for Resident D was reviewed on 6/26/23 at 12:34 p.m. The diagnoses included, but were not limited to, dislocation of internal right prosthesis and anemia. The admission observation assessment, dated 6/15/23 at 3:30 p.m., indicated the resident had a sacral ulcer which measured 4 cm (centimeters) in length, 4 cm in width with a depth of 0.2 cm; an area to the right calf which measured 4.4 cm in length, 0.6 cm in width with a depth of 0.6 cm; and a smaller area to the right calf which measured 1.5 cm in length, 0.5 cm in width with a depth of 0.6 cm. The physician's order, dated 6/19/23, indicated the gently cleanse the sacral/coccyx area with normal saline, gently pat and cover the area with optifoam daily. The physician's order, dated 6/19/23, indicated to clean the opens areas (both) to the right outer calf, apply medihoney to the wound beds, cover with foam and secure with border gauze daily. The clinical record lacked documentation of the physician's notification of the wound upon admission and the implementation of a treatment until 6/19/23. On 6/27/23 at 12:29 p.m., the Director of Nursing indicated treatment orders for wounds should be implemented upon admission. On 6/27/23 at 10:00 a.m., the Director of Nursing provided a current copy of the document titled Skin Management Program dated 5/2022. It included, but was not limited to, Policy .It is the policy .to ensure that each resident receives care .and a resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing .Procedure .Alterations in skin integrity will be reported to the MD/NP .Treatment order will be obtained from MD/NP 3.1-40

Based on interview and record review, the facility failed to ensure a resident's (Resident C) convulsion medication was received in a timely manner for 1 of 3 residents reviewed for pharmaceutical services. Findings include: The clinical record for Resident C was reviewed on 6/26/23 at 12:12 p.m. The diagnosis included, but was not limited to, convulsions. The admission order, dated 5/5/23, indicated the resident was to receive Phenobarbital 32.4 mg (milligrams) in the morning between 7:00 a.m. and 11:00 a.m. and in the evening between 7:00 p.m. and 11:00 p.m. Review of the May 2023 medication administration record indicated the resident did not receive the first dose of the medication until 5/7/23 between 7:00 a.m. and 11:00 a.m. On 6/27/23 at 10:00 a.m., the Director of Nursing provided a copy of the pharmacy order timelines. It indicated that medications ordered Monday through Friday by 8:00 p.m. would arrive at the facility the following morning. Review of the pharmacy deliver sheet indicated the medication was shipped on 5/6/23 and received by the facility on 5/7/23 at 1:37 a.m. During an interview 6/27/23 at 1:53 p.m., Pharmacist 6 from the facility pharmacy indicated medications were sent based on cut off times. If a resident was admitted and admission orders faxed to the pharmacy by 6:00 p.m., the medications would be delivered the next day. This Federal tag relates to Complaint IN00410795 3.1-25(g)(2)

Based on observation, record review, and interview, the facility failed to ensure appropriate notification to the physician for elevated blood sugar values, administration of insulin and performance of blood glucose monitoring for 2 of 3 residents reviewed for notification of change. (Residents 4 and 70) Findings include: 1. The clinical record for Resident 4 was reviewed on 4/14/23 at 9:31 a.m. The diagnosis included, but was not limited to type 2 diabetes mellitus. The care plan, dated 1/29/16 and last revised on 3/26/23, indicated the resident was at risk for adverse effects of hyperglycemia or hypoglycemia related to the use of glucose lowering medication and the diagnosis of diabetes mellitus. The interventions, dated 1/29/16, indicated to document abnormal findings and notify the MD (medical doctor), and monitor blood sugars as ordered. The physician's order, dated 2/26/21, indicated to conduct an accu (accurate) check (blood glucose monitoring test) as needed for signs or symptoms of hyperglycemia or hypoglycemia. Notify the MD if the blood sugar was less than 70 mg/dL (milligrams per deciliter) or greater than 400 mg/dL as needed. The Quarterly MDS (Minimum Data Set) assessment, dated 12/27/21, indicated the resident was moderately cognitively impaired. The physician's order, dated 1/27/22, indicated to conduct an accu check four times daily. Notify the MD if the accu check was below 70 mg/dL or greater than 400 mg/dL. The physician's order, dated 1/27/22, indicated to administer 10 units of lispro subcutaneously three times daily. The May 2022 Diabetic Administration History report indicated the following: - On 5/3/22 the resident's blood sugar reading was not obtained at 8:00 p.m. There was no documentation to indicate why the blood sugar was not obtained. - On 5/15/22 at 7:28 p.m., the resident's blood sugar reading indicated 422 mg/dL. The documentation indicated the physician was not notified. - On 5/27/22 the blood sugar was not obtained at 8:00 p.m. The 45 units of Lantus was not documented as administered. There was no documentation to indicate why the medication was not administered. The physician's order, dated 5/23/22, indicated to administer 45 units of Lantus subcutaneously at bedtime. The June 2022 Diabetic Administration History report indicated on 6/10/22 the resident's blood sugar reading was not obtained at 6:30 a.m. and the 10 units of lispro was not documented as administered. The clinical record lacked documentation of why the blood sugar was not obtained and the medication was not given. The August 2022 Diabetic Administration History report indicated on 7/11/22 the resident's blood sugar reading was not obtained at 8:00 p.m. and the 45 units of Lantus was not documented as administered. The clinical record lacked documentation of why the blood sugar was not obtained and the medication was not given. The October 2022 Diabetic Administration History report indicated the following: - On 10/6/22 the 10 units of lispro was not documented as administered at 6:30 a.m. There was no documentation to indicate why the medication was not administered. - On 10/26/22 the resident's blood sugar reading was not obtained at 6:30 a.m. The 10 units of lispro was not documented as administered. There was no documentation to indicate why the blood sugar was not obtained or the medication was not administered. - On 10/27/22 the 10 units of lispro was not documented as administered at 6:30 a.m. There was no documentation to indicate why the medication was not administered. The nurse's note, dated 11/21/22 at 2:26 p.m., indicated an order to increase the resident's Lantus to 48 units subcutaneously at bedtime. The November 2022 Diabetic Administration History report indicated the following: - On 11/28/22 the resident's blood sugar reading was not obtained at 6:30 a.m. The 10 units of lispro was not documented as administered. There was no documentation to indicate why the blood sugar was not obtained or the medication was not administered. - On 11/30/22 the 10 units of lispro was not documented as administered at 6:30 a.m. There was no documentation to indicate why the medication was not administered. The physician's order, dated 12/15/22, indicated to administer 48 units of Lantus subcutaneously at bedtime. Notify the MD if the blood sugar was less than 60 mg/dL or greater than 400 mg/dL. The January 2023 Diabetic Administration History report indicated the following: On 1/26/23 the blood sugar reading was not obtained at 8:00 p.m. The 48 units of Lantus was not documented as administered at 8:00 p.m. There was no documentation to indicate why the blood sugar was not obtained or the medication was not administered. On 1/30/23 the 10 units of lispro was not documented as administered at 6:30 a.m. There was no documentation to indicate why the medication was not administered. The February 2023 Diabetic Administration History report indicated the following: - On 2/8/23 the 10 units of lispro was not documented as administered at 6:30 a.m. There was no documentation to indicate why the medication was not administered. - On 2/20/23 the blood sugar was not obtained at 6:30 a.m. The 10 units of lispro was not documented as administered at 6:30 a.m. There was no documentation to indicate why the blood sugar was not obtained or the medication was not administered. - On 2/27/23 indicated the 10 units of lispro was not documented as administered at 6:30 a.m. There was no documentation to indicate why the medication was not administered. - On 2/28/23 indicated the blood sugar was not obtained at 4:00 p.m. The 10 units of lispro was not administered at 4:00 p.m. There was no documentation to indicate why the blood sugar was not obtained or the medication was not administered. - On 2/28/23 indicated the blood sugar was not obtained at 4:00 p.m. The 10 units of lispro was not documented as administered at 4:00 p.m. There was no documentation to indicate why the blood sugar was not obtained or the medication was not administered. The April 2023 Diabetic Administration History report indicated the following: - On 4/1/23 at 10:48 a.m., the blood sugar reading indicated HIGH. There was not documentation of physician notification. - On 4/9/23 the blood sugar was not obtained at 6:30 a.m. The 10 units of lispro was not documented as administered at 6:30 a.m. There was no documentation to indicate why the blood sugar was not obtained or the medication was not administered. During an interview on 4/17/23 at 8:52 a.m., LPN (Licensed Practical Nurse) 3 indicated the resident was good about letting them check her blood sugar and administer her insulin. The parameters when obtaining a blood sugar were to contact the MD if her blood sugar was below 70 mg/dL or above 400 mg/dL. During an interview on 4/17/23 at 10:11 a.m., RN 1 indicated if the MAR (Medication Administration Record) was left blank, that could have meant they forgot to chart. 40240 2. The clinical record for Resident 70 was reviewed on 4/11/23 at 10:49 a.m. The diagnosis included, but was not limited to type 2 diabetes mellitus. The care plan, initiated on 7/25/22 and last revised 2/26/23, indicated the resident was at risk for adverse effects of hyperglycemia or hypoglycemia related to use of glucose lowering medication and/or diagnosis of diabetes mellitus. The interventions included, but were not limited to document abnormal findings and notify the physician, medications as ordered, and monitor blood sugars as ordered. The physician's order, dated 3/20/23, indicated to administer insulin glargine (Lantus) 100 unit/ml 10 units subcutaneous daily at bedtime. Special instructions indicated to notify the physician if the resident's blood sugar was less than 60 mg/dL or greater than 400 mg/dL. The physician's order, dated 3/21/23 at 8:00 p.m., indicated to administer insulin lispro 100 unit/ml per sliding scale and to notify the physician of blood sugar levels of less than 60 mg/dL or greater than 400 mg/dL. The February 2023 MAR indicated for administration of the resident's 8:00 p.m. dose of sliding scale insulin lispro on 2/8/23, the resident's blood sugar was 498 mg/dL. The supplemental documentation on the MAR for physician notification indicated the physician was not notified. The April 2023 MAR for the resident's Lantus 10 units at bedtime order lacked documentation of administration on April 8 and 9, 2023. The April 2023 MAR for the resident's sliding scale insulin lispro indicated the following: - On 4/6/23 the 6:30 a.m. dose was not documented as administered. There was no documentation to indicate why the medication was not administered. - On 4/8/23 the 8:00 p.m. dose was not documented as administered. There was no documentation to indicate why the medication was not administered. - On 4/9/23 the 8:00 p.m. dose was not documented as administered. There was no documentation to indicate why the medication was not administered. - On 4/10/23 the 6:30 a.m. dose was not documented as administered. There was no documentation to indicate why the medication was not administered. - On 4/12/23 for the 4:00 p.m. dose, the resident's blood sugar was 462 mg/dL. The documentation indicated the physician was not notified. - On 4/13/23 for the 8:00 p.m. dose the resident's blood sugar was 420 mg/dL. The documentation indicated the physician was not notified. During an interview on 4/17/23 at 9:00 a.m., RN 6 indicated the resident received insulin at least four times daily. He used a sliding scale. They checked blood sugars when they did that. He got Lantus at night and lispro three times daily. He had parameters on his blood sugars. Staff were to call the NP (Nurse Practitioner) if the resident's blood sugar was over 400 mg/dL. They would document that on the MAR and they could also do a progress note. He had been known to refuse. He could not locate documentation of a reason for the holes in the resident's MAR. There were no comments on the documentation. The holes in the MAR without comments would indicate that the administration was missed. If the resident refused, he would expect to see the physician was notified. The N on the MAR would indicate the physician was not notified of the blood sugar level. When it was outside the parameters the MAR should indicate yes, the physician was notified. The Blood Glucose Monitoring policy, last revised 2/2015, provided on 4/14/23 at 11:11 a.m. by the Director of Nursing, included but was not limited to, . Procedure . Residents who have a physician's order specifying the blood glucose parameters requiring physician's notification . The physician will be notified when the resident's blood glucose is outside the physician stated parameters . Blood glucose results will be documented on the Capillary Blood Glucose Monitoring Tool or in the medication administration record . 3.1-5(a)(2)

Based on observation, record review, and interview, the facility failed to ensure accurate skin assessments for residents with pressure injuries were conducted for 2 of 3 resident's reviewed for pressure ulcers. (Residents 74 and 37) 1. The clinical record for Resident 74 was reviewed on 4/12/23 at 10:00 a.m. The diagnoses included, but were not limited to, acute osteomyelitis right ankle, foot, and heel, peripheral autonomic neuropathy, muscle weakness, abnormalities of gait and mobility, folate deficiency anemia, vitamin B12 deficiency anemia, and vitamin D deficiency. The Admission Observation, dated 11/6/22 at 5:21 p.m., indicated the resident had no alterations in skin. The nurse's note, dated 11/6/22 at 6:00 p.m., indicated the resident admitted to the facility at 1:50 p.m. The only skin impairments documented were a surgical incision to the right hip, multiple healed scratches, bruises to all four extremities, and redness to the right heel. The Braden Scale for Predicting Pressure Sore Risk, dated 11/6/22, indicated the resident had no sensory impairment, was rarely moist, walked occasionally, was slightly limited in mobility, had excellent nutrition, had no apparent problem with friction and shear, and was scored as 21 points which equated to the resident not being at risk for pressure ulcers and indicated there were no interventions necessary at the time. The care plan, initiated on 11/7/22 and last revised on 4/3/23, indicated the resident was admitted with an unstageable to the right heel and a left heel calloused area that was re-identified as an unstageable pressure ulcer identified on 1/30/23. The interventions included, but were not limited to, assess for pain, assess wound weekly documenting measurements and description. The care plan, initiated on 11/7/22 and last revised on 3/1/23, indicated the resident was at risk for skin breakdown due to needing assistance with transfers and bed mobility. The interventions included, but were not limited to, assess and document skin condition weekly and as needed, notify MD (Medical Doctor) of abnormal findings. The IDT (Interdisciplinary Team) note, dated 11/7/22 at 2:25 p.m., indicated the resident had an unstageable ulcer to his right heel. The resident reported he developed the wound at the hospital. The wound observation, dated 11/7/22 at 1:03 p.m., indicated the wound to the resident's right heel measured 8 cm (centimeters) in length by 8 cm in width. The wound was 100% (percent) slough and/or eschar. The Admission MDS (Minimum Data Set) Assessment, dated 11/12/22 indicated the resident was cognitively intact, required extensive assistance of 2 staff with bed mobility and transfers, and had one unstageable pressure ulcer which was present on admission. The Weekly skin assessment, dated 11/12/22, indicated the resident's bilateral feet were warm and dry with intact skin, and he had reddened or discolored areas. The assessment indicated the resident did not have any areas of skin integrity alteration. The skin assessment indicated if the resident had an open area to assess if they had pain at the site. The documentation indicated, NA (not applicable). The Weekly skin assessment, dated 11/18/22, indicated the resident's bilateral feet were warm and dry with intact skin, and he had reddened or discolored areas. The assessment indicated the resident did not have any current areas of skin integrity alteration. The skin assessment indicated if the resident had an open area to assess if they had pain at the site. The documentation indicated, NA. The IDT note, dated 11/22/22 at 4:03 p.m., indicated the resident had a new wound/skin injury which was a callus to the left heel. The area resulted from the resident using his foot to reposition himself in the bed and his foot frequently slipped created a callus to his left heel. The new intervention would be to continue to float the resident's heels, remind him to use his bed rails to help him reposition, and treatment with betadine. The Weekly Skin assessment, dated 11/26/22, indicated the resident's bilateral feet were warm and dry with intact skin, and he had no reddened or discolored areas. Under the discolorations/rashes section, the assessment indicated the resident had an unstageable r [right] heel, callous to left heel. The skin assessment indicated if the resident had an open area to assess if they had pain at the site. The documentation indicated, NA. The Weekly Skin assessment, dated 12/3/22, indicated the resident had no current areas of skin impairment. The resident's bilateral feet were warm and dry with intact skin, and he had reddened or discolored areas. The nurse's note, dated 12/9/22 at 4:39 a.m., indicated the resident had a small open area on his coccyx with pain. He also had excoriation in the same area. Barrier cream and a dry dressing were applied. All parties were notified. The Weekly Skin assessment, dated 12/10/22, indicated the resident's bilateral feet were warm and dry with intact skin, and he had reddened or discolored areas. The clinical record lacked documentation of any new skin events or wound measurements of this area. The nurse's note, dated 12/10/22 at 4:45 a.m., indicated the resident continued with an open area to his coccyx, the unstageable to his right heel, and a thick callus to the right heel. The Weekly Wound assessment of the right heel, dated 12/23/22 at 2:11 p.m., indicated the wound measured 2 cm (centimeters) in length by 3 cm in width, with no depth and no exudate. The wound was 100% necrotic tissue. The resident was non-compliant with shoe selection and was instructed again to get diabetic shoes or backless shoes. The resident had the shoes ordered but was unsure of the arrival date. He was instructed that slipper socks were acceptable until they arrived. The IDT note, dated 12/23/22 at 2:51 p.m., indicated the resident's redness to his sacrum was healed and the treatment was discontinued. The weekly skin assessment, dated 12/23/22, indicated the resident's bilateral feet were warm and dry with intact skin, and he had reddened or discolored areas. The wound assessment of the right heel, dated 12/30/22 at 9:21 p.m., indicated the wound measured 4.5 cm in length, 3.5 cm in width, with no depth, light bloody exudate, and 100% necrotic tissue. The weekly skin assessment, dated 1/13/23, indicated indicated the resident's bilateral feet were warm and dry with intact skin, and he had no reddened or discolored areas. The skin assessment indicated if the resident had an open area to assess if they had pain at the site. The documentation indicated, NA. The weekly skin assessment, dated 1/20/23, indicated the resident's bilateral feet were warm and dry with intact skin, and he had no reddened or discolored areas. The wound assessment of the left heel, dated 1/30/23 at 4:20 p.m., indicated the wound measured 3 cm in length, 2 cm in width, and was reclassified as an unstageable pressure ulcer due to 100% necrotic tissue. During an interview on 4/10/23 at 1:20 p.m., Resident 74 indicated he had pressure ulcers to his bilateral heels. The right heel he had admitted with, the left heel had developed in the facility. He had used a heel lift pillow since admission, he could turn and reposition himself, and they used pillows to elevate his heels, his foot would slip during the night. The facility was ordering L'nard splints for him. The wounds were improving and he saw wound care. During an interview on 4/14/23 at 9:34 a.m., RN 1 indicated the resident had admitted with a pressure injury to the right foot. The left foot had started as a callous because he was pushing it into the bed to reposition himself. He was initially very reluctant to care. During an observation of wound care for Resident 74, on 4/14/23 at 10:46 a.m., RN 1 removed the resident's dressings to his bilateral heels.The left heel had an open area which was quarter sized. There was a brown eschar cap to the center of the wound which was surrounded by pink granulation tissue. The right heel was fully granulating with minimal serous drainage and no necrotic tissue. During an interview on 4/14/23 at 12:08 p.m., the DON (Director of Nursing) indicated when a resident arrived to the facility the nurse should go in and look at all of their skin. They would then put what they find in the notes or the assessment. They should document weekly skin assessments and those should reflect if they have a wound, and document any pain to the wound and what preventative measures were in place. During an interview on 4/17/23 at 12:03 p.m., RN 6 indicated he did not recall admitting the resident. He could not recall if the resident had a pressure ulcer or not. For new admissions, he did his best to go from head to toe. He did physically look at their skin from head to toe. He would document any impairments in the progress notes. They didn't put it on the admission observations. It was just something he missed. He indicated he would mark, the admission assessment as no for impairments even if they had impairments because it would throw off the system, so he would document it in the progress notes. On the admission progress note if it was unstageable it would say the unstageable was present with the estimated size. The wound nurse would follow up on the nursing note. He did do weekly skin assessments. If a resident had an open area he would indicate it on the weekly skin assessments. He would document any pain and he would document the resident had bilateral heel unstageable ulcers. During an interview on 4/17/23 at 12:12 p.m., RN 1 indicated nurses did the initial skin assessment. It's supposed to be documented under the initial observation, but sometimes they put it in a note. If they marked it as no they needed to put a note in. He would have like to have seen more on his note or observation. The impairments should be on assessment the skin assessment. He would never have told someone to mark it as no. On the weekly skin impairments they should mark old impairments. During an interview on 4/17/23 at 12:22 p.m., the DON indicated they had not ever informed nursing staff to not accurately complete the admission observation and it should reflect open areas. She wanted nurses to document that an area was there, and she would not expect them to stage it but she would like measurements. She felt the nurses lacked confidence documenting it and indicated they might be afraid to mess it up. 35732 2. The clinical record for Resident 37 was reviewed on 4/12/23 at 10:12 a.m. The diagnoses included, but were not limited to, sepsis, urinary tract infection, type 2 diabetes mellitus with hypoglycemia without coma, dementia, and reduced mobility. The Admission MDS assessment, dated 2/8/23, indicated the resident was severely cognitively impaired. The physician orders, dated 4/11/23, indicated encourage the resident to turn and reposition q (every) 2 hours and gently cleanse the open area on the coccyx, pat dry and place an Opti foam dressing over the open area of the coccyx. The care plan, dated 4/11/23, indicated Resident 37 had impaired skin integrity due to risks that included slightly impaired sensory perception with the risk for friction or sheering, occasional moist skin, needs assistance with significant position changes, and chair fast status. Interventions included but were not limited to assess the wound weekly and document measurements and description. The wound care note, dated 4/11/23 at 1:09 p.m., indicated, the resident had a wound to the left second toe, which measured 0.4 cm in length by 0.2 cm in width. The resident also had a stage 2 pressure ulcer to the coccyx measuring 0.4 cm in length and width. The IDT note, dated 4/11/23 at 12:54 p.m., indicated the resident had 2 new areas the skin. One was a small skin tear to the left second toe, and stage 2 pressure area to the coccyx. The Weekly Skin assessment, dated 4/11/23 at 6:47 p.m., indicated the resident had no open areas of skin impairment. During an interview on 4/14/23 at 9:00 a.m., RN 1 indicated prevention included turn and reposition every 2 hours and as needed, float heels, weekly skin assessments, low air loss mattress, treatment as ordered by the physician, a cushion in her wheelchair, and monitor for worsening or signs and symptoms of infection. During an interview on 4/14/23 at 11:37 a.m., LPN (Licensed Practical Nurse) 2 indicated the residents had a weekly skin assessment. She would do a head-to-toe assessment for any skin impairments. Whatever impairment was observed she would document it in the observation section of the clinical record. If the nurse was doing the weekly skin assessment and looking at her resident, and there was a pressure wound, she would document in the weekly skin assessment section that the resident had a wound. During an interview on 4/14/23 at 12:20 p.m., the DON indicated when a skin impairment was observed, such as a pressure wound the nurse, would open a new skin event, inform the IDT team, wound management, family and the doctor. The skin impairment should have been added to the resident's weekly assessment when the nurse did the assessment. The skin impairment would be documented on the weekly skin assessment until the wound was healed. The Skin Management Program policy, dated 3/2010 and last revised on 5/2022, provided on 4/14/23 at 11:11 a.m., by the Executive Director, included, but was not limited to, . 1. All residents will be assessed at admission using a skin risk (Braden) assessment to determine risk for pressure ulcer/injury with initiation of a plan of care. 2. The admission skin assessment will include but not limited to: Head-to-toe skin assessment . Skin alterations present on admission, skin discoloration and any evidence of scarring on pressure points . 6. Any skin alteration noted by direct care givers during daily care and or shower days must be reported to the licensed nurse for further assessment, to include but not limited to bruises, open areas, redness, skin tears, blisters, and rashes. The licensed nurse is responsible for assessing all skin alterations by the direst caregivers on the shift reported . Facility skin sweeps (head-to-toe assessments) are conducted monthly to assess all residents' current skin condition and to ensure appropriate preventative measures are in place . 3. All alterations in skin integrity will be documented on the admission observation in the medical record on the admission observation (new admitted and readmitted residents). 4. All newly identified areas after admission will be documented on the New Skin Event . 3.1-40(a)(1)

Based on observation and interview, the facility failed to ensure employees provided meal service in a safe and sanitary manner for handling of food while serving meals in the Cottage Unit Dining Room for 1 of 4 staff observed. (CNA 4) Findings include: During the lunch meal service in the Cottage Unit Dining Room on 4/10/23 at 11:20 a.m., CNA (Certified Nurse Aide) 4 was delivering a meal to Resident 36. She picked up the top bun for the fish sandwich with her bare hands and added tartar sauce. She placed the bun on top of the fish with her bare hand, mashing down on the bun with her palm. During the lunch meal service in the Cottage Unit Dining Room on 4/10/23 at 11:30 a.m., CNA 4 delivered a meal to Resident 53. She picked up the top bun of the fish sandwich with her bare hand, laying it in the plate. She applied the tartar sauce to the fish and placed the bun on top of the fish, using her bare hand. During an interview on 4/13/23 at 1:26 p.m., CNA 4 indicated she would perform hand washing prior to the provision of meal trays. She would also apply hand sanitizer between resident's trays. She should not touch the food with her hands and would use utensils for the bread products. During an interview on 4/13/23 at 1:32 p.m., the DON indicated the staff should not touch the food with their hands. The General Food Preparation and Handling policy, revised on October 2022, was provided by the DON on 4/13/23 at 2:10 p.m. The policy included, but was not limited to, . 3). Bare hands should never touch raw or ready to eat food directly. Food will be prepared and served with clean tongs, scoops, forks, spoons, spatulas, or other suitable implements to avoid bare hand contact of foods . 3.1-21(i)(3)

Based on interview and record review, the facility failed to ensure staff provide an accurate and complete assessment for a resident's (Resident C) change in condition to the nurse practitioner, for 1 of 3 residents reviewed for quality of care. Findings include: The clinical record for Resident C was reviewed on 8/5/22 at 4:21 p.m. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The vital signs record for the resident indicated the following blood pressure (B/P) and heart rate (HR): - On 4/26/22 at 9:33 a.m. - B/P - 121/74 and HR - 76 - On 5/10/22 at 9:57 a.m. - B/P - 134/71 and HR - 71 - On 5/24/22 at 9:21 a.m. - B/P - 128/79 and HR - 71 - On 7/07/22 at 9:21 a.m. - B/P - 132/81 and HR - 77 The progress note, dated 7/16/22 at 12:41 a.m., indicated the staff had assisted the resident to the bathroom, she became dizzy, and the resident fell on to the bed due to weakness. Her blood pressure was 89/71 and her heart rate was 110. NP (Nurse Practitioner) 6 was notified with a new order to monitor for weakness. The progress note, dated 7/16/22 at 11:50 p.m., indicated the resident's B/P was 75/51, heart rate 103, oxygen saturation was 90%, the resident was very weak, and her lung sounds were diminished. NP 6 was notified and gave orders to send the resident to the hospital. The clinical record lacked documentation of an assessment of the resident's blood pressure or heart rate between 7/16/22 at 12:41 a.m. and 7/16/22 at 11:50 p.m. During an interview on 8/8/22 at 10:23 p.m., LPN 5 indicated when she notified NP 6 of the resident's change of condition, the only order given was to monitor for weakness. During an interview on 8/8/22 at 3:28 p.m., NP 6 indicated she had received a call on 7/16/22 at 12:41 a.m. related to Resident C, however, she felt the vital sign information was not provided. That the resident with a blood pressure that low was not normal. If the resident's low blood pressure was communicated to her, she would have treated the low blood pressure and obtained stat labs. On 8/8/22 at 4:16 p.m., the Executive Director provided a current copy of the document titled Resident Change of Condition Policy dated 11/2018. It included, but was not limited to, Policy .It is the policy of this facility that all changes in resident condition will be communicated to the physician .Any sudden or serious change in a resident's condition manifested by a marked change in physical .behavior will be communicated to the physician .All symptoms and unusual signs will be documented .and communicated to the attending physician promptly This Federal tag relates to Complaint IN 639 3.1-37

Based on interview and record review, the facility failed to ensure the physician was notified of a resident's first [CONDITION(S)] like episode for 1 of 2 residents reviewed for physician notification. (Resident 65) Findings include: The clinical record for Resident 65 was reviewed on 5/5/22 at 9:30 a.m. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission MDS assessment, dated 4/6/22, indicated the resident was moderately cognitively impaired. The care plan, dated 4/1/22 and revised on 4/15/22, indicated the resident had impaired gas exchange. The interventions included, but were not limited to, administer medications as ordered, assess vital signs, and lung sounds as needed, elevate the head of bed as needed, encourage diversional activities, monitor oxygen saturations rates as needed and as ordered and notify the physician of respiratory distress. The nurse's note, dated 3/27/22 at 2:30 p.m., indicated the resident had a [CONDITION(S)] like episode while he was in bed. The activity lasted 2 minutes. The resident's lips turned blue, he was short of breath and vomited 90 ml (milliliters). The resident came back to normal within a few minutes. The nurse's note, dated 3/27/22 at 3:50 p.m., the resident had another [CONDITION(S)] like episode. However, the resident never came back to his baseline of alert and oriented times 4. He exhibited total confusion. The fire department arrived at 4:05 p.m., followed by the EMS (Emergency Medical Services) at 4:20 p.m. The nurse explained the resident's base line to the fire department and EMS. Both departments stated the resident was no where close to his baseline. The clinical record lacked documentation the physician was notified, an assessment was completed, and vital signs were taken when the resident had the change in condition ([CONDITION(S)] like episode). During an interview, on 5/10/22, at 9:30 a.m., LPN 3 indicated when the resident had a change in condition the doctor should have been called immediately. During an interview, on 5/10/22, at 9:45 a.m., the DNS indicated the resident had no history of seizures. After the first episode he returned to his baseline. After the second episode of [CONDITION(S)] like activity the resident did not return to his baseline and was sent to the hospital. The doctor should have been called when the resident had a change in condition the first time. Staff monitored for further changes. When a resident had a change in condition there should be a full assessment with vitals documented in the clinical record. The Resident Change of Condition policy, effective date 8/1998 and revised on 11/2018, was provided on 5/8/22 by the Director of Nursing Services, and included, but was not limited to, .a. Any sudden or serious change is a resident's condition manifested by a marked change in physical or mental behavior will be communicated to the physician. b. If unable to contact the attending physician or alternative physician in a timely manner, notify the Medical Director for medical intervention. c. The responsible party will be notified that there has been a change in the resident's condition and what steps are being taken. d. All nursing actions/interventions will be documented in the medical record as soon as possible after resident needs have been met . 3.1-5(a)(2) 3.1-5(a)(3)

Based on record review and interview, the facility failed to ensure further attempts to reschedule the orthopedic appointment, address the resident's refusal, and monitor arrangements for a resident's post operative surgical site and infection for 1 of 2 residents reviewed for Quality of Care. (Resident 57) Findings include: The clinical record for Resident 57 was reviewed on 5/5/22 at 10:00 a.m. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The care plan, dated 1/7/22 and last revised on 5/5/22, indicated the resident was status post [MEDICAL RECORD OR PHYSICIAN ORDER] . The goal indicated the resident's fracture would heal without complication. The interventions included, but were not limited to, administer medications as ordered, assess for pain, assist resident with transfers as needed, call light within reach, encourage physical activity as tolerated, follow-up orthopedic surgeon as directed, keep room and pathways free of clutter, right hip fracture repair, and therapy screen quarterly and as needed. The nurse practitioner's note, dated 12/28/21 at 10:51 a.m., indicated the resident was seen for reports of right hip pain. The resident denied a specific fall or injury to the hip, but was walking in her room prior to the pain and felt like her leg gave out. The NP (Nurse Practitioner) ordered a right hip complete view x-ray. The nurse's note, dated 12/28/21 at 9:04 p.m., indicated the resident was transported to the local hospital due to an abnormal right hip x-ray. The nurse's note, dated 12/29/21 at 2:06 a.m., indicated the resident was admitted to the hospital with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] The nurse's note, dated 1/5/22 at 1:54 a.m., indicated the resident was back in the facility with a wound vac to the right hip for 7 days with a start date of 12/31/21. The nurse's note, dated 1/5/22 at 1:59 a.m., indicated on the resident's discharge instructions, the resident was to follow-up with the orthopedic surgeon in 3 to 4 weeks. The wound detail, dated 1/24/22, indicated the resident's incision to her right hip had been healed with the sutures removed and no signs of infection. The nurse's note, dated 1/28/22 at 11:37 a.m., indicated the resident refused to go to her orthopedic surgeon follow-up appointment due to not having stretcher transport. The appointment was canceled and they would attempt to reschedule at a later time after transport needs were determined. The resident did not qualify for stretcher transport at that time. The clinical record lacked documentation of any further attempts to reschedule the orthopedic appointment. The NP's note, dated 4/18/22 at 9:23 a.m., indicated the resident was seen for evaluation of an area to the right hip. The patient had a previous right hip replacement due to hip fracture. Her skin to the hip was warm and red, new orders were given for the resident to take [MEDICATION(S)]. The nurse's note, dated 4/20/22 at 10:19 a.m., indicated the resident's right hip was firm, warm to the touch, with an open area observed with yellow drainage. The NP's note, dated 4/20/22 at 11:02 a.m., indicated the resident's assessment was [CONDITION(S)] of the right hip. The resident had an open area which had formed with purulent drainage coming from the area. The wound assessment, dated 4/20/22 at 12:05 p.m., indicated the resident had an incision with an open area to the right hip measuring 1 cm (centimeters) in length by 1 cm in width. The skin surrounding the area was red and warm. The incision drainage was seropurulent (yellow or tan, cloudy and thick), and it was a small open area with drainage along the surgical incision related to [CONDITION(S)]. A new treatment to cleanse with wound cleanser, pat dry, cover with a dry dressing and add calcium alginate. The nurse's note, dated 4/20/22 at 1:27 p.m., indicated the NP gave an order to send the resident to the hospital for evaluation. The hospital discharge summary, dated 4/20/22, indicated the resident was treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . The ER (emergency room ) diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The nurse's note, dated 5/5/22 at 11:00 a.m., indicated the facility received a call form the resident's orthopedic surgeon. She was admitted to the hospital for hip surgery the following day. The orthopedic surgeon's report, dated 5/5/22, indicated the resident was seen for her first post operative appointment. She went to the facility post operatively and had not been seen since. The resident had right hip pain, purulent drainage, malaise, was unable to walk, and brought in on a stretcher. The resident would be transferred to the hospital for planned irrigation and debridement of the right hip, deep hardware removal and revision to the right hip antibiotic eluting cement space and would require a long course of IV (intravenous) antibiotics. During an interview, on 5/9/22 at 10:52 a.m., LPN (Licensed Practical Nurse) 4 indicated the resident was in the hospital. She was aware the resident had refused to go to her orthopedic follow-up, but she was not sure if there were any further attempts made to arrange the appointment. The management team would have been responsible for that. If a resident refused an appointment, they should try to re-educate and reschedule the appointment, because it was important for them to go to follow-up appointments. During an interview, on 5/9/22 at 1:39 p.m., the DNS (Director of Nursing Services) indicated she went back and talked to the ADNS (Assistant Director of Nursing Services) and the resident had not wanted to go to the appointment until she had the change. When her wound reopened that was when the facility told her she really needed to go to see her orthopedic surgeon. They did not document any further attempts after the initial refusal by the resident. The ADNS had indicated he'd talked to the resident at times, but unfortunately he didn't document it. When the resident went to her new appointment on 5/5/22, the orthopedic surgeon felt she needed to be admitted for incision and drainage because she had an abscess. During an interview, on 5/9/22 at 2:25 p.m., the DNS indicated the physician's report was not accurate. The resident's hip incision had resolved in January, and did not reopen again until April. During an interview, on 5/10/22 at 10:01 a.m., the DNS indicated she could not find any further appointments for the resident. They did not have a policy, but if a resident refused to go to an appointment they should attempt to reschedule the appointment and talk to the resident. 3.1-37

Based on observation, interview, and record review, the facility failed to ensure resident to resident sexual abuse did not occur when two residents (Resident B and C), without the capacity to consent, were found engaged in a sexual act for 2 of 4 residents reviewed for abuse. Findings include: 1. The clinical record for Resident B was reviewed on 3/3/21 at 12:38 p.m. [DIAGNOSES REDACTED]. The quarterly MDS (Minimum Data Set) assessment, dated 1/22/21, indicated the resident's cognition was severely impaired. The care plan, dated 2/2/21, indicated the resident seeked female companionship as expressed by wanting to hold hands with female peers. Interventions included to offer the resident a drink/snack and to redirect resident to the common area. The incident report, dated 2/27/21 at 7:01 p.m., indicated CNA (Certified Nursing Aide) 5 found Resident B laying in his bed with his pants down and Resident C laying toward the end of the bed engaged in a sexual act. The nurse's note, dated 1/29/21 at 6:09 p.m., indicated the resident was observed with increased sexual behaviors, the nurse practitioner was notified, and a new order received for a [MEDICATION NAME] Patch ([MEDICATION NAME] used for aggressive behavior in men with advanced dementia) 0.025 mg (milligrams)/24 hour, [MEDICATION NAME] (topical) every week on Tuesday. The nurse's note, dated 1/31/21 at 6:02 p.m., indicated the resident continued to follow a female resident and was redirected numerous times. The nurse's note, dated 1/31/21 at 11:25 p.m., indicated the resident would stop and talk with female residents and follow them to their rooms. He was easily redirected. The nurse's note, dated 2/1/21 at 3:23 p.m., indicated the resident continued to follow a female resident up and down the hallway and was redirected by staff several times throughout the shift. The nurse's note, dated 2/4/21 at 7:21 p.m., indicated the resident continued to follow a female resident down the hallway. During an interview on 3/3/21 at 1:10 p.m., Staff Member 4 indicated the resident followed all of the female residents around, but he mostly followed Resident C. During an interview on 3/3/21 at 2:16 p.m., Staff Member 5 indicated after dinner on 2/27/21, she had taken a resident to change him because he had food on his clothes. The nurse asked her where Resident B was. She went to look for her and got to Resident B's room and the curtain was pulled. She heard something, looked around the curtain and found Resident B laying on his back with his pants down. Resident C was wearing nothing except her pull-up, which was down to her knees. She had her mouth on his penis. She went to separate them and Resident C told the staff member to leave them alone and he was her husband. When Resident B saw her, he pushed Resident C off and pulled up his pants. During an interview on 3/3/21 at 2:35 p.m., Staff Member 6 indicated over the past couple of months, they noticed Resident B would try to coach female residents into his room. That was why they always keep someone in the hallway. He has gotten females in his room and they have always caught them and redirected them out of his room. 2. The clinical record for Resident C was reviewed on 3/3/21 at 12:58 p.m. [DIAGNOSES REDACTED]. The quarterly MDS assessment, dated 3/1/21, indicated the resident's cognition was severely impaired and she had wandering behavior. The incident report, dated 2/27/21 at 7:01 p.m., indicated CNA 5 found Resident C engaged in a sexual act with Resident B in his room. The psychosocial well-being care plan, dated 1/6/21, indicated the resident desired male companionship expressed by wanting to hold male peers hand. Interventions included to offer the resident a snack/drink of choice and to redirect the resident to an activity of interest. On 3/3/21 at 4:10 p.m., the Social Services Director provided a current copy of the document titled Abuse Prohibition, Reporting, and Investigation dated February 2020. It included, but was not limited to, Policy .It is the policy of .to provide each resident with an environment that is free from abuse .This includes but is not limited to .sexual abuse .Will not permit residents to be subjected to abuse by anyone, including .other residents This Federal tag relates to Complaint IN 545 3.1-27(a)(1)

Based on observation and interview, the facility failed to ensure infection control practices were followed during the COVID-19 pandemic related to the use of Personal Protective Equipment during resident care. (Residents G, H, and J) Findings include: During an interview on 11/12/20 at 10:21 a.m., Resident B indicated there were a few nurses and aides who did not wear masks or face shields. During observations on 11/12/20 from 10:46 a.m. through 11:10 a.m., CNA (Certified Nursing Aide) 4 walked down the 100 Hallway with her mask below her nose. She applied a gown and entered Resident G's room to answer a call light. The resident was overheard asking for briefs. CNA 4 left the room and applied a gown and entered Residents H and J's room to answer a call light. Her mask was observed below her nose. As she left the room, her mask was observed to still be below her nose. The CNA then entered the elevator to go to the 2nd floor. The CNA returned to the 100 Hallway with a cart of briefs. She adjusted her mask grasping it by the mouth area. She applied a gown and entered the room of Resident G with a package of briefs. Her mask was below her nose as she entered and left the room. As she left the room the CNA readjusted her mask by grasping it by the mouth area. During an interview on 11/12/20 at 11:10 a.m., CNA 4 indicated she was just adjusting her mask because it was hitting her eyes. During an interview on 11/12/20 at 11:32 a.m., the Director of Nursing indicated masks should be worn to cover the staff's nose and mouth. The mask should not be adjusted at the front of the mask, it should be adjusted at the straps on the ears. The review on 11/12/20 at 12:10 p.m., of the COVID-19 Resident Policy, revised last on 10/26/20, indicated .Source Control: Use of a cloth face covering or facemask to cover a person's mouth and nose to prevent spread of respiratory secretions when they are talking, sneezing, or coughing .13. Staff and healthcare workers should strictly follow basic infection control practices between residents including .respiratory etiquette . 3.1-18(k)(1)

Based on interview and record review, the facility failed to ensure adequate supervision was in place when a cognitively impaired resident (Resident B) with dementia and a wanderguard in place exited the facility on 7/7/19 at 11:45 a.m., without supervision through the A-hall fire exit door. The fire exit door alarm sounded for 4 minutes prior to a housekeeping staff member resetting the door alarm to turn it off without looking outside the door to ensure a resident did not exit the facility for 1 of 3 residents reviewed for accident hazards. This deficient practice resulted in an Immediate Jeopardy. The Immediate Jeopardy began on 7/7/19 at 11:45 a.m. when a cognitively impaired resident with dementia and with a wanderguard in place exited the facility through the A-hall fire exit door, without supervision. The fire exit door alarm sounded for 4 minutes prior to a housekeeping staff member resetting the door alarm to turn it off without looking outside to ensure a resident did not exit the facility. The Health Facility Administrator, Interim Director of Nursing, and Director of Nursing Services Specialist were notified of the Immediate Jeopardy on 7/24/19 at 4:16 p.m. Findings include: The incident report, dated 7/7/19 at 11:45 a.m., indicated the resident was found outside by a staff member. The resident was redirected into the building and believed to have been outside for 15 minutes. The temperature outside was 89.6 degrees Fahrenheit on 7/7/19 at 11:45 a.m. The clinical record for Resident B was reviewed on 7/24/19 at 10:52 a.m. The resident's [DIAGNOSES REDACTED]. The care plan, dated 7/1/19, indicated the resident was at risk for elopement due to wandering aimlessly near exit doors with interventions of all facility exits secured and a wanderguard in place, per physician order. The progress note, dated 6/25/19 at 11:58 a.m., indicated a relocation meeting was held with Resident B's family and discussed the resident's decreased participation in activities on the dementia unit. The resident was relocated from the locked unit to the A-hall. The progress note, dated 7/1/19 at 11:46 a.m., indicated the resident had been ambulating up and down the hallway towards the back exit (A-hall fire exit door) door. The resident was non-verbal and unable to communicate his intentions. The resident was a recent transition from the dementia unit with severely impaired cognition. On 7/1/19, a wanderguard was placed to the left ankle of the resident and he was placed on staff member 15 minute checks. The Safety Check List, dated 7/4/19 through 7/7/19, was reviewed on 7/24/19 at 11:00 a.m. The 15 minute check box was left blank on 7/6/19 at 6:45 p.m. The 15 minute check boxes lacked a nurse signature from 7/6/19 at 7:15 a.m. through 7/6/19 at 6:30 p.m. and the handwritten marks, dated 7/7/19 at 7:00 a.m. to 7:45 a.m., lacked a nurse signature. The 19 check marks on the sheet, that were hand written on the left margin, dated 7/7/19 after 7:45 a.m., lacked a time note and nurse signature. During an interview on 7/24/19 at 11:40 a.m., Wellness Assistant 4 indicated on 7/7/19, around lunch time, she saw the resident outside in the side visitor parking lot. She went out the back therapy door, next to the parking lot, and the resident was standing by a car with his hand inside the window. The resident was redirected back in the building through the front doors. During an interview on 7/24/19 at 11:45 a.m., the Administrator indicated the resident exited the facility at the end of A-Hall. The resident pushed on the door for 15 seconds at which time the door opened due to the fire release. The alarm sounded for 4 minutes at which time a housekeeping staff member turned off the alarm, but did not go outside and look to see why the door alarmed. The aides were in other resident rooms providing care at the time the alarm was sounding and were not sure where the nurse was. The resident was outside for approximately 13 minutes before another staff member found the resident and brought him back into the building. During an interview on 7/24/19 at 3:19 p.m., Housekeeping Staff 5 indicated she turned off the alarm to the A-hall fire door exit but did not go out the door due to her not being able to get back in. On 7/25/19 at 9:30 a.m., the A-hall exit fire door was observed to exit into a breezeway with stairs to the right that led to the second floor and an exit unlocked door that lead outside the building. Once outside there was an 8 foot sidewalk with a decline which lead to the sidewalk located next to the back parking lot. To the far right end of the back parking lot was a 3 foot pathway that led to a neighborhood. To the left, the sidewalk extended 20 to 30 feet then veered left and extended down another 20 to 30 feet towards the exit door to the therapy gym door and around the building to the front entrance. There was a 6 foot privacy fence around the courtyard next to the sidewalk which extended from the A-hall fire exit door around to the left side of the therapy exit door. There were clear glass windows showing the metal stairs leading to the second floor in the breezeway and there were no other visible windows on the side of the building the resident walked out. During a second interview on 7/25/19 at 2:22 p.m. in the therapy office, Wellness Assistant 4 indicated she was sitting at her desk when she looked out the therapy gym door and saw Resident B standing next to a car, which was about 9 parking spaces down from the building. She picked up her purse, put in the door code and exited the facility with the resident in sight. She and the resident stood by the car for several minutes while she attempted to redirect him. She told the resident it was lunch time, at which time she was able to redirect him back into the building. Due to the resident's slow gait, it took about 6 to 7 minutes to get him back in the building. She escorted the resident into the main dining room and went to report the incident to the A-hall nurse. The back parking located outside the A-hall fire exit door could not be observed from the therapy gym due to the privacy fence. On 7/24/19 at 1:25 p.m., the Administrator provided a current copy of the document titled Elopement Prevention and Response Program dated (MONTH) (YEAR). It included, but was not limited to, Policy .It is the policy of the facility that staff who have residents under their care are responsible for knowing the location of those residents The Immediate Jeopardy that began on 7/7/19 at 11:45 a.m. was removed on 7/25/19 when the facility completed staff education on elopement procedures and door alarm response, test operations of doors/alarms, and elopement drills with staff response. The Immediate Jeopardy was removed on 7/25/19, but noncompliance remained at the lower scope and severity of isolated, no actual harm with potential for more than minimal harm that is not immediate jeopardy because not all staff had been educated elopement drills with staff response. This Federal tag relates to Complaint IN 372 3.1-45(a)(2)

Based on observation, interview, and record review, the facility failed to ensure residents at risk to experience falls received adequate supervision to prevent falls and effective interventions were implemented to prevent injury for 3 of 3 residents who met the criteria for review of accidents in a sample of 8 residents reviewed. This deficient practice resulted in Resident D experiencing a jaw fracture. (Resident D, Resident R, Resident J) Findings include: 1. On 6/6/16 at 3:10 P.M., Resident D was observed laying in her bed in no apparent distress. Resident D was observed at that time to have blue and black bruising present around her left eye and forehead and jawline. A mattress was observed to be placed on the floor near Resident D's bedside. The clinical record for Resident D was reviewed on 6/6/16 at 10:00 A.M., the [DIAGNOSES REDACTED]. A significant change MDS (Minimum Data Set) assessment dated [DATE], indicated Resident D had a BIMS (Brief Interview for Mental Status) score of 3 indicating she was severely cognitively impaired. The MDS further indicated Resident D required extensive assist of 2 for toileting, transfers, and bed mobility. The care plans included, but were not limited to, Resident is at risk for fall due to impaired mobility and cognition, complicated by use of an assistive device, incontinence, recent fall(s), and high risk medication. initiated 9/24/14. The interventions included, but were not limited to, .15 min checks (6/6/16), move room closer to nurses station (6/3/16), Roho overlay (A pressure reliving device) on bed, with 1/2 side rails on open side of bed to stabilize matress (sic) (5/27/16), matt on the floor beside the bed (3/14/16), place bed along wall, in low locked position (9/14/15), dysem (an anti-slip device) material to wheel chair (2/23/15) . Fall #1 A fall event report indicated Resident D had experienced an unwitnessed fall from her bed on 5/27/16. The report further indicated Resident D had hit her head and had experienced a left black eye and gash to the left side of her forehead. A Nursing note dated 5/27/16 at 12:54 A.M., included, but was not limited to, While CNA was doing her hourly round found resident on fall mat on her left side of body. Resident had hit left side of head on bedside dresser, with a large amount of bright red blood on resident's clothing and coming from a gash to left side of forehead. Resident also had bruise forming to left eye, black, and blue in color. Resident's bed was against the wall and in lowest position. Resident had night gown on, PJ (pajama) pants, geri sleeves to BUE (bilateral upper extremities, and gripper socks on. Call light was within reach .Resident's pupils were sluggish but reactive. Resident is alert and oriented to person only but could answer simple yes and no questions appropriately . A Nursing note dated 5/27/16 at 9:10 A.M., included, but was not limited to, This nurse has placed resident on neuros .Resident placed on 15 minute checks, resident room rearranged with no furniture around bed . An IDT (interdisciplinary team) fall note dated 5/27/16 at 3:01 P.M., included, but was not limited to, Res (Resident) was noted to .have an un-witnessed fall on 5/27 at 12:37 am (sic). While staff was completing hourly checks, res was found on mat beside bed Res was found lying on left side .Head adjacent to bedside table, Wedge on mat .Res has dementia w (with)/sever (sic) cognitive loss, unable to state details of fall. immediate (sic) intervention Res remained immobile until 911 responded .Root Cause Res: has dementia w (with)/sever (sic) congnitive (sic) impairment, current tx (treatment) for UTI (Urinary Tract Infection), and believe she was unable to feel her bed boundry (sic) and rolled to far towards edge and was unable to prevent rolling of edge of bed on to Mat .new intervention to DC (discontinue) wedge cushion and hourly checks, replace mattress with scoop matress (sic) w/roho overlay and 1/2 side rail to open side of bed to stabilize mattress. Careplan (sic) and profile updated. An Emergency Department referral dated 5/27/16 included, but was not limited to, the following: Arrival Time 5/27/16 at 00:58 (12:58 A.M.) .[DIAGNOSES REDACTED]. Fall #2 A fall event report indicated Resident D had experienced an unwitnessed fall on 6/4/16 at 8:21 P.M. in her room. The fall report included, but was not limited to the following, .Describe what the resident was doing prior to the fall .Sitting in her wheelchair in her room. CNA was getting ready to lay her down .Describe the position of the resident when first observed after fall .Res was on her right side on the floor. Resident had fallen into floor mat that was propped against the dresser .Resident of witness statement of how fall occurred .CNA had pushed resident in room to lay her down for the night. CNA went to gather supplies to clean resident up, resident was found in floor by another CNA passing by her room .What intervention was put into place to prevent another fall .Placed in bed, Bed rail up, fall mat in place, non-skid seat on w/c (wheel chair) . A nurses note dated 6/4/16 at 11:52 P.M., included, but was not limited to, This nurse was called into resident's room. CNA had found resident on the floor. CNA had pushed resident into her room and went to gather supplies to clean resident up. CNA went to answer another residents cal (call). While resident (sic) was gone, another aid (sic) walked by and found resident on the floor .15 min checks .in place . An IDT note for this fall could not be provided. Unit Manager (UM) #10 was interviewed on 6/7/16 at 10:30 A.M. She indicated Resident D had experienced two falls since 5/27/16. UM #10 indicated Fall #1 was an unwitnessed fall that occurred on 5/27/16 at 12:34 A.M. She indicated Resident D had fallen out of bed and hit her head on her bedside table that was located at her bedside above the fall mat that had been placed as an intervention to prevent Resident D from experiencing injuries if she were to fall out of bed. UM #10 indicated Resident D had experienced a laceration to the left side of her forehead that required stitches and a broken left jaw. UM #10 indicated Resident D was sent to the hospital and received 5 stitches to a laceration and x rays that confirmed a fracture of her left jaw. She indicated the intervention added was a side rail to stabilize the roho mattress overlay on Resident D's bed and her nightstand was moved away from her bed. UM #10 indicated fall #2 occurred on 6/4/16 at 8:25 P.M. She indicated Resident D was pushed into her room by a CNA who what going to assist her into bed. She indicated the CNA left the room and another CNA who was passing observed Resident D lying on the floor with the top half of her body positioned on a fall mat that was propped against the dresser. UM #10 further indicated Resident D had no injuries as a result of Fall #2 and the immediate intervention was to place Resident D in bed. 2. On 6/6/16 at 10:00 A.M., Resident R was observed ambulating independently in the hallway of the dementia care unit with an unsteady gait. The clinical record of Resident R was reviewed on 6/7/16 at 9:45 A.M. The record indicated Resident R was admitted to the dementia care unit on 5/17/16 with [DIAGNOSES REDACTED]. The Admission MDS (Minimum Data Set) assessment dated [DATE] indicated Resident R experienced severe cognitive impairment, inattention, disorganized thinking, and altered level of consciousness. A CNA Point of Care History indicated Resident R required the limited physical assistance of one staff for transfers between 5/17/16 and 6/7/16. The June 2016 Physician order [REDACTED].Start Date .5/18/16 .Activity Level: Up Ad Lib (at liberty) . An Admission Nursing assessment dated [DATE] indicated Resident R experienced cognitive impairment, unsteady balance and had a history of [REDACTED].able to stabilize without human assistance . A Care Plan dated 5/20/16 for, .at risk for fall . indicated safety interventions of, Call light in reach, Environmental changes: bed aligned along the wall for open floor space, Non skid (sic) footwear (sic) all times, Personal items in reach, Therapy Screen An Occupational Plan of Care dated 5/18/16 indicated, .Precautions: Fall risk .Functional Deficits .Balance .unable to accept challenge or move without loss of balance .unable to maintain balance without mod (moderate)/max (maximum) support . Fall #1: A Fall Event report dated 5/22/16 at 4:10 A.M. indicated Resident R experienced an unwitnessed fall from bed. The report further indicated immediate interventions implemented after the fall were, Frequent checks for proper positioning while resident abed (in bed) and request further review by unit mgr (manager)/NP (Nurse Practitioner) r/t (related to) meds (medicines) r/t lethargic state. A Nursing note dated 5/22/16 at 7:00 A.M. indicated, This nurse was called to residents (sic) room by the nursing assistant to assist with resident on the floor was fully dressed (sic) shoes on (sic) lying on .left side .speech is mumbled which made for poor communication .was assisted to .bed (sic) assessment was done. Red/purple in color and swelling to the right eye, pupils were non reactive (sic) he was lathargic (sic) the right hand red with swelling. NP was called to send resident to U of L. The note lacked any documentation to indicate adequate supervision was provided or new, immediate, effective interventions were implemented to ensure the safety of Resident R. A Nursing note dated 5/23/16 at 12:51 P.M. indicated, IDT (Interdisciplinary Team) review of fall .Resident had a (sic) unwitnessed fall on 5/22/16 at 4:10 am (A.M.) Prior to the fall the resident was sleeping in .bed. Resident was found in .room lying on .left side .was fully dressed with shoes on. A full body assessment was completed .had bilateral weak hand grasp .did hit .head on the right side around eye and eyebrow was red/purple in color .right hand was red and swollen .is on anticoagulant, is not a diabetic and does not have a history of orthostatic hypotension was continent at the time of fall .Root Cause: (sic) New Intervention .was lethargic R/T (related to) medications and new surroundings. Have psychiatrist review medication and therapy to evaluate The note lacked any documentation to indicate adequate supervision was provided or new, immediate, effective interventions were implemented to ensure the safety of Resident R. Fall #2: A Fall Event Report dated 5/23/16 at 10:34 P.M. indicated Resident R experienced an unwitnessed fall from bed. The report further indicated the immediate interventions implemented after the fall were, Frequent checks for proper positioning while resident abed and request further review by unit mgr/NP r/t meds r/t lethargic state. The note lacked any documentation to indicate adequate supervision was provided or new, immediate, effective interventions were implemented to ensure the safety of Resident R. A Nursing note dated 5/23/16 at 10:36 P.M. indicated, Res (resident) was found on floor in room, unwitnessed fall. Res was unable to give statement of incident or event .placed on neuro (neurologic) checks. Redness noted to left cheek area .was assisted to standing position and placed in bed. Will continue to monitor. The note lacked any documentation to indicate adequate supervision was provided or new, immediate, effective interventions were implemented to ensure the safety of Resident R. A Therapy assessment dated [DATE] at 10:56 A.M. indicated Resident R experienced poor balance and required assistance with transfers and walking. A Nursing note dated 5/24/16 at 4:47 P.M. indicated, IDT fall review .Resident had an unwitnessed fall on 5/23/16 at 10:34 pm (P.M.) .Prior to fall resident was lying in bed. Staff entered room and resident was on floor lying on left side .was wearing shirt, jeans and socks .Redness noted to side of face. After assessment resident was assisted up per two assist. Assisted resident to change into bed clothes. Root cause: It appeared resident was uncomfortable with jeans on and was getting up to take them Off. Current interventions.: Psych (Psychiatrist) to review meds. Therapy to screen bed mobility and functional transfer. Call light in reach. Bed along wall for open floor space. Non skid footwear. New intervention: Offer to change into bed clothes at HS (hour of sleep) Call placed to (name of physician) to discuss current psych (psychiatric) meds. (name of physician) has worked with resident and .meds for a while (sic) (name of physician) does not wish to change any meds at this time .feels any decrease .would not be beneficial for resident .will review and make note on .next visit. The note lacked any documentation to indicate new, immediate, effective interventions were implemented or adequate supervision was provided to ensure the safety of Resident R. A Care Plan for Falls dated 5/23/16 indicated new interventions of, psych to review medication regimine (sic) .therapy to screen bed mobility and functional transfers . were implemented. The plan lacked any documentation to indicate new, immediate, effective interventions were implemented or adequate supervision was provided to ensure the safety of Resident R. A Care Plan for Falls dated 5/24/16 indicated new interventions of , .assist to ensure resident wears pajamas or gowns at night .keep night light on from dusk to dawn . were implemented. The plan lacked any documentation to indicate new, immediate, effective interventions were implemented or adequate supervision was provided to ensure the safety of Resident R. An Occupational Therapist (OT) Progress note dated 5/24/16 indicated, .Current Level of Function .Standing Balance .demonstrates .able to maintain balance with minimum assistance, mod assist to reach ipsalateral (on the same side of the body) side and unable to weight shift .Fall risk . Fall #3: A Fall Event Report dated 6/1/16 at 10:10 P.M. indicated Resident R experienced an unwitnessed fall from bed. The report further indicated, the immediate interventions implemented were, Ensure res is wearing non-slip socks. Assist .with transfers. Ensure call-light (sic) is within reach. A Nursing note dated 6/1/16 at 10:10 P.M. indicated, Res had unwitnessed fall this shift at 10:10 pm .found by CNA during bed checks in supine (on back) position on floor next to bed and notified nurse. Small cut to middle of forehead with forehead (sic) .not incontinent at time of fall .lethargic and confused .unable to verbally give statement of event. Neuro check started .wearing (name of facility) provided night gown. Non-slip socks on feet. Call light within reach .assisted back into bed by nurse and two CNA's. Current interventions in place consist of ensuring res wearing non-slip socks, assistance with transfers, call light within reach, and frequent positioning checks when .in bed. New intervention for this current fall includes (sic) 15 min (minute) checks X (times) 24 hours and medication review. Neuro checks continue. The note lacked any documentation to indicate adequate supervision was provided or new, immediate, effective interventions were implemented to ensure the safety of Resident R. A Nursing note dated 6/2/16 at 10:40 A.M. indicated, IDT fall review .Resident had an unwitnessed fall on 6/1/16 at 10:10 P.M Prior to fall resident was lying in bed. When staff entered room resident was on floor lying on back .was dressed in gown and non skid socks .moves all extremities as usual. Fall was not witnessed so neuro checks were started and are WNL (within normal limits) .has small cut to middle of forehead .Light was on in room. Root cause: sleep pattern fragmented. Resident gets up at random times and has unsteady gait. Current interventions: Ensure .is wearing nightclothes, night light in place. psych review of meds. Therapy to screen bed mobility and transfers. Call light in place. Immediate intervention: Resident placed on 15 minute checks times 24 hours. New intervention: Room eval (evaluation) for safety. Bed to be positioned along back wall to allow for change of other furniture. The note lacked any documentation to indicate adequate supervision was provided or new, immediate, effective interventions were implemented to ensure the safety of Resident R. Fall #4: A Fall Event Report dated 6/4/16 at 11:59 A.M. indicated Resident R experienced a witnessed fall while walking into a crowded dining room area. The report further indicated, the immediate interventions implemented were, 15 minute checks X 24 (sic) hours. Possible medication review .resident to wear shoes when out of bed. For therapy to evaluate for possible assistive device The Nursing notes from 6/3/16 at 9:48 P.M. through 6/5/15 at 1:58 A.M. were reviewed and lacked any documentation related to the fall on 6/4/16 at 11:59 A.M. A Nursing note dated 6/6/16 at 4:16 P.M. indicated, IDT Fall Review .Resident had a witnessed fall on 6/4/26 .Resident was walking into dining room. Area was crowded room, a family member was blocking the doorway. Resident was required to navigate around .fell on .buttocks and rolled to side .No noted injuries .Root cause .lost balance and fell . Current interventions: Bed along the wall, night light, PJs (sic) (pajamas) at night, gripper socks. Immediate Intervention: 15 minute checks. Resident to wear shoes when out of bed. Therapy to eval for possible assistive device. Upon IDT review due to .shuffling gait .should not wear shoes as they may cause a fall. New intervention: Hipsters (a padded undergarment) to keep resident safe with falls . The note lacked any documentation to indicate adequate supervision was provided or new, immediate, effective interventions were implemented to ensure the safety of Resident R. A Care Plan for Falls dated 6/6/16 lacked any documentation to indicate new immediate, effective interventions were implemented or supervision was provided to ensure the safety of Resident R after the fall on 6/4/16. A Therapy assessment dated [DATE] at 11:28 A.M., indicated Resident R required assistance with transfers and walking. The assessment further indicated, .Pt (patient) currently required CGA (contact guard assist) (staff to provide assistance to steady balance) for ambulation due to balance . An OT Daily Treatment Note dated 6/7/16 at 12:46 P.M. indicated, .Nursing education of patient requiring CGA and close supervision while up ambulating . A Therapy Wheelchair assessment dated [DATE] at 2:28 P.M. indicated, .Pt (patient) required one on one (supervision) during w/c (wheelchair) use due to decreased safety awareness (sic) not locking w/c brakes, standing up X 10 (sic) times (sic) in 15 minutes, max verbal and tactile cues for redirection . Recommendation .Physical Therapy (PT) Eval (evaluation) .PT to screen pt for possible treatment as pt allows related to balance, strength, and endurance impacting falls reduction . Fall #5 During a random observation of the dementia care unit on 6/7/16 at 3:58 P.M., a loud noise was heard. Upon further investigation, at that time, Resident R was observed lying on the floor in the threshold of another resident's room with no staff observed near Resident R. During an interview on 6/7/16 at 4:05 P.M., the Regional DNS (Director of Nursing Services) was made aware Resident R had experienced another unwitnessed fall. During an interview on 6/7/16 at 4:15 P.M., the ADNS (Assistant Director of Nursing Services) indicated one on one supervision would be provided continuously to ensure the safety of Resident R. 3. The clinical record of Resident J was reviewed on 6/6/16 at 11:32 A.M. The record indicated the [DIAGNOSES REDACTED]. A Quarterly MDS (Minimum Data Set) assessment dated [DATE] indicated Resident J was admitted to the facility on [DATE], experienced severe cognitive impairment, cognitive skills for daily decision making were moderately impaired (decisions poor, cues/supervision required), did not require an assistive device (wheelchair or walker), required the assistance of one staff for transfers, ambulating, and two staff for toileting. A Care Plan for Falls dated 8/27/14, and updated on 1/27/16 included, but was not limited to, .Resident is at risk for fall due to: impaired balance, frequent incontinence, and high risk medications .Toilet right after breakfast. A Care Plan for Falls dated 8/27/14, and updated on 2/1/16 included, but was not limited to, .Resident is at risk for fall due to: impaired balance, frequent incontinence, and high risk medications .Encourage resident to sit in regular chair at table . Fall #1 An Event Report indicated Resident J experienced an unwitnessed fall on 1/27/16 at 8:54 A.M., and it read as follows, .lying on left side .location of fall .room .pain .difficulty in movements .yes .limping on left side .Describe injuries .limping on left side .scratch on neck .intervention .toilet after breakfast . An IDT (Interdisciplinary team) note dated 1/28/16 at 11:20 A.M., read as follows: .x ray of left hip and left ankle. Both were negative for injury. Resident had an unwitnessed fall in peer's room. Resident had just finished breakfast. Prior to fall was in hallway .Full body assessment was completed per nurse .Resident was moving all extremities without difficulties .scratch with bruising was on right side of neck .After he was up he was up and walking noted to have a limp .x rays were obtained . An incident report was provided by the Health Care Administrator on 6/6/16 at 1:16 P.M., and it read as follows. .1/27/16 (name) Resident Q pushed (name) Resident J resulting in (name) Resident J fall to the floor .Raised area to side of neck of (name) Resident J . An Event Report, Behavior Events, dated 1/27/16 at 7:45 A.M., read as follows, .where did behavior occur .A resident room .Resident had just finished his breakfast .Describe environment .Busy. Staff picking up dishes .Resident urinated in trash can in another resident's room .Resident had a fall during behavior so he was assessed and redirected . A PHYSICIAN'S PROGRESS NOTES dated 1/28/16 (no time documented) read as follows, .fell yesterday .c/o (complained of) pain L (left) hip, L ankle, Better now, Pt (patient) ambulating .shuffling gait, unchanged, xray (sic) - (negative) . Fall #2 An Event Report indicated Resident J experienced a witnessed fall on 1/31/16 at 9:51 A.M., and it read as follows: .Resident was sitting in wheelchair, while pushing on the table .location of fall .dining room area .small ST (skin tear) to right elbow .CNA witnessed fall said resident was pushing at dining table tipping the wheelchair and resident fell .Intervention .Continue to monitor resident, ambulate and reposition resident to prevent further falls . A Radiology Report dated 1/31/16 read as follows, .HIP UNILATERAL W (with) PELVIS 1 VIEW, RIGHT .Results: Possible fracture right hip. Additional oblique view recommended. Osteopenia with degenerative change Question fracture . A notation on the form dated 1/31/16 at 10:15 P.M. indicated the physician had been notified, new orders had been obtained and that the family had been notified. A PHYSICIAN'S PROGRESS NOTES dated 2/1/16 (no time documented) read as follows, .R (Right) hip pain now .Not willing to walk .Xray R hip . A Radiology Report dated 2/1/16 read as follows, .HIP UNILATERAL W PELVIS 2-3 V, RIGHT .Results: There is deformity of right femoral neck consistent with age indeterminate mildly displaced fracture .There is no dislocation .Conclusion: The exam is overall no significantly changed compared with prior dated 1/31/16 . A notation on the form dated 2/1/16, indicated the physician had been notified, new orders had been obtained. An IDT note dated 2/1/16 at 9:34 A.M., read as follows: .Resident had a witnessed fall on 1/31/16 at 951 am (9:51 A.M.) in the dining room .Dr .notified with new order for xray of right hip . After assessment resident was noted to have right hip pain with bruising noted to the right trochanter area .CNA who witnessed fall was interviewed, She reports resident tipped his chair backwards and before anyone could reach him he fell on to his right side .xray (sic) of right hip was obtained times two per MD order. Xray (sic) shows fracture and Dr .admitted resident to (hospital name) . An Physician Examination Report was provided by (Name) hospital on [DATE] at 1:17 P.M., and read as follows, .Multiple areas of bruising on right upper extremity and right lower extremity .There is a slight length inequality on orthopedic exam, right shorter than the left. The patient does respond to .leg roll in the hip .Radiographics of the right hip, 2 views, demonstrate a varus (an inward angulation) alignment at the femoral neck. It is difficult to determine whether or not there is an acute fracture of the hip .ASSESSMENT: Right hip pain after fall, possible acute right hip fracture .If this fractures appears acute and the patient has a history of being ambulatory, recommended prosthetic replacement. If there is some evidence that this is a chronic healed fracture or chronic nonunion, surgery would not be as aggressively pursued given the patient's multiple medical history. During an interview on 6/8/16 at 3:05 P.M., OT #2 indicated Resident J was ambulatory prior to his fall on 1/27/16 at 8:55 A.M. OT #2 indicated OT would ordinarily complete an evaluation and do a trial test with a wheelchair, but due to Resident J's fall occurring on the weekend he was placed in a wheelchair by nursing staff and OT could not complete a trial test with a wheelchair. The policy and procedure for Fall Management Program provided by the Health Care Administrator on 6/7/16 at 2:50 P.M. indicated .It is the policy of (facility name) to ensure residents residing within the facility will maintain physical functioning through the establishment of physical, environmental, and psychosocial guidelines to prevent injury related to falls. This Federal tag relates to complaint IN 251. 3.1-45(a)(2)

Based on observation, interview, and record review, the facility failed to ensure a resident without pressure ulcers, developed pressure ulcers for 3 of 5 who met the criteria for review of pressure ulcers. This deficient practice resulted in Resident F experiencing Stage 3 wounds to the coccyx, left buttock, and right buttock, Resident Q experiencing a Stage 3 wound to the coccyx, and Resident Z experiencing a Stage 3 wound to the left heel. (Resident F, Resident Q, Resident Z) Findings include: 1. On 4/20/16 at 6:45 P.M., Resident F was observed lying in bed on his/her back with the head of bed raised. During an interview on 4/20/16 at 6:56 P.M., LPN #10 indicated Resident F was not interviewable, required staff assistance for bed mobility, was incontinent of bowel, and experienced a small area of pressure on the coccyx. A Resident Profile provided by the DON (Director of Nursing) on 4/20/16 at 8:00 P.M., indicated pressure interventions of, .assist as needed to turn and reposition at least every 2 hours, preventative treatment as ordered . The Profile lacked any documentation to indicate Resident F experienced pressure related skin impairment to the coccyx, left buttock, and right buttock and lacked any documentation to indicate Resident F had a pressure reducing mattress. During an observation of care on 4/21/16 at 10:25 A.M., CNA #5 and CNA #6 were observed to reposition Resident F to a right side-lying position and remove an incontinence brief. Resident F was observed to not have any dressings on the coccyx or bilateral buttocks and to have wounds with white slough on the coccyx, left buttock, and right buttock. RN #9 was observed to enter the room of at 10:45 A.M. and indicated she was going to provide wound care to Resident F. At that time, RN #9 indicated Resident F experienced facility acquired wounds on the coccyx, left buttock, and right buttock and further indicated the following: Wound #1 (coccyx) measured 1.0 cm (centimeter) L (length) X (by) 1.7 cm W (width) X < (less than) 0.1 cm D (depth) and the wound bed contained 97% white slough. Wound #2 (left buttock) measured 4.2 cm L X 1.5 cm W X undetermined D and the wound bed contained 98% white slough. Wound #3 (right buttock) measured 3.0 cm L X 1.0 cm W X undetermined D and the wound bed contained 97% slough. The clinical record of Resident F was reviewed on 4/21/16 at 11:00 A.M. The record indicated the [DIAGNOSES REDACTED]. The most recent Quarterly MDS (Minimum Data Set) assessment dated [DATE] indicated Resident F experienced severe cognitive impairment, required the extensive assistance of two staff for bed mobility, was at risk to develop pressure, and experienced no skin impairment. A Significant Change MDS assessment dated [DATE] indicated Resident F experienced severe cognitive impairment, required the extensive assistance of two staff for bed mobility, was at risk to develop pressure, and experienced no skin impairment. The most recent care plan dated 4/13/16 lacked any documentation to indicate Resident F experienced actual skin impairment to the coccyx, left buttock, and right buttock. The clinical record lacked any documentation to indicate Resident F was thoroughly assessed for the risk of pressure ulcer development. The April 2015 physician's orders [REDACTED].every shift . The recap lacked any documentation related to a dressing to the wounds on the coccyx, left buttock, or right buttock. A Weekly Nursing Summary dated 4/11/16 at 6:42 A.M., indicated Resident F did not experience skin impairment to the coccyx, left buttock, or right buttock. The Summary lacked any documentation to indicate Resident F was thoroughly assessed for pressure ulcer development risk and lacked any documentation to indicate pressure ulcer prevention interventions were implemented. Wound #1: A New Skin Event assessment dated [DATE] at 4:10 A.M. indicated, .coccyx .1 x 1 x 0.5 (sic) .open area .pink . The assessment lacked any documentation to indicate an immediate, new pressure relieving intervention was implemented. A Non-Pressure Wound Skin Evaluation Report dated 4/18/16 at 2:06 P.M. indicated, .coccyx .moisture associated skin damage .partial thickness wound .1 x 1.5 x< (less than) 0.1(sic) .wound color white with pink . A Non-Pressure Wound Skin Evaluation Report dated 4/20/16 at 1:26 P.M. indicated, .coccyx .moisture associated skin damage .partial thickness wound .1 x 1.5 x<0.1 (sic) .wound color pink red . Wound #2 The Nursing notes from 4/16/16 were reviewed and lacked any documentation to indicate Resident F experienced skin impairment on the left buttock. A Non-Pressure Wound Skin Evaluation Report dated 4/18/16 at 2:07 P.M. indicated, .originally noted 4/16/16 .left buttock .moisture associated skin damage .partial thickness wound .3 x 1.0 x < 0.1 .wound color pink/flesh tone . A Non-Pressure Wound Skin Evaluation Report dated 4/20/16 at 1:24 P.M. indicated, .left buttocks .moisture associated skin damage .partial thickness wound .2.8 x 1.2 x<0.1 (sic) .wound color pink/red . Wound #3 The Nursing notes from 4/16/16 were reviewed and lacked any documentation to indicate Resident F experienced skin impairment on the right buttock. A Non-Pressure Wound Skin Evaluation Report dated 4/18/16 at 2:09 P.M. indicated, originally noted 4/16/16 .right buttock .moisture associated skin damage .partial thickness wound .1 x 0.8 x < 0.1 .wound color pink . A Physician's Telephone Order dated 4/20/16 at 3:28 P.M., indicated a new order was received for Cleanse coccyx and buttocks with wound cleanser pat dry. Apply Exuderm (a [MEDICATION NAME] wound dressing) q (every) 3 days . During an interview on 4/21/16 at 11:30 A.M., the WCN (Wound Care Nurse) indicated Resident F did not experience pressure related wounds to the coccyx, left buttock, and right buttock. The WCN further stated Resident F experienced, .moisture associated damage to the to the buttocks and center of buttocks due to incontinence, significant decline, poor nutrition, and not getting up like .used to The WCN further indicated all 3 areas of skin impairment were facility acquired, discovered as pinkish red diaper rash on 4/16/16, and were not pressure-related because the wounds were located in the buttocks. The WCN then indicated skin assessments were completed weekly, skin sweeps were completed monthly, but no assessments were done related to a resident's risk to develop pressure ulcers. The WCN then indicated all residents were at risk to develop pressure ulcers and a new pressure ulcer prevention interventions were implemented if a resident developed a Stage 2 wound. A Pressure Wound Report provided by the WCN on 4/21/16 at 11:45 A.M. indicated, Stages of pressure wounds/definitions .Stage II-Partial thickness loss of skin layers that present clinically as an abrasion, blister or shallow crater. Stage III-Full thickness of skin is lost, exposing the subcutaneous tissue-presents as a deep crater with/without undermining tissue . During an interview on 4/21/16 at 2:00 P.M. the DON indicated residents were not assessed for their risk to develop pressure ulcers because all residents were at risk to develop pressure ulcers and every resident received a pressure reducing mattress upon admission to the facility. The DON further indicated the ulcers on the coccyx, left buttock, and right buttock were moisture associated skin damage and not pressure related. A Policy and Procedure for Skin Management Program provided by 4/21/16 at 2:30 P.M., lacked any documentation related to pressure ulcer prevention or pressure ulcer staging. A Policy and Procedure for Pressure Ulcer Prevention and Pressure Ulcer Staging was requested of the DON (Director of Nursing) on 4/21/16 at 2:30 P.M. and was not provided as of 4/26/16 at 9:00 A.M. During an interview on 4/26/16 at 9:30 A.M., the HFA (Health Facilities Administrator) indicated the facility did not have specific policies for Pressure Ulcer Prevention and Pressure Ulcer Staging. 2. The clinical record for Resident Q was reviewed on 4/21/16 at 1:10 P.M. The [DIAGNOSES REDACTED]. An Admission assessment dated [DATE] indicated Resident Q was alert and oriented, and is unable to move from a seated to standing position , turn, and perform surface to surface transfers. The assessment further indicated Resident Q was admitted with a condom catheter (an external catheter) is incontinent of bowel and bladder function. The Admission assessment indicated Resident Q had no skin impairment when he was admitted to the facility, but has a history of pressure ulcers. A New Skin Event form dated 3/24/16 included, .3/24/16 .Wound/Area present on admission No .6 x 4.6 x 0.1 .open area .Wound /Area color bright red .LEFT BUTTOCK .Wound/Area appearance Red/Warm/Hot around the wound/area . An IDT Weekly Update Skin Event form dated 3/30/16 included New area .Wound present on admission No .Stage II Most Severe tissue type granulation . right buttock bottom .Describe measurements 1.8 x 1.2 x <0.1 . An IDT Weekly Update Skin Event form dated 3/30/16 included .New Area .Wound present on admission No . Stage II .Most Sever Tissue type Granulation .Site Right top buttock 2.3 x 1.5 x <0.1 (centimeters) An IDT note dated 3/30/16 included, .Resident noted to have three Stage II areas to bilateral buttock, two on the right and one on the left .Current treatment is to apply Venalex (a skin protectant ointment) to buttock q (every) shift and cover with dry dressing .Resident is incontinent of bowel and bladder and has a Foley catheter at this time .Resident has Roho overlay (A pressure reducing overlay) to bed and cushion to wheel chair . A New Skin Event dated 4/3/16 included, .right heel Wound/Area present on admission No .3.0 x 4.0 x U (undetermined) .Wound/Area type blister .Wound/Area color White Waxy . A New Skin Event dated 4/3/16 included, .left heel Wound/Area present on admission No .3.0 x 4.0 x U (undetermined) .Wound/Area type blister .Wound/Area color White Waxy . An IDT note dated 4/6/16 included Resident noted to have three worsening Stage II areas to bil (bilateral) buttock two on the right and one on the left, resident also has new Stage II areas to bilateral heels. Current treatment is to apply santyl (sic) (a debridment agent) to buttock, cover with fluffed gauze, then cover with Abd (an absorbent dressing) pad q shift. Treatment to heels is to cleans areas with wound cleanser, pat dry. Then apply [MEDICATION NAME] (an antimicrobial ointment used for burns) and wrap with kerlix. Buttocks wound contains approximately 25% yellow slough .Resident is incontinent of bowel and bladder and has a catheter at this time . National Pressure Ulcer Advisory Panal (NPUAP), Pressure Ulcer Treatment Quick Referance guide dated 2009, define a Stage II pressure ulcer as a Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum filled blister. The NPUAP further defines a Stage III pressure ulcer as a Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. A IDT Weekly Update Skin Events form included, but was not limited to, . Existing area .Stage II, Most Severe tissue type Slough (yellow or white tissue adhering to ulcer bed) .Site RIGHT TOP BUTOTOCK (sic) .measurements 2.3 x 1.5 x <0.1 Describe wound drainage YELLOW SLOUGH Current treatment cleanse area to buttock pat dry and apply nickel thick layer of santyl only to open area on buttock cover with fluffed gauze then cover with ABD dressing indications :area on buttock . A IDT Weekly Update Skin Events form included, but was not limited to, . Existing area .Stage II, Slough (yellow or white tissue adhering to ulcer bed) .Site RIGHT TOP BUTOTOCK (sic) .measurements 1.8 x 1.2 x <0.1 Describe wound drainage YELLOW SLOUGH Current treatment cleanse area to buttock pat dry and apply nickel thick layer of santyl only to open area on buttock cover with fluffed gauze then cover with ABD dressing indications :area on buttock . A IDT Weekly Update Skin Events form included, but was not limited to, . Existing area .Stage II, Slough (yellow or white tissue adhering to ulcer bed) .Site RIGHT TOP BUTOTOCK (sic) .measurements 7.6 x 5.3 x <0.1 Describe wound drainage YELLOW SLOUGH Current treatment cleanse area to buttock pat dry and apply nickel thick layer of santyl only to open area on buttock cover with fluffed gauze then cover with ABD dressing indications :area on buttock . An IDT Weekly Update Skin Event dated 4/3/16 included, but was not limited to, .Existing area .Stage II .Most severe tissue type granulation .Site RIGHT HEEL .measurements 3.0 x 4.0 x < 0.1 Current treatment CLEANSE AREA TO BILATERAL HEELS PAT DRY AND APPLY SILADENE (sic) TO BOTH HEELS AND WRAP WITH KERLIX Q SHIFT . An IDT Weekly Update Skin Event dated 4/3/16 included, but was not limited to, .Existing area .Stage II .Most severe tissue type [MEDICATION NAME] .Site LEFT HEEL .measurements 3.0 x 4.0 x < 0.1 Current treatment CLEANSE AREA TO BILATERAL HEELS PAT DRY AND APPLY SILADENE (sic) TO BOTH HEELS AND WRAP WITH KERLIX Q SHIFT . A IDT Weekly Update Skin Events form dated 4/13/16 included, but was not limited to, . Existing area .Stage II, most severe tissue type granulation .Site BUTTOCK (sic) .measurements 9 x 6 x 1.5 Describe wound drainage YELLOW SLOUGH Current treatment DAKINS (a disinfecting/debridment agent) . An IDT note dated 4/13/16 included, .Unstagable area to buttock which had previously identified as two separate areas .Current treatment changed to soak gauze in Dakins solution, loosely pack wound and then cover with ABD dressing q shift Buttock wound contains approximately 20% yellow slouth (sic) Resident is incontinent of bowel and bladder .FMH Wound center appointment scheduled During an interview with the WCN (Wound care nurse) on 4/25/16 at 11:10 A.M., she indicated Resident Q entered the facility on 3/17/16 with no areas of skin impairment. She indicated Resident Q was on was at risk to develop pressure because of this incontinence of bowel and bladder and immobility related to [MEDICAL CONDITION] and [MEDICAL CONDITION]. She indicated on 3/34/26 a stage 2 pressure ulcer was observed on on Resident Q's left buttock that was treated with a barrier cream. The WCN further indicated on 3/30/16 Resident Q had developed the two new stage 2 pressure ulcers to his right buttock that were treated with a barrier cream as well. She indicated on 4/13/16 the 3 pressure areas were combined into one large pressure ulcer as the tissue separating them had broken down. The WCN indicated Resident Q did not resist care. The WCN indicated she was unaware why Santyl (a debridment agent) was used on the Stage 2 pressure ulcers on Resident Q. The care plans were reviewed and included, but were not limited to: A care plan for ADL Functional/Rehabilitation dated 3/18/16. The interventions included, Resident to have 2 1/2 side rails. AM Cares including bathing, dressing oral care, hair care. A care plan for incontinence dated 3/31/16. The interventions included, but were not limited to, assessed and monitor skin condition weekly and PRN, assist with elimination, assist with incontinence care as needed, and check regularly for incontinence. A care plan for an indwelling Foley catheter dated 3/31/16. The interventions included, change catheter per MD order, do not allow tubing or any part of drainage system to touch floor, help resident choose new clothing that will not constrict catheter system. A care plan for impaired mobility dated 3/31/16. The interventions include, assess and document skin condition weekly and as needed, assist with incontinence care as needed, encourage resident to participate in transfers and bed mobility, notify therapy, side rail as enabler to promote independence, turn and reposition regularly. A care plan for self care deficit dated 3/31/16. The interventions included, encourage resident to do as much for self as possible, incontinent care as needed. A care plan for impaired skin integrity dated 3/30/16 related to Unstagable to left and right buttock now merged (prev was 1 area to left buttock and 2 areas to right buttock) . interventions included, but was not limited to, FMH wound care clinic apt per order (4/13/16), Incontinence care as needed with peri wash and moisture barrier (3/30/16), Stage IV (4) air mattress on bed (3/30/16), treatment as ordered (3/30/16), Turn and reposition regularly (3/30/16). During an interview with the DNS on 4/26/16 at 9:25 A.M., she indicated Resident Q was incontinent of bowel and bladder when he entered the facility and utilized a condom catheter (external catheter) by choice. The DNS indicated Resident Q did not refuse care but was very conscientious of they way he was turned as he had a fear of falling. She indicated while Resident Q had an order for [REDACTED]. 3. On 4/20/16 at 6:40 P.M., Resident Z was observed to be sitting up in a wheel chair in the memory care dining room wearing boots on her feet. The MCF (Memory Care Facilitator) indicated Resident Z had developed 2 unstagable areas to her heels. The MCF indicated the area on Resident Z's left heel had formed 1st and then an area on her Right heel had formed later from her heels rubbing on the floor when she was pushed or propelled herself. On 4/21/16 Resident Z was observed to be propelled by by CNA #26 to her room, during the observation Resident Z's feet and boots were observed to be rubbing on the floor as she was pushed. The heel area in the boots was observed to be open. The clinical record for Resident Z was reviewed on 4/21/16 at 10:15 A.M., [DIAGNOSES REDACTED]. A New Skin Event form dated 1/8/16 at 6:15 P.M. indicated a 1.4 cm (centimeters) by 1.2 cm, red and purple blood blister was found on Resident Z's left heel. The treatment put into place was to monitor area. An IDT (Interdisciplinary Team) note dated 1/13/16 included Resident is noted with stage II to left heel 1.4 x (by) x 1.2. x 0. Wound is the result of improper fitting shoes. treatment is granule heel q (every) shift. An IDT Weekly Update Skin Event dated 2/24/16 included .Existing area .left heel .Unstagable .Most severe tissue type .Necrotic/eschar (Black, brown or tan tissue adheres to wound bed) .describe wound color black An IDT not dated 3/2/16 included Resident is noted with unstable area to left heel .Resident continues not wearing shoes and but (sic) wearing non skid socks . A New Skin Event dated 3/24/16 included .3/24/16 .right heel blister 1.7 cm x 2 cm blood filled blister . Wound/Area color .red/yellow clear . The new order put into place was Venelex ointment to right heel blister, apply a non adherent pad and wrap with kerlix (gauze roll). An IDT note dated 3/30/16 included Resident is noted with a healing unstagable to left heel and a new Stage II to the right heel current treatment is Venelex to heels and cover with a non adherent pad . An IDT Weekly Update Skin Event dated 4/8/16 included .Existing area .Unstageable .Right Heel measuring 1.0 x 1.0 x 0cm .Describe wound color Black. An IDT note dated 4/13/16 included, Unstagabele to left and right heel .current treatment is Venelex to heels and cover with a non adherent pad then wrap with kerlix every shift . Resident has new order for zero gravity boots for pressure relief when up in wheel chair . The care plans for Resident Z was reviewed and included, but were not limited to the following: A care plan for a risk for skin breakdown or further skin breakdown dated 11/6/14, the interventions included, but were not limited to Assess and document skin condition (11/6/14), Pressure reducing/redistribution cushion in chair/wheelchair (11/6/14), and Turn and reposition at least every 2 hours (11/6/14). A care plan for impaired skin integrity, unstagable blister to left heel and an unstagable flat blister visualized as a stage II to right heel.- no shoes to be worn, resident uses non-skid socks for wound healing .Interventions included, but were not limited to, zero gravity boots all times when up out of bed (4/21/16), An observation of the wounds to Resident Z's bilateral heels were observed on 4/26/16 at 10:44 A.M., with LPN #23. The Right heel had a closed purple area approximately 1 cm x 1 cm. The Left heel was observed to have a quarter sized open area with yellow and white wound bed. LPN #23 indicated the area was open and contained slough. During an interview with the MCF (Memory Care Facilitator) on 4/26/16 at 10:10 A.M., she indicated the area on Resident Z's left heel was from a tight shoe and the intervention was to remove her shoes and place gripper socks on her. She indicated at that time the unstagable pressure area on her right heel had formed formed from friction caused when Resident Z's foot would rub when being propelled in her wheel chair. She indicated the zero gravity boots were added as an intervention to assist with friction in April following the formation of the second pressure area. 3.1-40(a)(1)

Based on observation, interview, and record review, the facility failed to ensure adequate supervision or new immediate, effective interventions were provided to prevent falls for 2 of 3 residents who met the criteria for the review of accidents. This deficient practice resulted in Resident P experiencing 2 fractured ribs. (Resident P, Resident E) Findings include: 1. During an observation on 4/21/16 at 9:25 A.M., Resident P was observed sitting in a wheelchair in his room. CNA #32 was observed wiping up a large amount of liquid from the floor around the base of the commode in Resident P's bathroom. At that time, CNA #32 indicated Resident P would get up by himself and go to the bathroom and miss the commode when urinating. CNA #32 further indicated Resident P should call for assistance. The clinical record of Resident P was reviewed on 4/21/16 at 10:31 A.M. The record indicated Resident P had been admitted to the facility on [DATE]. The [DIAGNOSES REDACTED]. A Comprehensive Admission Assessment completed on 12/29/16 was provided by the DON on 4/25/16 at 11:30 P.M., and the assessment for musculoskeletal read as follows: .Balance: moving from seated to standing position .Not steady, but able to stabilize without human assistance . .Balance: walking .did not attempt . .Balance: surface to surface transfer .did not attempt . The Admission MDS (Minimum Data Set) assessment dated [DATE] indicated Resident P experienced severe cognitive impairment and needed the assistance of one person for transfers, ambulation, toileting and was unable to balance without the assistance of a staff person. The Admission MDS (Minimum Data Set) assessment dated 4/ 6/16 indicated Resident P experienced severe cognitive impairment and needed the assistance of 2 persons for transfers, ambulation, and toileting, and was unable to balance without the assistance of a staff person. A Care Plan for Falls dated 12/31/15 and updated on 3/8/16 included, but was not limited to, Problem .Falls: .Resident is at risk for fall due to: weakness h/o (history of) left foot metatarsal fx (fracture), complicated by arthritis and high risk meds (medications) . Initial interventions dated 12/31/15 included, but were not limited to, .call light in reach .Environmental changes as needed .keep rollator walker near bed during periods of rest .non skid footwear .Personal items in reach .Therapy screen . Care Plan for Falls updated on 1/25/16 included, but was not limited to, interventions of .may align bed along the wall for open floor space . Care Plan for Falls updated on 3/8/16 included, but was not limited to, .educate resident to ask for assistance in obtaining items from the refrigerator . Care Plan for Falls updated on 4/6/16 included, but was not limited to, .non skid strip in front of the bed. A RADIOLOGY REPORT dated 3/7/16 read as follows: .Results: There is a fracture involving the lateral portion of the right 7th - 9th ribs with minimal displacement . A Progress Note by the Nurse Practioner dated 3/9/16 read as follows: .Pt (patient) .fall with new rib fractures. lateral 7th - 9th ribs . Fall 1. A Fall Event report indicated Resident P experienced an unwitnessed fall on 1/22/16 at 11:54 A.M. Resident P was found on his knees in front of his electric wheelchair and stated that his legs, gave ou. (sic) The Event Report read as follows: .What intervention (s) was put into place to prevent another fall .IDT to review . A Progress Note dated 1/25/16 3:35 P.M., read as follows: .IDT review of falls .Resident was found on knees in front of his electric wheelchair .resident was self transferring and his legs gave out. New intervention is to move bed along wall to provide for additional space for transferring .Current interventions: Call light in reach, personal items in reach, rollator within reach . Fall 2. A Fall Event report indicated Resident P experienced an unwitnessed fall on 3/7/16 at 11:00 A.M. The Event Report read as follows: .Resident was getting into the fridge and getting ice cubes .Resident found laying (sic) on his back .What intervention (s) was put into place to prevent another fall .Residents skin tears where cleaned and dressed, resident assisted from floor to bed . A Progress Note dated 3/8/16 12:19 P.M., read as follows, .IDT REVIEW OF FALL .Resident was up getting ice out of fridge .resident was noted to have 3 S/T's (skin tears) to right hand, wrist and elbow. resident was noted to have a small laceration on the top of his head. Resident did c/o pain to right side ribs. A (sic) x-ray was ordered at that time .New Intervention: Reeducate resident to use call light when he needs assistance . Documentation was lacking concerning the results of the x-ray. Fall 3. A Fall Event report indicated Resident P experienced an unwitnessed fall on 4/5/16 at 1:47 P.M. The Event Report read as follows: .attempting to change seats .lying on side .What intervention (s) was put into place to prevent another fall .educate resident to call for help when transferring; reminder of call light use . A Progress Note dated 4/5/16 4:29 P.M., read as follows, .IDT REVIEW OF FALL .Resident was attempting to change seats. resident was found lying on his side .Resident is not a diabetic .Residents (sic) walker was not next to his bed. NEW INTERVENTIONS: add non skid strips next to bed. All other interventions in place, bed along wall, ask for assistance when needed, resident walker next to bed, to make transfers easier for resident . Fall 4. A Fall Event report indicated Resident P experienced an unwitnessed fall on 4/8/16 at 7:42 A.M. The Event Report read as follows: .sitting on the floor talking .res (resident) stating sliding his self off the bed into (sic) floor, and wanted staff to pick him up .res room is cluttered. drinks and urinal were out of reach of the resident .What intervention (s) was put into place to prevent another fall .educate staff on importance of keeping resident items within reach of the resident . A Progress Note dated 4/8/16 4:29 P.M., read as follows, .IDT REVIEW OF FALL .Resident was found sitting on his buttocks .NEW INTERVENTION: resident to wear non skid socks at all times . During an interview on 4/25/16 at 10:20 P.M., the Director of Nursing (DON) indicated Resident P was assessed at admission to be at a high risk to experience a fall. The DON further indicated Resident P had experienced 2 rib fractures as a result of a fall on 3/7/16. The DON further indicated Resident P's subsequent hospitalization for pneumonia on 3/13/15 was a result of Resident P not moving much and not deep breathing due to pain from the fractures. 2. The clinical record of Resident E was reviewed on 4/21/16 at 1:38 P.M. The record indicated the [DIAGNOSES REDACTED]. The Significant Change MDS (Minimum Data Set) assessment dated [DATE] indicated Resident E experienced moderate cognitive impairment, required the extensive assistance of two staff for bed mobility, required the total assistance of two staff for transfers, had a history of [REDACTED]. The most recent Quarterly MDS dated [DATE] indicated Resident E experienced severe cognitive impairment, required the extensive assistance of two staff for bed mobility and transfers, and had experienced no falls since the previous assessment period. A Care Plan for Resident is at risk for fall due to: weakness and decreased cognitive status dated 3/21/16 indicated the following interventions: Comfort care foam chair when up out of bed, place dycem (an anti-slip device) between w/c (wheelchair) seat and cushion, and between alarm and bottom, 15 min (minute) personal checks when in bed, Keep resident in common area, in view of staff when not in bed, toilet after meals before laying down, add wedge cushion under back to support side laying position when in bed, may align bed along the wall for addition floor space, scoop mattress on bed, call light in reach, non skid footwear, personal items in reach, therapy screen Fall #1 A Fall Event assessment dated [DATE] at 12:00 A.M. indicated Resident E experienced an unwitnessed fall from the bed. The assessment further indicated, .The resident was sitting on the floor, leaning against .bed . and an immediate intervention of When restless on HS (hour of sleep) assist res (resident) up in to (sic) wheelchair was implemented. A Nursing Progress note dated 4/9/16 at 2:00 A.M. indicated, Resident was checked on around 11:30 pm (P.M.), when an aid (sic) checked her call light. Resident was found sitting on the edge of .bed stating .'wanted to go home.' Resident was placed back down in bed and a wedge was placed on .left side. At approximately 12 am (A.M.), resident was found sitting beside .bed. Resident again stated .wanted to, 'go home,' and to 'please get .out of here.' Resident was assessed and placed in .chair for a little while to monitor for awhile . An IDT (Interdisciplinary Team) progress note dated 4/11/16 at 4:07 P.M. indicated, .un-witnessed (sic) fall on 4/9/16 at 12AM (sic) .New intervention: When restless on HS gwet (sic) res up in Wheelchair (sic) Fall #2 A Fall Event assessment dated [DATE] at 10:36 P.M., indicated Resident E experienced an unwitnessed fall from the bed. The assessment further indicated, .lying on L (left) side beside bed and an immediate intervention of, Placed Wedge (sic) cushion in bed to prevent res from rolling was implemented. A Nursing Progress note dated 4/13/16 at 10:54 P.M. indicated, Cna (sic) called this nurse to res room at approx (approximately) 10:30 pm (sic). Res was found lying on .left side in floor beside .bed . The note lacked any documentation to indicate a new, immediate intervention to ensure the safety of Resident E was implemented. An IDT progress note dated 4/14/16 at 11:09 A.M. indicated, .un-witnessed (sic) fall on 4/13/16 at 10:36pm (sic) .New Intervention: Fall mat to open side of bed . Fall #3 A Fall Event assessment dated [DATE] at 6:47 P.M. indicated Resident E experienced an unwitnessed fall from the bed. The assessment further indicated, .lying on L side in floor and an immediate intervention of, .Ensure wedge cushion in firmly in place, fall mat in floor to side of bed was implemented. A Nursing Progress note dated 4/14/16 at 9:50 P.M. indicated, At approx 6:47pm (sic), this nurse went into res room to check res vital signs, and res was on the floor beside .bed. his nurse called for help, and immediately assessed res for injuries. No injuries found. Assisted staff in getting res back into bed. Ensured that fall mat was in place, wedge cushion was in place, and call light within reach. Neuro (neurological) checks already in place from earlier unwitnessed fall . Fall #4 A Fall Event assessment dated [DATE] at 7:32 P.M. indicated Resident E experienced an unwitnessed fall from the bed. The assessment further indicated, .lying on R (right) side in floor beside bed and an immediate intervention of, .Fall mat in floor to side of bed, wedge cushion firmly in place. Place res in geri chair was implemented. The assessment lacked any documentation to indicate a new, immediate intervention to ensure the safety of Resident E was implemented. A Nursing Progress note dated 4/14/16 at 9:50 P.M. indicated, .At approx 7:32 pm (sic), this nurse was going into res room again to check on res and administer evening medications when res was found on fall mat beside bed. Assisted staff in getting res into .chair to ensure res safety. Placed chair in front of nurses station to be able to monitor res closely . The note lacked any documentation to indicate a new, immediate intervention to ensure the safety of Resident E was implemented. An IDT progress note dated 4/15/16 at 10:42AM (sic) indicated, .Res was noted to have 2 un-witnessed (sic) fall on 4/14/16 .New Intervention: Med (medication) review . During an interview on 4/21/16 at 2:00 P.M., the DON (Director of Nursing) indicated the immediate intervention implemented after Fall #1 was to transfer the resident in a chair to the nursing station for closer supervision when he/she experienced restlessness at night. The DON then indicated the immediate intervention implemented after Fall #2 was to place a fall mat beside the bed and the immediate intervention implemented after Fall #3 was to educate staff to make sure the wedge cushion was placed firmly. The DON further indicated the immediate intervention implemented after Fall #4 was to complete a medication review. During an interview on 4/21/16 at 2:15 P.M., the DON indicated every resident in the building was at risk to experience a fall. The DON further indicated no documentation could be provided to indicate the fall risk of Resident P and E was thoroughly assessed. During an interview on 4/26/16 at 10:50 A.M., the Regional DON indicated no documentation could be provided to indicate any resident's risk to fall was thoroughly assessed. The Policy and procedure for Fall Management Program was provided by the DON (Director of Nursing) on 4/25/16 at 2:00 P.M., and read as follows: .It is the policy .to ensure residents residing within the facility will maintain maximum physical functioning through the establishment of physical, environmental, and psychosocial guidelines to prevent injury related to falls. 3.1-45(a)(2)

Based on record review and interview, the facility failed to monitor to ensure the use of [MEDICATION NAME] for [MEDICAL CONDITION] control was indicated. The deficient practice affected 1 of 1 resident reviewed related to [MEDICATION NAME] administration in a sample of 3. (Resident F) Resident F's [MEDICATION NAME] level was above normal range, the medication continued to be administered, the blood level was not monitored again, and the resident was transferred to the emergency room with [DIAGNOSES REDACTED]. Findings include: The clinical record for Resident F was reviewed on 7/7/11 at 3:00 p.m. The record indicated Resident F had [DIAGNOSES REDACTED]. physician's orders [REDACTED]. A lab report for 3/25/11 indicated the resident's [MEDICATION NAME] level was 17.7 micrograms/milliliter with a normal range of 10 to 20 micrograms/milliliter. Nurse's Notes for 5/16/11 at 6:10 a.m., indicated, "Res. (resident) seizuring while (arrow pointing up) in W/C. Extremities rigid, eyes rolled up in forehead. Full body tremor." A physician's orders [REDACTED]. Repeat in 10 min prn (as needed). CBC (complete blood count), CMP (complete metabolic profile), UA (urinalysis), [MEDICATION NAME] (blood levels)." A physician's orders [REDACTED].([MEDICAL CONDITION]). May repeat dose X 1 in 10 min (minutes) if not effective." A lab report, dated 5/16/11 at 8:22 a.m., indicated, "[MEDICATION NAME] ([MEDICATION NAME]) 24.1 C (small number 2) with normal range of 10 to 20 micrograms per milliliter. A footnote for the small number 2 indicated, "Critical value(s) called to, repeated, and verified by (name). A handwritten notation on the report indicated, "Hold [MEDICATION NAME]. Call out to Dr. (name of Resident F's attending physician) 5/16/11 9:45 a.m. Awaiting return call." Initials followed the notation. Another notation on the report indicated, "Hold [MEDICATION NAME] in AM. Re (checkmark) [MEDICATION NAME] on Wed." The attending physician's orders [REDACTED]. Redraw [MEDICATION NAME] level on 5/18/11." The Care Plan Update on the Physician Telephone Order indicated, "Goal: Lab WNL (within normal limits)." The attending physician's orders [REDACTED]. Re (check mark) [MEDICATION NAME] level 5/18/11." The Care Plan Update on the Physician Telephone Order indicated, "Goal: Lab WNL (within normal limits)." A lab report, dated 5/18/11, indicated a [MEDICATION NAME] level of 19.5 with a normal range of 10 to 20 micrograms per milliliter. A handwritten notation on the lab report indicated, "Faxed to Dr. (name of attending physician) 5/20/11 (symbol for no) orders." The notation was unsigned. Nurse's Notes for 5/16/11 through 5/23/11 at 6:30 a.m., indicated no [MEDICAL CONDITION] activity was indicated during this time. Nurse's Notes on 5/23/11 at 6:30 a.m., indicated, "[MEDICAL CONDITION] activity noted. Rigid, screaming between spasms. Eyes rolled into head." A physician's orders [REDACTED]." A lab report, dated 5/23/11, indicated, "[MEDICATION NAME] 23.5 C (small number 1)" with normal range of 10 to 20 micrograms per milliliter. A footnote for the small number 1 indicated, "Critical value(s) called to, repeated, and verified by (name). Handwritten notations on the report indicated, "Dr. (name), neuro consult, Hold [MEDICATION NAME] in AM X 2 d (days) [MEDICATION NAME] (level) in AM Wed [MEDICATION NAME] 50 mg tabs - 400 mg once day. [MEDICATION NAME] [MEDICATION]) 200 mg ii (two) tabs TID (three times daily) for [MEDICAL CONDITION], [MEDICATION NAME] 500 mg BID (twice daily) 12 N (noon) - nurse will tell (name of attending physician) as soon as he comes in." Initials were indicated after the last notation on the page. The attending physician's orders [REDACTED]. Hold [MEDICATION NAME] in AM X 2 days. [MEDICATION NAME] level on Wed morning [MEDICATION NAME] 500 mg P.O. (by mouth) BID R/T (related to) [MEDICAL CONDITION]." A lab report, dated 5/25/11 indicated, "[MEDICATION NAME] ([MEDICATION NAME]) 22.6 H (high)" with a normal range of 10 to 20 micrograms/milliliter. A handwritten notation with a circled #1 on the lab report indicated, "MD notified. (symbol for no) N. O. (new orders)." The notation was followed by initials and the date 5/25/11. Another handwritten notation with a circled #2 indicated, "5-23 held Mon. [MEDICATION NAME] until Wed." The notation was unsigned. Another notation was circled with an arrow pointing to the #2 notation, and indicated, "On [MEDICATION NAME] 400 mg once daily. Other notations indicated, "Called nurse at office & re-faxed 5-27-11," " Last lab 5-23-11 [MEDICATION NAME] 23.5," and "Currently on [MEDICATION NAME] 500 mg Bid." Another notation with a circled #3 indicated, "5-30-11 Called again & faxed," and was signed with a nurse's first initial and last name. A stamped mark indicating "FAXED" included a handwritten date of 5/27/11. Documentation on Nurse's Notes, Physician's Progress Notes, and physician's orders [REDACTED]. The Medication Administration Records for May, June, and July (through 7/3/11) 2011 indicated the resident's [MEDICATION NAME] was administered at 400 mg daily except for 5/17, 5/18, 5/24, and 5/25/11. physician's orders [REDACTED]." A Short Term Patient Referral Form indicated the resident was transferred for neurological consultation on 6/20/11. "Reason for Transfer" indicated, "Please review attached meds (medications) & labs for any recommendations." Paperwork sent with the resident included the June 2011 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. A "Neurological Consultation," dated 6/20/11, indicated, "(Resident F)...was seen in our office on 6-20-11 for neurological evaluation through the courtesy of (name of attending physician) who is concerned about the patient's on going and progressive deterioration in memory and cognitive dysfunction. Neurological examination: Awake but unable to communicate verbally. She is combative when an attempt to touch her. We tried placing [MEDICATION NAME] on her scalp but were unsuccessful. The patient would move her upper and lower extremity spontaneously and no focal weakness noted. Remarks: This patient is on her late spectrum of dementia, Alzheimer type. Recommendations: There is no need for treating her dementing process except to calm her down prn (as needed) with appropriate medication for her age. Invasive neuroprocedure is not indicated. Continue with all her anticonvulsant medication." Nurse's Notes for June 2011 indicated the resident was treated with antibiotics for "abnormal urine" beginning 6/16/11 with [MEDICATION NAME] (antibiotic) and on 6/29/11 with [MEDICATION NAME] (antibiotic) injections. The Interdisciplinary Team Note for 6/23/11 indicated the resident's food intake had decreased, she had lost weight, was placed on [MEDICATION NAME], and had fortified foods added to the diet. A physician's orders [REDACTED]. [REDACTED]. The resident's Care Plan, dated 1/10/11, indicated, "Resident has risk for injury related to [MEDICAL CONDITION] activity; Has potential for [MEDICAL CONDITION] activity." Interventions on the plan did not indicate a plan for the resident's blood level parameters for [MEDICATION NAME]. Nurse's Notes on 7/3/11 at 6:00 a.m., indicated, "Call placed to (name of attending physician) - res (resident) lethargic and slow to respond. Temp 100.2 cont. (continues) w (with) abt (antibiotic) appetite has been decreased w good fluid intake at most xs (times). res up in w/c (wheel chair) leaning to rt (right) side has outbursts of yelling then quiets and has moments of fixed stare and won't respond to staff...." Notes indicated the physician returned the call and ordered the resident to be sent to the emergency room for evaluation and treatment. The Physician emergency room Documentation, with handwritten date of 7/2/11 (sic) indicated, "Unresponsive. Sent from NH (nursing home) (symbol for secondary to) wouldn't open eyes & (arrow pointing down) resp (responsiveness) this a.m. No C/O (complaints) (illegible word) Hx (history of) F/C (Foley catheter) recently Dx (diagnosis) UTI - on [MEDICATION NAME], known [MEDICAL CONDITION] disorder - non witnessed." The Emergency Department lab report indicated the resident's [MEDICATION NAME] Level was 41.5 micrograms/milliliter with a normal range of 10 to 20 micrograms/milliliter, the urinalysis indicated values outside normal ranges, and the blood sugar by Accucheck was 134 at 7:46 a.m. The Emergency Department Discharge Instruction Summary, dated 7/3/11 at 9:48 a.m., indicated the resident's [DIAGNOSES REDACTED]. Recheck [MEDICATION NAME] level Tuesday (7/5/11) AM and advise (name of attending physician) of results. Check urine culture results 3 days. Continue [MEDICATION NAME]." A lab report. dated 7/5/11. indicated "[MEDICATION NAME] ([MEDICATION NAME]) 37.9 H (high)" with normal range of 10 to 20 micrograms/milliliter. The attending physician's orders [REDACTED]. Repeat [MEDICATION NAME] level on 3rd day." The Care Plan Update on the Physician Telephone Order indicated, "Goal: Lab value will be WNL (within normal limits) next lab draw." A Nursing Progress Note, dated 7/7/11 at 3:45 p.m., indicated, "Called (sic) placed to (name of attending physician) r/t (related to) multi meds for [MEDICAL CONDITION] disorder/dementia. Called (sic) was placed at 9:35 a.m. Message left with office. MD to return call by end of the day or in the am (morning)...." The attending Physician's Progress Notes, dated 7/8/11, indicated, "Patient (symbol for with) recent confusion & (arrow pointing up) agitation. Sent to (name of local hospital) ER (emergency room ) on 7/2/11 (sic). Noted to be [MEDICATION NAME] toxic (symbol for with) level of 41.5. [MEDICATION NAME] (sic) put on hold until level w/in (within) therapeutic level. [MEDICATION NAME] level 7/5/11 was 37. Currently still on hold....A/P (assessment/plan) [MEDICAL CONDITION] Dis (disorder) (symbol for with) [MEDICATION NAME] toxicity Hold & D/C [MEDICATION NAME] (sic). (arrow pointing up) [MEDICATION NAME]. UTI. Completed course of abx (antibiotic)...Above plan has been d/w (discussed with) staff, especially management of [MEDICATION NAME] toxicity since 7/2/11 (sic). All levels have been called to me." During interview on 7/7/11 at 4:30 p.m., in regard to the lab report of 5/25/11 with the notations about contacting the physician's office, the Director of Nursing indicated a nurse could contact the facility's Medical Director if the attending physician was not responding to contacts. During interview on 7/7/11 at 5:10 p.m., the Director of Nursing indicated Resident F's [MEDICATION NAME] level had been maintained on the high side to manage her [MEDICAL CONDITION]. She also indicated she could not locate any progress notes to indicate the resident's physician had visited the resident and commented on the [MEDICATION NAME] levels outside the therapeutic range until the note of 7/8/11. During interview on 7/8/11 at 10:30 a.m., the Director of Nursing indicated the resident's attending physician would be in to see her today. During interview on 7/8/11 at 12:15 p.m., the Director of Nursing indicated the physician had visited the resident and would be taking the resident off [MEDICATION NAME] so managing the [MEDICATION NAME] levels would not be necessary. The Director of Nursing indicated the resident was doing well now and eating 100%. During interview on 7/8/11 at 1:30 p.m., during the Exit Conference, Unit Manager #1 indicated she had spoken with the nurse who wrote "MD notified. No new orders" on the lab report for 5/25/11. The Unit Manager indicated the nurse told her she had spoken with the physician about the lab. Review of the Geriatric Dosage Handbook, 12th edition, on pages 1229 through 1235, indicated information including, but not limited to, "Concentration-related effects: [DIAGNOSES REDACTED], blurred vision, diplopia, ataxia, slurred speech, dizziness, drowsiness, lethargy, coma, rash, fever, nausea, vomiting, gum tenderness, confusion, mood changes, folic acid depletion, [DIAGNOSES REDACTED], [MEDICAL CONDITION].Reference range: Therapeutic 10 - 20 mcg/mL (micrograms per milliliter)....Toxicity is measured clinically, and some patients require levels outside the suggested therapeutic range; Toxic: 30 - 50 mcg/mL. Lethal: > (greater than) 100 mcg/mL." 3.1-48(a)(3) 3.1-48(a)(4)

Based on observation, record review and interview, the facility failed to provide supervision to ensure a resident at risk for falls did not fall from her chair for 1 of 3 residents reviewed related to falls in a sample of 3. (Resident B) Resident B sustained a brain contusion and soft tissue hematoma to the scalp. The facility also failed to ensure the resident was transferred safely using a gait belt as required by facility policy for 1 of 3 residents observed during transfer in a sample of 3. (Resident B) Findings include: During interview on Initial Tour of the facility which began on 5/23/11 at 5:35 p.m., RN #3, Unit Manager, indicated Resident B had fallen previously and was at risk for falls. RN #3 indicated the resident's most recent fall resulted in a "brain bleed." RN #3 indicated she was not present at the time of the fall, but her understanding was the aide was preparing to lay the resident down in bed, when the aide heard an emergency alarm sounding and went to answer the emergency alarm. RN #3 indicated she had not seen the resident try to get up on her own. RN #3 indicated the resident now wears a seat belt on her recliner. On 5/23/11 at 5:55 p.m., CNA #4 was observed pushing a resident down the hallway. The resident was reclined in a gerichair. The resident was observed to have a raised purplish area about the size of a golf ball to the left side of the forehead. The side of the face was yellowish from the forehead to the bottom of the cheek. RN #3 indicated the resident was Resident B. CNA #4 indicated to RN #3 she needed to put the resident to bed and requested the help of RN #3. The resident's gerichair was rolled next to the bed, and the resident was wearing a seat belt. The gerichair was placed in an upright position, and nurse and CNA grasped under the resident's arms and held the back of her pants on each side as the resident was transferred to bed. The resident bore minimal to no weight during the transfer. A gait belt was not used for the transfer. RN #3 left the room, and CNA #4 provided personal care. During interview at this time, CNA #4 indicated she was on duty when Resident B fell and bumped her head. CNA #4 indicated the resident was in the hallway in her gerichair , and an emergency call light was going off. CNA #4 indicated Resident B was "laid back with eyes closed." CNA #4 indicated she went to answer the emergency call light. CNA #4 indicated she got the other resident in the bathroom cleaned up, and when she came out of the other resident's room, Resident B had fallen and had already been moved into her bed. CNA #4 indicated the nurse had "gone upstairs," and the other CNA had found the resident when she fell from her chair. CNA #4 indicated the fall did not knock Resident B out. CNA #4 indicated the resident's alarms (used to alert staff to a resident's rising unassisted) had been discontinued prior to the resident's fall. The clinical record for Resident B was reviewed on 5/24/11 at 12:00 p.m. The record indicated the resident had resided at the facility since 2006. The resident's most recent admission to the facility was 4/23/10 following hospitalization for a fracture to the left hip and left shoulder after a fall from her gerichair. The resident's Plan of Care, with "Problem" dated 5/14/10, with the most current goal date of 3/16/11, indicated a problem of "Risk for fall with history of fall r/t (related to) impaired safety judgement (makes attempts to rise per self, weakness related to decline in general health. Recent fall occurrence." Interventions included, but were not limited to, getting the resident up to her gerichair "just before meals, to bed after meals," "place gerichair near nurses station for closer observation during periods of extreme restlessness," and chair alarms to the bed and gerichair. The resident's Care Plan, with a "Problem Start Date" of 3/8/11, with goal date of 8/24/11, indicated, "Resident is at risk for fall due to impaired mobility complicated by high risk medication." Approaches included, but were not limited to, "When up in gerichair place near nurses station for closer observation" and "Alarm to bed and chair." Handwritten next to the intervention for the alarm was: "5/3/11 D/C'ed (discontinued)." A physician's orders [REDACTED]." The resident's annual Minimum Data Set (MDS) assessment, dated 2/25/11, indicated in the CAA (Care Assessment Analysis) section for falls: "...no HX (history) of recent or frequent fall. Current meds (medications) are not new or recently changed for her, and she has no noted side effects. She is assisted up daily to a recliner chair for comfort, and when restless has tendency to slide, and would be unable to prevent fall is slid too far...." No documentation in Nurse's Notes from 2/25/11 to 5/13/11 or Interdisciplinary Team notes from 2/25/11 to 5/13/11 indicated information related to the resident's tendency to slide from the gerichair or decision-making on the removal of the alarms from the resident's bed and gerichair. Two Fall Risk Assessments, dated 5/13/11, untimed, were in the record. One Fall Risk Assessment indicated, "Yes," and the other Fall Risk Assessment indicated, "No" to the question, "Resident is non-compliant or has history of non-compliance?" A Fall Circumstance Report, dated 5/13/11 at 7:45 p.m., indicated the resident had an unwitnessed fall when sitting in the recliner in the hallway by the resident's room. Interventions planned to prevent further falls indicated, "To sit at nurse's station or Rd (resident) placed immediately to bed (symbol for after) meals. A physician's orders [REDACTED]." emergency room notes, dated 5/13/11, indicated, "Impression: 1) Head contusion (symbol for with) intracranial hemorrhage....Admit observation." Results of Diagnostic Imaging, dated 5/15/11, indicated, "CT Head without Contrast...Impression: 1. Focal hyperdensity noted involving the right temporoparietal cortex most consistent with a brain contusion. Findings related to focal intracerebral hemorrhage may also be considered. There is mild adjacent edema. There is minimal localized mass effect in this region. These findings are likely related to head trauma with the presence of a countercoup injury given the presence of a scalp soft tissue hematoma seen involving the scalp soft tissues of the left frontal region. 2. A large scalp soft tissue hematoma is seen involving the soft tissues overlying the left frontal bone....." During interview on 5/23/11 at 8:05 p.m., LPN #11, Unit Manager for Hall F, indicated gait belts are to be used for all transfers. The facility's policy related to use of gait belts was provided 5/24/11 at 3:00 p.m. by LPN #9, Unit Manager for Hall C. Review of the record at this time indicated, "Gait belts are to be used at all times for transfers or mobility with the exception of recent surgical sites...." This federal tag is related to Complaint IN 791. 3.1-45(a)(2)