Every finding on record at Riverwalk Village

Based on record review and interview, the facility failed to ensure ophthalmologic (eye) medications were administered per physicians' orders for 1 of 3 residents reviewed for medication administration. (Resident B)Findings include:Resident B's clinical record was reviewed on 8/24/26 at 12:00 p.m. Diagnoses included type 2 diabetes mellitus with proliferative diabetic retinopathy without macular edema (diabetic eye disease), traction detachment of the retina in an unspecified eye, and legal blindness.Current orders included brimonidine (to lower pressure in the eye) 0.2% eye drops, give one drop to both eyes three times a day (5/22/26); dorzolamide-timolol (to lower fluid pressure in the eye) 2-0.5% eye drops, give one drop to both eyes three times a day (8/18/26); erythromycin (an antibiotic) ointment 5 grams (gm), apply 1/4 inch to the right eye twice daily (8/7/26); prednisolone acetate (a steroid) 1% eye drops, give one drop to the left eye twice daily (8/18/26); and, on Tuesday, Thursday, and Saturday, the resident should be ready to go to dialysis at 4:00 a.m. (4/20/26).Discontinued orders included atropine (for dilation and relaxation of the eye) 1% eye drops, give one drop to the left eye twice daily (8/7/26-8/18/26).Review of the electronic medication administration record (eMAR) from 8/1/26-8/24/26 indicated the resident missed the following eye medications:On 8/3/26 from 7:00 a.m.-11:00 a.m., the erythromycin ointment was not given as the resident was not in the facility and was attending dialysis treatment.On 8/8/26 from 7:00 a.m.-11:00 a.m., the erythromycin ointment and the atropine eye drop were not given as the resident was attending dialysis treatment.On 8/11/26 from 7:00 a.m.-11:00 a.m., the erythromycin ointment and the atropine eye drop were not given as the resident was attending dialysis treatment.On 8/13/26 from 7:00 a.m.-11:00 a.m., the erythromycin ointment and the atropine eye drop were not given as the resident was attending dialysis treatment.On 8/18/26 from 7:00 a.m.-11:00 a.m., the erythromycin ointment and the atropine eye drop were not given as the resident was attending dialysis treatment.On 8/20/26 from 7:00 a.m.-11:00 a.m., the erythromycin ointment and the prednisolone acetate eye drop were not given as the resident was attending dialysis treatment.On 8/22/26 from 7:00 a.m.-11:00 a.m., the erythromycin ointment and the prednisolone acetate eye drop were not given as the resident was at dialysis.An 8/3/26 progress note, recorded on 8/13/26, indicated Resident B returned from an eye surgery appointment. New orders for multiple eye drops were received and implemented.An 8/9/26 progress note, recorded on 8/10/26, indicated slight drainage from the left eye and slight discomfort in the left eye. Eye drops were administered without issues.An 8/17/26 progress note indicated light red drainage noted from the left eye. The ophthalmology center was contacted and a voicemail was left.An 8/18/26 progress note indicated slight drainage from the left eye continued. The upper left eyelid was puffy, and the resident complained of pain in the eye.An 8/4/26 grievance form completed by Resident B indicated a concern that eye medications were not being administered. The grievance form indicated the action taken was a review of the resident's medications with staff. The grievance form was signed by the Social Services Director on 8/7/26. The grievance form was unsigned by the grievance official.An 8/14/26 grievance form completed by Resident B indicated concern that the eye medications were not being administered correctly. The grievance form indicated the action taken was an unanswered call to the ophthalmology office and a review of the medications. The grievance form was signed by the department head on 8/14/26 and signed by the grievance official on 8/17/26.During an interview on 8/24/26 at 2:04 p.m., LPN 1 indicated she usually worked the same assignment daily and was familiar with the residents and their medications. When a resident was outside the facility at the time of medication administration, she would document why the medication was not given and why the resident was outside the facility. Medication orders had a timeframe for administration, such as between 7:00 a.m. and 11:00 a.m., and medication could be given one hour before or one hour after this timeframe. If she noticed a pattern of missed doses because a resident was outside the facility, she would report this to the unit manager, DON, or call the physician to request a time change for the medication.On 8/24/26 at 2:15 p.m., LPN 2 indicated she usually worked the same assignment and was familiar with her residents and many of their medications. If she noticed a pattern of missed medications related to appointments such as dialysis, she would report this to the physician immediately and request a change in medication times. If a resident was not available when medications were due, she would document why in the resident's clinical record.On 8/24/26 at 2:25 p.m., the DON indicated that when a resident was not in the facility at the time of an ordered medication, staff were expected to document why the medication was not given. If a nurse noticed a pattern of missed medications, they were to report this immediately. The nurse would contact the DON and the physician to inform them of the missed doses and request changes to administration times. Resident B was missing eye drops while out at dialysis, and this should have been caught by staff. The facility should have contacted the physician and had the medication times changed. Resident B filed two grievances about not receiving her eye drops correctly. Medication concerns would have been a clinical issue, and the DON would have been responsible for ensuring correction. The grievance official verified issues were resolved and signed the form afterward. The grievances were tracked by the Social Services Department, and the Administrator served as the grievance official. The Administrator was currently on vacation.On 8/24/26 at 3:02 p.m., the Social Services Director indicated the grievance process allowed residents and others to report a concern. The concern or complaint was written on the orange grievance forms. The department responsible for the specific area of concern resolved the issue. The department head completed the review and action sections explaining how the complaint was resolved. The grievance official reviewed the grievance form and ensured resolution before signing and filing it. If the grievance was not resolved appropriately, it could be returned to the department head for further review and evaluation.On 8/24/26 at 3:05 p.m., the DON indicated the facility did not have a policy for following physicians' orders.This citation relates to Intake 3156544. 410 Indiana Administrative Code 16.2-3.1-37(a)

Based on observation, interview, and record review, the facility failed to ensure residents were free from chemical restraints regarding the use of antipsychotic medication without gradual dose reductions and/or documented behavioral indicators for use for 2 of 4 residents reviewed for the use of antipsychotic medications (Resident 19 and 13). Findings include: 1. Resident 19's clinical record was reviewed on 1/15/26 at 10:25 a.m. Current diagnoses included dementia severe with agitation, anxiety and bipolar disorder.The resident had a current physician's order for the following antipsychotic medication: Risperdal 1mg- give 1 tablet two (2) times daily. This order originated 11/25/24 (1 year and 2 months).A 12/22/25, quarterly, Minimum Date Set (MDS) assessment indicated the resident was moderately cognitively impaired, did not have either hallucinations or delusions during the assessment period, did not display maladaptive behaviors during the assessment period, and received antipsychotic and antidepressant medications.The resident's clinical record contained documentation of three behavioral events during the past three-and-a-half-month period (October 1, 2025, to January 16, 2026). The behavioral events did not contain documentation of hallucinations (see, hearing or feeling things that aren't present), delusions (fixed false beliefs), or psychotic behaviors (loss of contact with reality). The documented events occurred on 10/2/25, 10/6/25 and 11/4/25 and involved yelling, name calling, exit seeking, and refusing or resisting care.A 12/1/25, Pharmacy Recommendation indicated the following recommended dose reduction: . receives Risperidone 1 mg twice a day for expressions of distress related to dementia (e.g. dementia with psychosis). Recommendation: Please attempt a gradual dose reduction (GDR) of Risperidone to 0.5 mg in the morning and 1 mg in the afternoon. Rational for Recommendations: CMS [Center for Medicare/Medicaid Services] requires that antipsychotics, being used to treat expressions or indications of distress related to dementia, be evaluated at least quarterly with documentation regarding continued clinical appropriateness.GDR is attempted in 2 separate quarters, with at least 1 month between attempts.The medical provider declined the dose reduction and documented the following reply: Was placed on it while inpatient psych. Currently doing well on unit. Guardian has refused med changes. The form did not contain a statement of contraindication which included a risk benefit analysis (the evaluation of potential negative outcomes against the potential positive benefits to make an informed determination to determine if advantages outweigh the potential for harm.) The clinical record lacked documentation of any education to the guardian regarding the restrictions associated with the right to decline care and treatment and the requirement that medication be medically necessary at its current dosage to treat a current medical symptom or condition.A 1/16/26, Psychiatry Progress Note, indicated the resident received the antipsychotic medication Risperidone one tablet two times a day. The medication was started on 11/25/24 and was used to treat dementia. She displayed no hallucinations or delusions. The resident was tearful and stated she had been down in the dumps. She had periods of agitation due to behavioral and psychological symptoms of dementia. Her symptom of agitation was listed as intermittent exit seeking. The resident was negative for signs of anxiety, psychotic symptoms, or suicidal ideations. During an observation on 1/16/26 at 10:20 a.m., Resident 19 was resting on her bed. There was a person seated in a chair beside her. She was conversing with the visitor.During an observation on 1/20/26 at 12:51 p.m. the resident was seated on her bed in her room. She indicated she had eaten a good lunch. 2. Resident 13's clinical record was reviewed on 1/15/26 at 2:42 p.m. Current diagnoses included dementia with behavioral disturbances, schizoaffective disorder, depression and anxiety.The resident had a current physician's order for the following antipsychotic medication(s): Zyprexa 2.5 mg daily in the morning. This order originated 2/11/25 (11 months prior).Zyprexa 7.5 mg daily at bedtime. This order originated 2/11/25. A 1/7/26, quarterly MDS assessment indicated the resident was moderately cognitively impaired, did not have either hallucinations or delusions during the assessment period, did not display maladaptive behaviors during the assessment period, and received antipsychotic, antianxiety, antidepressant, and hypnotic medications.The resident's clinical record contained documentation of two behavioral events during the past three-and-a-half-month period (October 1, 2025, to January 16, 2026). The behavioral events did not contain documentation of hallucinations, delusions, or psychotic behaviors. The documented events occurred on 10/6/25 and 10/20/25 and involved refusing medication, yelling out, and cursing.A 1/7/26, Pharmacy Recommendation indicated the following recommended dose reduction: received an antipsychotic, Olanzapine (Zyprexa) 2.5 mg a day and 7.5 mg in the evening for Schizoaffective disorder since January 2025. Please consider a gradual dose reduction to 2.5 mg once a day and 5 mg in the evening. Rationale for Recommendation: CMS requires that antipsychotics, used to treat an enduring condition other than dementia, be evaluated at least quarterly with documentation regarding continues clinical appropriateness.The medical provider declined the dose reduction and documented the following: Resident has continued to have periods of delusions & increasing Namenda (dementia medication) dose today. The form did not contain a statement of contraindication which included a risk benefit. The clinical record lacked any documentation of delusions during the period of 10/1/25 to 1/16/26. A, 1/16/26, Psychiatry Progress Note, indicated: The resident received the antipsychotic medication Zyprexa 2.5 mg in the morning and 7.5 mg at bedtime for persecutorial delusions which become distressful to the resident. The resident had no hallucinations and was believed to have persecutorial delusions. The medication Zyprexa had not had a GDR and was contraindicated for reduction on 5/2/25, 8/8/25, 9/5/25, and 1/9/26.During an observation on 1/14/2026 at10:50 a.m., Resident 13 was participating in a group activity. She was calm, smiling and participating.During an observation on 1/16/26 at 10:19 a.m., the resident was resting on her bed. She was awake and calm. During an observation on 1/20/26 at 12:51 p.m., the resident was seated on the side of her bed in her room. She was calm. During an interview on 1/20/26 at 12:47 p.m., the Dementia Unit Director indicated Resident 13 did not display maladaptive behaviors and she had never witnessed her display signs of delusions or hallucinations. Resident 19 wandered some, but did not display behaviors that negatively impacted her quality of life or quality of care. Resident 19 did have a past history of assault and at times appeared to believe that event was current or just happened.During an interview on 1/20/26 at 12:53 p.m., C.N.A. 13 indicated Resident 13 called down the hall at times and forgot she had received her medications. Resident 13 did not appear to have delusions or hallucinations. Resident 19 did not display negative behaviors and did not appear to have delusions or hallucinations.During an interview on 1/20/26 at 12:57 p.m., LPN 12 indicated Resident 13 sometimes yelled down the hallway wanting her medication or forgetting she had her medication. She did not display symptoms of hallucinations or delusions. Resident 19 sometimes displayed exit seeking behaviors and went to the backdoor to go outside and smoke. The resident did not display symptoms or hallucinations.During an interview on 1/20/26 at 1:01 p.m., C.N.A. 11 indicated Resident 13 often spoke loudly or called out down the hallway, but she didn't display negative behaviors nor appear to have hallucinations or delusions. Resident 19 did not display negative behaviors and did not appear to have delusions or hallucinations.During an interview on 1/20/26 at 1:29 p.m., the Social Services Director, Social Services Assistant, and Dementia Unit Director each indicated the facility did not have statements of contraindication for GDRs of antipsychotic medications for Residents 13 and 19 which included a risk benefit analysis. The facility did not have any additional documentation of hallucinations, delusions, psychosis or maladaptive behaviors displayed by Residents 13 and 19 from October 1, 2025, until present. Maladaptive behaviors were to be documented in the resident's clinical record. Review of a current 7/2025, facility policy titled Psychotropic Management, provided by the Administrator via email on 1/20/26 at 12:42 p.m., indicated the following: .Gradual dose reductions (GDR) and the use of non-pharmacological interventions will occur for residents receiving psychotropic medication unless contraindicated by the prescriber with specific rationale why the reduction was not indicated.5. For antipsychotic medications, diagnoses alone do not necessarily warrant the use the medications (sic). Antipsychotic medication may be indicated if:a. behavior symptoms present a danger to the resident or others;b. expressions or indications of distress that are significant distress to the resident;.c. GDR was attempted but symptoms returned. 3.1-3(w)3.1-26(k)(1)(o)

Based on observation, record review, and interview, the facility failed to implement immediate fall interventions and/or follow fall interventions to prevent further falls for a dependent resident at high risk for falls for 1 of 5 residents reviewed for accidents. (Resident 112)Finding includes:During an observation on 1/14/26 at 2:03 p.m., Resident 112 was seated in her wheelchair at the table in the dining room and being assisted with her meal. Resident 112's clinical record was reviewed on 1/14/26 at 3:16 p.m. Diagnoses included Alzheimer's Disease, atrial fibrillation, abnormal posture, unsteadiness on feet, and other abnormalities of gait and mobility. Current orders included metoprolol tartrate (blood pressure/heart rate) 25 mg every 12 hours (8/26/25).A 10/17/25, annual, Minimum Data Set (MDS) assessment indicated the resident was severely cognitively impaired. A wheelchair was used for mobility. The resident was dependent on staff assistance for eating toileting, bathing, dressing, footwear, and personal hygiene. She required substantial staff assistance to stand and transfer. Resident 112 had one fall with injury since the prior assessment. A current care plan, dated 6/3/22, indicated the resident was at risk for falls due to advanced age, incontinence, high risk medication use, impaired cognition, impaired mobility, Alzheimer's disease, dementia, anxiety, hypertension, unsteadiness on feet, and abnormalities of gait and mobility. Interventions included the following: Assist the resident to the recliner or bed after meals (6/6/22), the resident is a high fall risk (6/30/23), transfer the resident to a standard chair for all meals (7/11/25), therapy screening for the resident (10/22/25), labs to rule out an acute illness (10/27/25), and therapy screening for the resident (12/15/25). Review of the resident's fall risk assessments for July 2025 and October 2025 indicated the resident was at high risk for falls.Resident 112's fall events, immediate interventions, and progress notes indicated the following:On 7/11/25 at 7:26 a.m., the resident had an unwitnessed fall from her wheelchair in the dining room. The fall resulted in pain and an abrasion to the head. Continued resident care was the immediate intervention. On 7/11/25 at 10:44 a.m., the Interdisciplinary Team (IDT) note indicated the resident had a fall on 7/11/25 at 7:26 a.m. after she was wheeled to the dining room for breakfast. Ice was applied to the abrasion to the scalp, and the resident was assisted to bed for an immediate intervention. An intervention for the resident to be transferred to a standard chair for all meals was put into place to address the root cause of the fall. On 10/20/25 at 2:15 p.m., the resident had an unwitnessed fall with no injuries from her wheelchair in the dining room. The resident was placed in bed after her meal for the immediate intervention. On 10/21/25 at 10:44 a.m., the Interdisciplinary Team (IDT) note indicated the resident had a fall on 10/20/25 at 2:15 p.m. when the resident was found in the floor in the dining room. The resident was assessed and assisted back into the wheelchair for an immediate intervention.On 10/25/25 at 10:50 a.m., the clinical record lacked a fall event note with all the details of the resident's fall and immediate intervention.On 10/25/25 at 11:28 a.m., the resident had an unwitnessed fall with no injuries from her wheelchair in the dining room after she finished breakfast. The resident was placed in bed for the immediate intervention. On 10/25/25 at 11:35 a.m., a progress note indicated Resident 112 had two unwitnessed falls within the same time. The falls on 10/25/25 occurred at 10:50 a.m. and 11:20 a.m. (Details of each fall were not included.) On 10/27/25 at 10:15 a.m., the Interdisciplinary Team (IDT) note indicated the resident had two falls on 10/25/25. One occurred at 10:50 a.m. and another one at 11:20 a.m. Both falls were similar in the way they occurred. The resident was assisted back into the wheelchair for a small activity as an immediate intervention for the first fall. The resident was assisted to bed as an immediate intervention for the second fall that day.On 10/27/25 at 8:27 p.m., a progress note indicated a urinalysis was collected from the resident. On 12/14/25 at 6:26 a.m., the resident had a witnessed fall, near the nurse's station, when the resident leaned forward and slipped out of the wheelchair. A contributing factor was the resident's wheelchair pad was placed upside down by the night shift aide. The resident was sent to the emergency room for as an immediate intervention. On 12/14/25 at 10:30 a.m., a progress note indicated the resident had a witnessed fall early that morning with no sign of injury at the time of the fall. Upon reassessment, after 20 minutes, the resident was lethargic, sleepy, and had bruising to the top of the forehead. The provider was notified of the change in condition, and an order was obtained to send the resident to the Emergency Room.On 12/15/25 at 10:06 a.m., the IDT note indicated the resident had a fall from the wheelchair on 12/14/25 at 6:26 a.m. The resident was assessed and assisted back into the wheelchair as an immediate intervention. During an observation on 1/16/26 at 1:01 p.m., QMA 7 assisted Resident 112 down the hallway in her wheelchair from her room to the dining room. QMA 7 positioned the resident at the end of the dining room table in her wheelchair and locked the wheels. Resident 112 was not placed into a standard chair (according to her fall interventions). QMA 7 left the dining room and returned to the J Hall to assist other residents to the dining room. No staff were present in the dining room supervising until 1/16/26 at 1:10 p.m. A male staff member entered the dining room, but Resident 112 remained in the wheelchair. On 1/16/26 at 1:25 p.m., Resident 112's meal tray was delivered. The resident remained in her wheelchair and was assisted by a staff member with her meal. Interviews indicated the following:On 1/16/26 at 1:34 p.m., LPN 4 indicated Resident 112 was seated at the dining room table in her wheelchair while she was assisted with her meal. The resident was at high risk for falls due to cognitive impairment, a history of falls, non-verbal communication, and unsteadiness on her feet. The resident's fall intervention for a standard chair was not being followed. Failure to follow the resident's fall interventions placed the resident at risk for further falls. On 1/20/26 at 1:04 p.m., CNA 8 indicated Resident 112 had the following fall interventions: the resident required a gait belt for transfers, the resident was to be transferred to a standard chair in the dining room for all meals and required to be checked in bed and changed. On 1/20/26 at 1:38 p.m., RN 6 indicated nurses were required to complete a fall event to include an assessment of the resident with each fall. With each fall, the nurse must initiate a resident specific intervention to prevent further falls. The aides were aware of the fall interventions by report between shifts and by referencing the CNA care sheets.On 1/20/26 at 2:01 p.m., Unit Manager 9 indicated Resident 112 had a fall intervention on the CNA care sheet to be transferred to a standard chair for meals. The fall interventions on the CNA care sheets should have been followed. Failure to follow the fall interventions placed the resident at risk for further falls. The CNA care sheets were always available to the CNAs and were updated daily. Each fall required a new fall event, assessments, and surrounding events even when the falls occur on the same day. Unit Manager 9 could not provide two separate events for Resident 112's falls that occurred on 10/25/25. On 1/20/26 at 2:22 p.m., the DON indicated residents should have separate fall events for each fall to include immediate interventions to prevent further falls at the time of the fall. Failure to follow fall interventions placed the residents at risk for further falls. On 1/20/26 at 3:18 p.m., the Administrator indicated, on 1/16/26, the CNA care sheets lacked Resident 112's fall intervention to be placed in a standard chair at mealtimes. It had not pulled forward on the CNA care sheets from the resident's care plan. The CNAs were not aware of the intervention.A current facility policy, last revised 8/2022, titled Fall Management Policy, provided by the Administrator on 1/20/26 at 12:24 p.m., indicated the following: POLICY: It is the policy. to ensure residents residing within the facility receive adequate supervision and or assistance to prevent injury related to falls. Facilities must implement comprehensive, resident-centered fall prevention plans for each resident at risk for falls or with a history of falls.3.1-45(a)(2)

Based on observation, recorded review, and interview, the facility failed to ensure residents were assessed for and deemed appropriate to self-administer medications for 1 out of 3 residents reviewed for medication administration. (Resident J) Findings include:During an interview and observation on 11/17/2025 at 10:28 a.m., Resident J indicated her morning medications had been given to her between 9:00 a.m. and 9:30 a.m. On the over-the- bed table, medication cup with several pills was observed. The resident indicated she had too many pills to take in the morning at one time.During an interview on 11/17/2025 at 10:31 a.m., LPN 6 indicated she had left the medication at the bedside during the morning medication administration pass. She indicated medications should not be left at the bedside. LPN 6 identified the medications in the medication cup as follows: amlodipine (calcium channel blocker) tablet 2.5 mg, ascorbic acid (vitamin C) tablet 500 mg, cyanocobalamin (vitamin B-12) tablet 1,000 mcg, fluoxetine capsule (anti-depressant) 40 mg, furosemide (diuretic) tablet 40 mg, losartan (hypertensive) tablet 25 mg, magnesium gluconate (supplement) tablet 27 mg, metoprolol succinate (beta blocker) tablet 12.5 mg, pramipexole (non-ergot dopamine agonist) tablet 0.5 mg. These medications were confirmed with physician's medication orders.During an interview on 11/17/2025 at 2:10 p.m., LPN 3 indicated medications were only left at the bedside if there was a physician's order.Resident J's clinical record was reviewed on 11/17/2025 2:43 p.m. Diagnoses included chronic obstructive pulmonary disease, acute and chronic respiratory failure with hypoxia, pulmonary edema, congestive heart failure, multiple sclerosis, chronic pain, iron deficiency anemia, depression, unspecified, gastro-esophageal reflux disease, osteoarthritis, spinal stenosis, Other abnormalities of gait and mobility, Encounter for other specified aftercare, personal history of sudden cardiac arrest, presence of cardiac pacemaker, pulmonary hypertension, unspecified, chronic pain syndrome, glaucoma, hypertension, and nonrheumatic tricuspid valve insufficiency.The clinical record lacked a physician's order to leave medications at bedside.The clinical record lacked a physician's order for the resident to self-administer medications left at bedside.A current quarterly Minimum Data Set (MDS) assessment indicated the resident was cognitively intact. A 11/14/25 quarterly Minimum Data Set (MDS) assessment indicated the resident was cognitively intact.During an interview on 11/19/2025 at 11:02 a.m., the DON indicated it was the facility expectation that medications were not left at the bedside. The DON indicated LPN 6 should not have left Resident J's medications at the bedside. A current policy, dated 2/2010, titled Medication Administration (Medication Pass Procedure) was provided by the DON ono 11/17/2025 at 1:42 p.m. The policy indicated the following: 11. Observed resident taking medications -- Meds not left at bedside. 3.1-37(a)

Based on record review and interview, the facility failed to accurately assess for fall risks, to implement fall interventions, and to thoroughly document falls for 1 of 3 residents reviewed for falls with injury. (Resident F) Findings include: Resident F's clinical record was reviewed on 11/26/24 at 4:00 p.m. Diagnoses included unspecified dementia, difficulty walking, and history of falling. A 8/29/24, Geriatric Interim Care Note from Resident F's admission paperwork indicated the following: fall one week ago on 8/21/24, with right hip pain ongoing. The fall one week ago was out of a chair onto right hip, did not hit head, able to get up unassisted. Hip was painful without improvement. He still walked and bore his own weight. Dementia with behavioral disturbances, likely mixed vascular and Alzheimer's Disease. He had been getting more assistance with ADLs and iADLs, which family had been providing. Skilled nursing placement required for wound care. A 9/3/24, Admission Fall Assessment document indicated the resident had no falls in the previous six months, was incontinent of bowel and bladder, no tethering equipment, no mobility issues, and had an altered awareness of his surroundings. The fall assessment score was 9, which indicated a moderate fall risk. A new admission care plan, dated 9/3/24, indicated implementation of services to include assistance with activities of daily living. The approaches included the following: Assist with transfers, ambulation, bed mobility, toileting and/or incontinent care, eating/drinking, and bathing/hygiene, including oral/dental care. Provide fall prevention interventions: (call light in reach, area free of clutter, room orientation, non-skid footwear when out of bed, other). A progress note, dated 9/3/24 at 5:00 p.m., indicated the resident arrived with family, ambulated with a walker, was continent of bowel and bladder, and was seen with walker, peering under the bed. Resident F was shown the call light and told to alert staff if something was needed. Resident F was very unsteady on feet and left walker outside of bathroom and would not allow staff to help him. A late entry progress note, dated 9/3/24 at 6:45 p.m., initiated on 9/4/24 at 4:56 p.m., indicated the resident was found on the floor, in the doorway, seated upright with legs extended. Resident F was previously seen in bed. Resident was assessed for injury, assisted to stand, and given his walker. He indicated he fell . A late entry progress note, dated 9/3/24 at 7:16 p.m., initiated on 9/4/24 at 4:57 p.m., indicated the Director of Nursing (DON) and family were notified of fall and a new order to send the resident to the emergency room for assessment. A progress note, dated 9/3/24 at 7:59 p.m., indicated the resident was found lying on the floor, on his left side. There was a large amount of blood and an open area to his head that was larger than when he arrived. Resident F was assessed and assisted into a chair. Resident F was alert and answered questions. Pressure was held to the wound. Physician was notified and an order to send to the emergency room was given. A 9/4/24, Interdisciplinary Team (IDT) Fall note indicated the resident was a new admit and was observed ambulating with a walker. He had an unsteady gait prior to the fall. He was observed lying on his left side in street clothing and non skid shoes. He stated he was unsure what he was attempting to do. Staff earlier reported him attempting to look under furniture. Resident F received a laceration to the head. Resident F was sent to the emergency room for evaluation and treatment. He was admitted to the hospital. Root cause found to be new admission with confusion to immediate surroundings and unsteady gait. Care plan was updated. A 9/3/24 Fall Event, initiated on 9/4/24 at 4:47 p.m., indicated the resident had an unwitnessed fall without injury. The resident was previously seen lying in bed. The immediate intervention was to assess the resident and assist back to standing position. A 9/3/24 Fall Event, initiated on 9/3/24 at 7:59 p.m., indicated the resident had an unwitnessed fall with head pain and a laceration. The resident was up with walker in room. The immediate intervention was to send the resident to the emergency room for evaluation. A progress note dated 9/4/24 at 7:48 a.m., indicated the resident was admitted to the hospital with the diagnosis of a brain bleed. During an interview, on 11/26/24 at 12:23 p.m., RN 7 indicated when a resident fell , the staff needed to immediately assess the resident and the environment before moving them. The electronic medical record had a fall event staff were to complete with as much information as possible. This included vitals signs, the circumstances of the fall, and the new interventions immediately used after the fall. Fall interventions should be specific to each resident and the needs of the resident. The DON and physician should be called immediately. During an interview, on 11/27/24 at 11:14 a.m., the ADON indicated when a new resident admitted to the facility, the nursing staff received an intake referral form and general hospital or physician paperwork. The staff were able to access and review this information about a resident's condition and diagnosis. She was not on staff when Resident F admitted . During an interview, on 11/27/24 at 11:29 a.m., the DON indicated the nurses on staff reported falls to her. At the time of this report, the DON and staff member reviewed the current fall interventions and immediately added new interventions to prevent further falls. The fall interventions were reviewed in the next IDT meeting to ensure they were appropriate or if they should be changed. The DON indicated the staff member working the night Resident F admitted and had two falls did not follow the policies and procedures of the facility. A current facility policy, revised 8/22, titled, Fall Management Policy, provided by the Administrator on 11/27/24 at 12:51 p.m., indicated the following: . 1. Fall risk/fall prevention will be assessed upon admission . 2. All new admission will be considered a fall risk based upon his/her new living arrangements and his/her reasons for being admitted into the nursing facility. 3. A care plan will be developed at the time of admission with specific care plan interventions to address each resident's fall risk factors . 5. Residents who are categorized as moderate to high risk should have fall interventions based on resident specific risk factors .Post Fall . A fall event will be initiated as soon as the resident has been assessed and cared for. The report must be completed in full in order to identify possible root causes of the fall and provide immediate interventions This citation relates to Complaint IN00448034. 3.1-45 (a)(2)

Based on record review and interview, the facility failed to ensure shift-to-shift narcotic count and reconciliation was completed for 6 of 7 medication carts reviewed for medication reconciliation. (Carts HI, [NAME], [NAME], C, D, and Cottage 2) Findings include: 1. During a medication storage observation of the HI medication cart, on 10/25/24 at 11:27 a.m., accompanied by LPN 7, the Narcotic Count Sheet was reviewed and the following dates lacked shift-to-shift count and reconciliation signatures of controlled medications: October 2024- lacked a narcotic card count: 1st, 2nd, 3rd, 4th, 5th, 6th, 7th, 8th, 9th, 10th, 11th, and 12th. October 2024- lacked shift-to-shift narcotic reconciliation signatures: 10/2: 6:00 a.m. - 2:00 p.m., 10/5: 6:00 a.m. - 2:00 p.m. and 2:00 p.m. - 10:00 p.m., 10/6: 6:00 a.m. - 2:00 p.m., 10/9: 6:00 a.m. - 2:00 p.m. and 2:00 p.m. - 10:00 p.m., 10/10: 6:00 a.m. - 2:00 p.m., 10/12: 6:00 a.m. - 2:00 p.m. and 10:00 p.m. - 6:00 a.m. 10/25: 6:00 a.m. - 2:00 p.m. During an interview, at the time of observation, LPN 7 indicated no one had signed the narcotic count for the HI cart for days shift on 10/25/24. She had been late that day and LPN 6 completed the shift to shift narcotic count with the night shift nurse prior to her arrival. She had completed a shift to shift narcotic count with LPN 6 upon her arrival but neither of them had completed the reconciliation when the HI cart was transferred from one employee to the next. The shift to shift narcotic counts and signatures were required each time the medication cart was transferred from one employee to the next. 2. During a medication storage observation of the [NAME] medication cart, on 10/25/24 at 10:12 a.m., accompanied by LPN 8, the Narcotic Count Sheet was reviewed and the following dates lacked shift-to-shift count and reconciliation signatures of controlled medications: October 2024- lacked a narcotic card count: 1st, 2nd, 3rd, 4th, 5th, 6th, 7th, 8th, 9th, 10th, 21st, 22nd, 23rd, and 24th. October 2024- lacked shift-to-shift narcotic reconciliation signatures: 10/1: 10:00 p.m. - 6:00 a.m.- 2:00 p.m., 10/7: 2:00 p.m. - 10:00 p.m., 10/8: 2:00 p.m. - 10:00 p.m., 10/9: 6:00 a.m. - 2:00 p.m. 3. During a medication storage observation of the [NAME] medication cart, on 10/25/24 at 11:42 a.m., accompanied by LPN 6, the Narcotic Count Sheet was reviewed and the following dates lacked shift-to-shift count and reconciliation signatures of controlled medications: October 2024- lacked a narcotic card count: 1st, 2nd, 3rd, 4th, 5th, 6th, 7th, 8th, 9th, 10th, 22nd, and 23rd. October 2024- lacked shift-to-shift narcotic reconciliation signatures: 10/1: 2:00 p.m.- 10:00 p.m. and 10:00 p.m. - 6:00 a.m., 10/2: 2:00 p.m. - 10:00 p.m., 10/4: 2:00 p.m. - 10:00 p.m., 10/5: 6:00 a.m. - 2:00 p.m., 2:00 p.m. - 10:00 p.m., 10/6: 6:00 a.m. - 2:00 p.m., 2:00 p.m. - 10:00 p.m., and 10:00 p.m. - 6:00 a.m., 10/9: 2:00 p.m. - 10:00 p.m., 10/10: 6:00 a.m. - 2:00 p.m., 2:00 p.m.- 10:00 p.m., 10:00 p.m. - 6:00 a.m. During an interview, at the time of observation, LPN 6 indicated the narcotic count sheet should have been completed by both staff members when the medication cart was transferred from one staff member to another. A count should have included the number of controlled medication cards and bottles with each transfer of the medication carts. 48146 4. During a medication storage observation of the D hall medication cart, on 10/25/24 at 12:15 p.m., accompanied by RN 3, the Narcotic Count Sheet sheet was reviewed and the following dates lacked shift to shift count and reconciliation signatures of controlled medications: October 2024- lacked a narcotic card count 1st, 2nd, 3rd, 4th, 5th, 6th, 7th, 8th, 9th, 11th, 12th, 13th,14th, 15th, 19th, 20th, 21st, 22nd, and 23rd. October 2024- lacked shift-to-shift narcotic reconciliation signatures 10/1: 6:00 a.m. - 2:00 p.m., 2:00 p.m. - 10:00 p.m., 10:00 p.m. - 6:00 a.m., 10/2: 6:00 a.m. - 2:00 p.m. and 10:00 p.m. - 6:00 a.m., 10/4: 6:00 a.m. - 2:00 p.m. and 2:00 p.m. - 10:00 p.m., 10/9: 2:00 p.m. - 10:00 p.m., 10/17: 10:00 p.m. - 6:00 a.m., 10/21: 6:00 a.m. - 2:00 p.m., 10/23: 6:00 a.m. - 2:00 p.m. 5. During a medication storage observation of the C hall medication cart, on 10/25/24 at 12:15 p.m., accompanied by RN 3, the Narcotic Count Sheet sheet was reviewed and the following dates lacked shift to shift count and reconciliation signatures of controlled medications: October 2024- lacked a narcotic card count 1st, 2nd, 3rd, 4th, 5th, 6th, 7th, 8th, 9th, 11th, 12th, 13th, 14th, 15th, 16th, 19th, 20th, 21st, 22nd, and 23rd. October 2024- lacked shift-to-shift narcotic reconciliation signatures 10/1: 2:00 p.m. - 10:00 p.m. and 10:00 p.m. - 6:00 a.m., 10/2: 10:00 p.m. - 6:00 a.m., 10/6: 6:00 a.m. - 2:00 p.m. and 2:00 p.m. - 10:00 p.m., 10/7: 2:00 p.m.- 10:00 p.m. and 10:00 p.m. - 6:00 a.m., 10/8: 2:00 p.m. - 10:00 p.m. and 10:00 p.m. - 6:00 a.m., 10/9: 10:00 p.m. - 6:00 a.m. During an interview, at the time of the observations, RN 3 indicated her assignment included using both carts to administer medication. The sign in/sign out sheet was to be completed by nurses at the beginning and ending of their shifts. 6. During a medication storage observation of the Cottage 2 medication cart, on 10/25/24 at 12:24 p.m., accompanied by LPN 4, the Narcotic Count Sheet sheet was reviewed and the following dates lacked shift to shift count and reconciliation signatures of controlled medications: October 2024- lacked a narcotic card count 1st, 2nd, 3rd, 4th, 5th, 6th, 7th, 8th, 9th, 10th, 11th, 13th, 16th, 17th, 18th, and 20th. October 2024- lacked shift-to-shift narcotic reconciliation signatures 10/2: 2:00 p.m. - 10:00 p.m., 10/3: 2:00 p.m. - 10:00 p.m. and 10:00 p.m. - 6:00 a.m., 10/4: 10:00 p.m. - 6:00 a.m., 10/5: 6:00 a.m. - 2:00 p.m., 2:00 p.m. - 10:00 p.m., and 10:00 p.m. - 6:00 a.m., 10/7: 10:00 p.m. - 6:00 a.m., 10/10: 6:00 a.m. - 2:00 p.m. and 2:00 p.m. - 10:00 p.m., 10/11: 6:00 a.m. - 2:00 p.m., 2:00 p.m. - 10:00 p.m., and 10:00 p.m. - 6:00 a.m., 10/12: 6:00 a.m. - 2:00 p.m. and 2:00 p.m. - 10:00 p.m., 10/24: 2:00 p.m.- 10:00 p.m. During an interview, at the time of the observations, LPN 4 indicated the sign in/sign out sheet was completed at the beginning and end of each shift to verify the narcotic count was correct. During an interview, on 10/25/24 at 1:43 p.m., the DON indicated she discovered the facility was utilizing the wrong sign in/sign out forms and changed them on October 10th. The expectation for staff was for the sheet to be filled out completely. The oncoming nurse and offgoing nurse count narcotics and sign the count sheets at the beginning and end of every shift to help prevent drug diversion. A current facility policy, revised 8/1/24, titled, Inventory Control of Controlled Substances, provided by the DON on 10/28/24 at 1:49 p.m., indicated the following: . Facility should ensure that the incoming and outgoing nurse count all Schedule II controlled substances and other medications with a risk of abuse or diversion at the change of each shift or at least once daily and document the results on a Controlled Substance Count Verification/Shift Count Sheet. Facility should: Reconcile the total number of controlled medications on hand, add newly received medications to the inventory, and removed medications that are completed or discontinued from the inventory . 3.1- 25(b)(3)

Based on observation, interview, and record review, the facility failed to implement enhanced barrier precautions (EBP) during high contact care for 3 of 6 residents reviewed for infection control. (Residents 41, 2, and 79) Findings include: 1. During an observation on 10/23/24 at 11:16 a.m., there was no indication of EBP outside of Resident 41's room. A Resident Matrix document, provided by the facility on 10/23/24, indicated Resident 41 had a Stage III (full-thickness skin loss, exposing fat tissue but not muscle, tendon, or bone) pressure ulcer. During an observation on 10/24/24 at 4:29 p.m., the resident was in bed on a low air loss mattress. There was no indication of EBP outside or inside the resident's room. Resident 41's clinical record was reviewed on 10/25/24 at 10:22 a.m. Diagnoses included, dementia, anorexia, unspecified severe protein-calorie malnutrition, and abnormal posture. A current physician order, dated 10/10/24, included Santyl (wound treatment) ointment 250 units per gram - cleanse open area to the sacrum with normal saline and apply Santyl to the wound bed and cover with a foam dressing. The clinical record lacked indication of enhanced barrier precautions. A quarterly Minimum Data Set (MDS) assessment, dated 9/27/24, indicated the resident was cognitively impaired. She was dependent on staff assistance for toileting, dressing, transfers, and personal hygiene. The resident had an unhealed pressure ulcer. The clinical record lacked a care plan for enhanced barrier precautions. During a wound care observation on 10/25/24 from 10:24 a.m. to 10:40 a.m. , upon entry to the room, there was no indication of EBP inside or outside the room. LPN 6 and the ADON performed hand hygiene and donned gloves prior to the wound treatment. Gowns were not readily available for use inside the room. Both staff members walked over to the resident's right side of her bed, which was against the wall, leaned in against the resident's bed linens with their exposed clothing, and assisted the resident onto her left side for wound care on her right buttock near the sacrum. The old dressing was removed from the open right buttock wound, with scant serous drainage noted. Following wound care, LPN 6 and the ADON provided perineal care as they leaned in against the resident's bed linens with their exposed clothing. Gowns were not worn by either staff member during the course of the observation. During an interview on 10/29/24 at 11:59 a.m., CNA 11 indicated staff were required to wear a gown and gloves for high contact care activities when a resident was in enhanced barrier precautions. She was made aware when a resident was in enhanced barrier precautions by the enhanced barrier precaution signs hung outside the residents' doors. Specific precautions were also listed on the CNA assignment sheets. She indicated she was providing care for Resident 41 on this date and had not followed enhanced barrier precautions for her high contact care because the resident was not in enhanced barrier precautions. She had only worn gloves. The resident had a chronic wound, but had not been placed in enhanced barrier precautions. She knew residents with catheters required enhanced barrier precautions, but she was uncertain what other reasons a resident may need enhanced barrier precautions. Review of the provided CNA assignment sheet, at the time of the interview, lacked indication of enhanced barrier precautions. During an interview on 10/29/24 at 12:15 p.m., LPN 6 indicated residents with enhanced barrier precautions had a sign outside their room, above their bed, and an order in their chart for enhanced barrier precautions. Enhanced barrier precautions were required for residents with catheters, open wounds, and ostomies. Resident 41 should have had enhanced barrier precautions implemented by the Infection Preventionist, but it was not implemented. Since the sign was not present, she and the ADON had not followed enhanced barrier precautions during the resident's wound care observation and perineal care on 10/25/24. She should have known to follow enhanced barrier precautions, even though signs were not posted, since the resident had an open wound. A gown and gloves were required during the resident's high-contact care. During an interview on 10/29/24 at 12:31 p.m., the ADON indicated enhanced barrier precautions should have been previously initiated when the resident's open wound was identified. 48146 2. Resident 2's clinical record was reviewed on 10/25/24 at 9:30 a.m. Diagnosis included spastic quadriplegic cerebral palsy, unspecified severe protein-calorie malnutrition, oropharyngeal dysphagia, and epilepsy. A physician's order, dated 5/17/24, indicated may crush appropriate medications and administer per gastrostomy tube. Check placement of gastrostomy tube and check residuals (fluid or contents in the stomach). A physician's order, dated 6/4/24, indicated enteral feeding (to provide nutrition), gastrostomy tube, size 18 French (diameter of the tube). An isolation care plan, dated 6/10/24, indicated the resident was at risk of transferring Multidrug-Resistant Organisms (MDROs) and required enhanced barrier precautions related to indwelling medical devices. The approaches included to use standard precautions including hand hygiene and to wear gown and gloves for high-contact resident care activities. During an observation, on 10/23/24 at 9:50 a.m., Resident 2's room had an Enhanced Barrier Precautions sign on the wall directly beside the door. Personal protective equipment (PPE) was in a plastic container directly below the sign. Resident 2 was lying in bed with an enteral tube pump at bedside. During a medication administration observation, on 10/25/24 at 8:21 a.m., RN 3 crushed medications for Resident 2. RN 3 donned gloves and lifted the resident's gown to access the gastrostomy tube to her left abdomen and completed the medication administration. During an interview, on 10/25/24 at 8:51 a.m., RN 3 indicated Resident 2 was in enhanced barrier precautions and she had forgotten to don a gown while providing care to her gastrostomy tube. The enhanced barrier precaution required staff to wear protection when working with resident that have catheters, gastrostomy tubes and wounds or openings in the skin to prevent the spread of infection. 3. Resident 79's clinical record was reviewed on 10/28/24 at 10:08 a.m. Diagnosis included malignant neoplasm of the prostate, type 2 diabetes mellitus, benign prostatic hyperplasia, and a stage 3 (full thickness tissue loss) pressure ulcer to left heel. A physician's order, dated 10/22/24, indicated cleanse left heel wound with Dakin's (an antiseptic) solution, apply Hydrofera Blue (to treat bacteria and protect) to wound bed every 3 days on day shift and as needed. An isolation care plan, dated 4/17/24, indicated Resident 79 was at risk of transferring MDRO's and required enhanced barrier precautions related chronic wounds requiring a dressing. The approaches included to use standard precautions including hand hygiene and to wear gown and gloves for high contact resident care activities. During a wound care observation, on 10/28/24 at 9:47 a.m., Resident 79 was lying in bed. An enhanced barrier precautions sign was taped to the wall at the foot of his bed. His bed was against the wall horizontally. Two nursing staff members performed hand hygiene and donned gloves. The Unit Manager set up a sterile field on the bedside table. LPN 6 was assisting by holding the residents left leg up at the ankle. The Unit Manager removed the bandage to the resident's left leg. The open wound was approximately the size of a quarter. The Unit Manager performed wound care while LPN 6 held the resident's leg. The Unit Manager gathered the used supplies and trash to dispose of and performed hand hygiene. During an interview, at the time of the observation, LPN 6 and the Unit Manager both indicated Resident 79 was on enhanced barrier precautions for his open wound and they had both forgotten to don a gown prior to beginning his wound care treatment. LPN 6 indicated enhanced barrier precautions were to be worn when working with residents that have catheters, feeding tubes, and open wounds. During an interview, on 10/30/24 at 1:51 p.m., the DON indicated it was the expectation for staff to follow all the guideline for enhanced barrier precautions. These precautions assist in preventing the spread of infections. The residents who required enhanced barrier precautions had catheters, feeding tubes, MDRO's, and open wounds requiring a dressing. During an interview, on 10/30/24 at 2:25 p.m., the Infection Preventionist indicated staff were expected to understand the enhanced barrier precautions protocols. She placed signs and PPE at the residents' rooms that required enhanced barrier precautions. All staff should have worn PPE when providing care for an open wound or giving medications through a gastrostomy tube. A current facility policy, revised 4/24/24, titled, Standard Precautions and Transmission- Based Precautions (Isolation) Policy, provided by the DON on 10/28/24 at 1:49 p.m., indicated the following: .Enhanced Barrier Precautions (EBP): An intervention designed to reduce the transmission of resistant organisms that employs targeted use of gown and glove use during high contact resident care activities. EBP expands the use of PPE beyond situations in which exposure to blood and body fluids is anticipated, it refers to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing. Enhanced barrier precautions are used for: Resident(s) with chronic wounds and/or indwelling medical devices, regardless of their MDRO status .Wounds generally include .pressure ulcers . Indwelling medical device examples include .feeding tubes . 3.1-18(l)

Based on observation and interview, the facility failed to appropriately discard expired insulin pens and label medications with resident information in 2 of 6 medication carts observed for medication storage. (D and Cottage 2) Findings include: 1. During a medication storage observation of the D hall medication cart, accompanied by RN 3, on [DATE] at 12:15 p.m., the following was observed: One unlabeled 8 milligram (mg) ondansetron (to prevent vomiting) blister packaged pill. One glargine (insulin) pen, with approximately 25 units remaining, with an open date of [DATE]. During an interview, at the time of the observation, RN 3 indicated the ondansetron pill must have fallen out of the bag and the insulin was expired and should not be given to the resident. 2. During a medication storage observation of the Cottage 2 medication cart, accompanied by LPN 4, on [DATE] at 12:24 p.m., the following was observed: One unlabeled bottle of morphine (a narcotic pain reliever) with approximately 14 units remaining. During an interview, at the time of the observation, LPN 4 indicated the bottle had been removed from the facility's medication management system and should have been labeled with resident information. A current facility policy, revised [DATE], titled, Storage and Expiration Dating of Medications and Biologicals, provided by the Administrator on [DATE] at 10:46 a.m., indicated the following: .11. Once a medication or biological package is opened, facility should follow manufacture/supplier guidelines with respect to expiration dates for opened medications .12. Facility should destroy and reorder medications and biologicals with soiled, illegible,worn, makeshift, incomplete, damaged, or missing labels . A current facility document, dated 2022, titled, Dating Medications & Supplies, provided by the Administrator on [DATE] at 11:50 a.m., indicated the following: .Discard expired/undated medications and supplies . 3XXX,d+[DATE] (j) 3XXX,d+[DATE] (k)

Based on observation, interview, and record review, the facility failed to complete verification of the correct type of insulin prior to administration for 1 of 3 residents reviewed for insulin use, resulting in the wrong type of insulin being given. (Resident B) Findings include: Resident B's clinical record was reviewed on 4/4/24 at 9:43 a.m. Diagnoses included type 2 diabetes mellitus without complications. His physicians orders included glargine-yfgn insulin (long-acting insulin) pen 40 units subcutaneously daily in the a.m. (started on 3/11/24) and Levemir (long- acting insulin) 55 units subcutaneously at bedtime (started on 2/20/24 - discontinued on 3/19/24). A 2/9/24 significant change Minimum Data Set (MDS) assessment indicated he was cognitively intact. His blood sugars on 3/16/24 were 180 mg/dL at 8:00 p.m., 184 mg/dL at 8:13 p.m., 150 mg/dL at 8:20 p.m., and 167 mg/dL at 8:33 p.m. A nurses note, dated 3/16/24 at 8:45 p.m. (recorded as a late entry on 3/17/24 at 3:09 p.m.), indicated a medication error was made. He received 55 units of Novolog insulin (short acting insulin) instead of 55 units of Levemir insulin. An accucheck was performed and read 180 mg/dL directly afterwards. He was brought to the nurses station for monitoring. The on-call physician was notified immediately and requested to have him sent to the emergency room (ER). His accuchecks were done frequently until the EMTs arrived. An ER note, dated 3/16/24 at 8:58 p.m., indicated he was transferred to the hospital after a medication error. He was treated with 55 units of subcutaneous Novolog insulin rather than 55 units of Levemir insulin. His blood sugar was 150 mg/dL during transport to the hospital with EMS and 180 mg/dL upon arrival to the ER. He denied feeling like he had low blood sugar, and he was encouraged to eat and drink a soft drink. He was started on 5 % dextrose (solution used to provide your body with extra water and carbohydrates (calories from sugar)), however, his blood sugar continued to drop as low as 66 mg/dL and he was started on 10% dextrose. He had improvement and stability of his blood sugar (around 170's) in the ER. He was also given supplemental potassium for hypokalemia (low blood potassium), likely caused by the insulin. With the resolution of his hypoglycemia (low blood sugar), it was decided that it was safe for him to return to the facility from the ER. He resumed his regular insulin and staff should take caution with which insulin they gave him. A nurses note, dated 3/17/24 at 3:28 a.m., indicated the hospital was called to check his status. He had been admitted to have his blood sugars monitored. A nurses note, dated 3/17/24 at 11:17 a.m., indicated he was admitted to the hospital but there was no bed available, and he remained in the ER. He had dextrose running via IV. If his blood sugar remained within normal limits in the next couple of hours, he would be discharged back to the facility. A nurses note, dated 3/17/24 at 11:24 p.m., indicated he was at the facility, and he had an IV in his left arm. During an interview with RN 14, on 4/4/24 at 11:20 a.m., she indicated it had been her first time working on that medication cart. She went to give Resident B his insulin in his belly. She didn't look at the pen to verify it was his, or the right insulin, prior to administering it to him. As she administered the insulin, she realized the pen was orange (Novolog) rather than green (Levemir). She immediately stopped administering the insulin, went to the computer to look up the insulins and got the other two nurses that were working. They got him up in his wheelchair and rechecked his blood sugar. She thought his blood sugar was 150 mg/dL or 180 mg/dL. They called the on-call physician and they didn't answer, so they called the endocrinologist, who told them to just continue to monitor him. The on-call physician called back and told them to send him to the ER. He was transported to the ER and he stayed stable. The facility provided her education related to the medication error. During an interview with RN 14, on 4/4/24 at 1:00 p.m., she indicated she had grabbed the resident's storage bag containing his insulin from the medication cart. His name was on the storage bag, but someone must have put someone else's insulin pen in his bag. She wasn't sure whose insulin pen she used. During an interview with Resident B, on 4/4/24 at 1:02 p.m., he indicated he was sent to the hospital because a nurse gave him an immediate release insulin when he was supposed to get a long-acting insulin, but she caught it right away. They got him up, put him in his wheelchair and took him to the nurses station. They took his blood sugar, and kept checking on him. A current facility policy, revised on 1/1/22, tilted General Dose Preparation and Medication Administration, provided by the DON on 4/4/24 at 1:18 p.m., indicated the following: .Procedure .3.7 Facility staff should verify that the medication name and dose are correct when compared to the medication order on the medication administration record .4.1 Facility staff should: 4.1.1 Verify each time a medication is administered that it is the correct medication, at the correct dose, at the correct route, at the correct rate, at the correct time, for the correct resident, as set forth in facility's medication administration schedule 3.1-48(c)(2) This citation relates to Complaint IN00430621.

Based on observation, interview, and record review, the facility failed to date resident's insulin vials and insulin flex pens after opening in accordance with facility policy (Resident G, C, D, E, F, and H) for 2 of 3 medication carts observed. (H hall and K/I medication carts) During a medication administration observation, on 4/4/24 at 11:55 a.m., with RN 14, she administered 22 units of Lispro (short acting insulin) insulin to Resident G. Neither the insulin vial, nor the container, had an open date on it. RN 14 checked other in-use insulins stored in the H hall medication cart and the following in-use insulins lacked open dates: 1. Resident C's Lispro insulin vial. 2. Resident D's Lispro insulin vial and a glargine-yfgn (long acting insulin) insulin pen with 180 of 300 units used from the pen. 3. Resident E's insulin aspart (short acting insulin) insulin pen with 280 units of 300 units used from the pen. 4. Resident F's glargine-fygn insulin pen with 280 units of 300 units used from the pen. RN 12 indicated they would normally date the insulin vials and pens after opening. During an observation of the K/I hall medication cart, accompanied by LPN 23, on 4/4/24 at 12:45 p.m., Resident H's in-use insulin glargine pen had no open date on it, 160 units of insulin had been used from the 300 unit pen. LPN 23 indicated she would normally date the insulin as soon as she pulled it from the refrigerator. A current facility policy, revised on 1/1/22, tilted General Dose Preparation and Medication Administration, provided by the DON on 4/4/24 at 1:18 p.m., indicated the following: .Procedure .3.12 Facility staff should enter the date opened on the label of medications with shortened expiration dates (e.g., insulins .) 3.1-25(j) This citation relates to Complaint IN00430621.

Based on interview and record review, the facility failed to prevent the verbal and mental abuse of a severely cognitively impaired resident (Resident D) by a staff member (QMA 1). Using the reasonable person concept, it is likely this deficient practice would lead to chronic anxiety, or fear. Findings include: The clinical record of Resident D was reviewed on 3/6/24 at 12:18 p.m. Diagnoses included dementia with other behavioral disturbance, cognitive social or emotional deficit following cerebral infarction, depressive disorder, disorientation, and hypertension. The resident was living on the secured memory care unit. The most recent annual Minimum Data Set (MDS) assessment, dated 3/4/24, indicated the resident was severely cognitively impaired. Review of a facility self reportable, dated 3/1/24, indicated an allegation of verbal abuse was reported by staff. The reportable documented communication concerns between Resident D and QMA 1. Review of a written statement by Lab Tech 2, dated 3/1/24, indicated on 3/1/24 at 5:40 a.m., Resident D was standing up. The lab tech verbally encouraged the resident to sit down. QMA 1 was sitting at the nurse's station and indicated they were dealing with a fall follow-up. QMA 1 approached the resident to attempt to get them to sit down. Lab Tech 2 indicated as they were leaving the unit, they heard QMA 1 yell, I will call the cops on you. Do not touch me! The lab tech was concerned about what could have happened next and stayed within the line of sight of the resident until another staff member arrived. The lab tech left the unit and reported their concerns. Review of a written statement by CNA 3, dated 3/1/24, indicated they witnessed QMA 1 interact with Resident D. QMA 1 told the resident to sit down when they attempted to stand up from a chair. The resident said no. The resident was not aggressive nor combative towards QMA 1. The resident attempted to stand from the chair again and QMA 1 moved from the nurse's station towards the resident. QMA 1 told the resident they would call the police if the resident hit them. Review of an undated written statement by LPN 4 indicated they heard QMA 1 raise their voice at a resident. LPN 4 was not on the on the memory care unit. The raised voice was heard through double locked doors. Review of an email, dated 3/1/24, indicated QMA 1 denied yelling at the resident; they told the resident they would call the police and get the authorities involved if the resident didn't stop hurting them. QMA 1 indicated the resident had been squeezing their hand and hurting them. During an interview on 3/7/24 at 1:05 p.m., Lab Tech 2 indicated, on 3/1/24, they witnessed Resident D sitting in a common area. The resident attempted to stand and Lab Tech 2 told the resident she needed to sit down and tried to direct the resident back to the chair. QMA 1 was sitting in the nurse's station. The lab tech told QMA 1 staff usually have the resident sit in a recliner with her feet up. QMA 1 said she had to do a fall follow-up. QMA 1 then left the nurses' station and approached the resident. QMA 1 began yelling at the resident in a loud threatening voice. QMA 1 told the resident she was going to call the police if the resident touched them again. Lab Tech 2 did not see the resident touch QMA 1. The resident told QMA 1 responded Well don't touch me like that again. The lab tech did not see any physical contact between Resident D and QMA 1. The lab tech indicated they did not want to leave the resident alone with QMA 1 and waited for another staff member to be present. Lab Tech 2 left the memory care unit and reported the concerns to the night shift nurse. The night shift nurse indicated they had heard the commotion. During an interview on 3/8/24 at 8:20 a.m., CNA 5 indicated, on 3/1/24, QMA 1 had been yelling at Resident D throughout the shift and had been impatient with the resident. CNA 5 felt the verbal interactions were rude and inappropriate. CNA 5 was returning to the memory care unit when CNA 3 said QMA 1 threatened to call the police on the resident. CNA 3 indicated the statement was inappropriate. When they checked on the resident, the resident said they were alright, but appeared distressed. During an interview on 3/8/24 at 9:16 a.m., LPN 6 indicated, on 3/1/24, they arrived early and were at the Desk 1 nurses' station (not memory care unit). LPN 4 told them QMA 1 had told Resident D they were going to call the police on them. LPN 6 told LPN 4 to call the DON and report the incident. The DON instructed them to send QMA 1 home immediately. QMA 1 indicated to LPN 6 the resident became aggressive and no resident was going to lay hands on them. LPN 6 indicated the yelling had been heard through the double locked doors to the memory care unit. During an interview on 3/8/24 at 10:00 a.m., QMA 1 indicated, on 3/1/24, they were working on the memory care unit. Resident D had been sitting in a common area so they could be observed due to being a fall risk. The resident had attempted to stand and QMA 1 told them to sit down. When the resident attempted to stand again, QMA 1 sat her down. The resident grabbed QMA's hand and arm, which caused pain. QMA 1 told the resident they would call the police and authorities. The resident let go. QMA 1 told other staff members they were not a punching bag. QMA 1 indicated staff attempted to normalize this type of behavior by stating they get beat up. During an interview on 3/8/24 at 10:54 a.m., CNA 3 indicated Resident D would try to stand from the chair, but could be re-directed. CNA 4 was assisting in a resident room and QMA 1 was supervising in the dining room, where Resident D was. CNA 3 heard QMA 1 telling Resident D I need you to sit down in a loud aggressive voice. CNA 3 went to intervene. Resident D was assisted to the bathroom and returned to the dining room. CNA 3 left to continue with room checks. Later, QMA 1 was observed standing over Resident D. The resident calmly stood from the chair. The resident was not confrontational. QMA 1 told the resident, in a threatening and intimidating voice, they better not hit them or they would call the police. Resident D was visibly escalating from the interaction with QMA 1. Lab Tech 2 was near by and appeared to be shocked after witnessing the interaction. During an interview on 3/8/24 at 12:18 p.m., CNA 7 indicated they heard QMA 1 yell at Resident D, Don't hit me. I am going to call the police. QMA 1 was loud and agitated. CNA 7 indicated this was not appropriate and could be considered intimidating. A current policy, dated 2/2010, titled Abuse Prohibition, Reporting, and Investigation was provided by the DON on 3/6/24 at 10:07 a.m. The policy indicated the following: Policy: It is the policy of American Senior Communities to provide each resident with an environment that is free from abuse, neglect, misappropriation of resident property, and exploitation. This includes but is not limited to verbal abuse, sexual abuse, physical abuse, mental abuse, corporal punishment, and involuntary seclusion. Definitions/Examples of Abuse: Mental Abuse - Verbal or nonverbal infliction of anguish, pain, or distress that results in psychological or emotional suffering. This includes any episode of staff to resident; and resident to resident if it appears to be willfully directed to a specific resident. Examples of mental abuse include but are not limited to: Harassing a resident Mocking, insulting, ridiculing Yelling or hovering over a resident, with the intent to intimidate . This citation relates to Complaint IN00429561. 3.1-27(a)(1)

Based in record review and interview, the facility failed to ensure staff (QMA 1) reported suspicions of physical abuse of a severely cognitively impaired resident (Resident J) to the Administrator immediately per facility policy for 1 of 4 residents reviewed for abuse. Findings include: The clinical record for Resident J was reviewed on 3/8/24 at 11:27 a.m Diagnoses include dementia, epilepsy, and hypothyroidism. During an interview on 3/8/24 at 10:00 a.m., QMA 1 indicated on 3/1/24, during the night shift, while assisting with a lab draw, several staff members held Resident J down by force. QMA 1 indicated they did not report this incident to the Administrator per policy. During an interview on 3/8/24 at 10:33 a.m., the DON indicated the facility was not aware of the allegations until an unrelated interview was conducted with the QMA, approximately seven days after the incident. A current facility policy, dated 2/2010, titled Abuse Prohibition, Reporting, and Investigation was provided by the DON on 3/6/24 at 10:07 a.m. The policy indicated the following: Policy: It is the policy of American Senior Communities to provide each resident with an environment that is free from abuse, neglect, misappropriation of resident property, and exploitation. This includes but is not limited to verbal abuse, sexual abuse, physical abuse, mental abuse, corporal punishment, and involuntary seclusion. This citation relates to Complaint IN00429561. 3.1-28(e)

Based on observation, record review, and interview, the facility failed to resolve resident grievances by providing adequate laundry services related to the accurate and timely return of personal resident clothing. (Resident C and Resident D) Findings include: 1. Review of a grievance form, dated 9/21/23, Resident C indicated missing personal items that included 1 black braided belt, 1 brown braided belt, missing teeth (dentures) costing $5000.00, and a $400.00 comforter. During an interview on 2/5/24 at 3:36 p.m., the DON indicated she had spoken to a family member of Resident C. The family had been able to find 1 missing belt. The teeth (bottom dentures) had been missing since 5/3/23. As of the survey, the missing comforter had not been found. The facility would start working with family to resolve the issue. 2. During an observation of a care conference on 2/2/24 at 1:31 p.m., Resident D and a family member verbalized the resident had been missing several personal clothing items for several months. After the care conference, the resident was allowed to go through the lost and found personal items to look for the missing items. Review of a grievance form, dated 1/23/23, Resident D indicated missing clothes to include black and white pants, flannel pants, shirts, a gold sweater, a black robe, and a gray robe. The facility located all missing items (on 10/25/23), except the gold sweater. The facility replaced the gold sweater on 12/1/23. During an observation of the lost and found room on 2/2/24 at 2:04 p.m., it was observed to be filled with clothing in multiple bins and boxes. There were two large plastic bags of blankets. The DON indicated these items were not tabled and had not been returned to the residents. This citation relates to Complaints IN00426593 and IN00427114. 3.1-7(a)(2)

Based on interview and record review, the facility failed to assess a resident (Resident B) after an unwitnessed fall, resulting in an delay of identification and treatment for a fracture of the left hip for 1 of 3 residents reviewed for change in condition. Findings include: The clinical record for Resident B was reviewed on 2/1/24 at 10:10 a.m. Diagnoses included chronic obstructive pulmonary disease, hypertension, atrial fibrillation, and weakness. The resident was admitted to the hospital and discharged from the facility on 1/25/24. The most recent quarterly Minimum Data Set (MDS) assessment, dated 12/5/24, indicated the resident required supervision and touch assistance for transfers and bed mobility. The resident used a wheelchair and walker for mobility. Review of a facility self-reportable, dated 1/25/24 at 3:43 p.m., indicated on 1/25/24 at 5:01 a.m., Resident B had an unwitnessed fall. Review of a Interdisciplinary Team progress note, dated 1/25/24 at 12:41 p.m., indicated a family member called the facility and stated the resident had fallen and had decrease movement on the left side. Staff went to the resident's room to assess the situation and found the resident in bed. When interviewed, the resident stated he had fallen at 5:03 a.m. and two staff members picked him up and put him back into bed. The resident complained of left hip socket pain. Review of the clinical record lacked documentation of the fall. No resident assessment, including a neurological assessment, was completed until the day shift staff received a call from the resident's family member. Review of a progress note, dated 1/25/24 at 2:05 p.m., indicated the results of an x-ray showed an acute intertrochanteric left femoral (hip) fracture The resident was transferred to the hospital for treatment. Review of a written statement by LPN 2 indicated, during shift report on 1/25/24, there was no information shared about Resident B experiencing a fall. There was no documentation of the fall in the electronic clinical record. At approximately 7:30 a.m. on 1/25/24, Resident B reported he had fallen at 5:03 a.m. that morning. The resident indicated 2 staff members assisted him back to bed. The resident was then assessed and found to have pain in the left hip area. The NP was notified and an x-ray was ordered. Review of a written, 1/26/24, statement by LPN 5 indicated they had been informed of a supposed fall at 5:00 a.m. on 1/25/24. LPN 5 and CNA 1 arrived at the resident's room and got him back into bed. LPN 5 indicated they did not document the incident and did not notify anyone about the incident. LPN 5 was unavailable for interview during the survey. During an interview on 2/1/24 at 3:28 p.m., CNA 2 indicated during the night shift on 1/25/24, LPN 5 asked for help getting Resident B off the floor. When CNA 2 arrived at the room, the resident was observed on the floor. The resident kept repeating he had fallen. CNA 2 and LPN 5 assisted the resident to the wheelchair, then from the wheelchair to the bed. The resident told them he had been trying to get from the bed to his walker, which he used to walk with in his room. During an interview on 2/5/24 at 3:36 p.m., the DON indicated LPN 5 should have documented the incident with Resident B. The physician and family should have been notified, the resident should have been assessed, and a neurological assessment should have been initiated. Review of a current policy, dated 7/01, titled Fall Management Policy and provided by the Administrator on 2/2/24 at 8:31 a.m., indicated the following: Post fall 1. Any resident experiencing a all will be assessed immediately by the charge nurse for possible injuries and necessary treatment will be provided. A neurological assessment will be initiated on all un-witnessed falls 2. If the resident experienced an injury from the fall, contact facility DNS/ED per facility policy. 3. The physician will be contacted immediately, if there are injuries, and orders will be obtained. 4. The family will be notified immediately by the charge nurse of falls with injury. 5. All fall events will be initiated as soon as the resident has been assessed and cared for. The report must be completed in full in order to identify possible root causes of the fall and provide immediate interventions 3.1-37(a)

Based on observation, interview and record review, the facility failed to ensure meal service was completed in a sanitary manner for 3 of 3 residents reviewed for dietary services. (Residents H, J, and K) Findings include: The following was observed on 1/2/24 at 12:26 p.m.: LPN 4 picked up the top bun from Resident H's sandwich, in her ungloved hand, to place tartar sauce on top of the fish. LPN 4 replaced the bun and moved the plate in front of Resident H and returned to the cafeteria window to collect the next tray. LPN 4 picked up the top bun from Resident J's sandwich, in her ungloved hand, to place tartar sauce on top of the fish. LPN 4 replaced the bun on the plate in front of Resident J and returned to the cafeteria window to collect the next tray. LPN 4 picked up the top bun from Resident K's sandwich, in her ungloved hand, to place tartar sauce on top of the fish. LPN 4 replaced the bun on the plate in front of Resident K. 1. Resident H's clinical record was reviewed on 1/3/24 at 10:05 a.m. Diagnosis included type 2 diabetes mellitus, chronic viral hepatitis C, and thrombocytopenia. A current physician's order, dated 5/31/23, indicated Resident H had a regular diet. 2. Resident J's clinical record was reviewed on 1/3/24 at 10:05 a.m. Diagnosis included heart failure, myasthenia gravis and hypertension. A current physician's order, dated 12/3/22, indicated Resident J had a no salt added, ground meat diet. 3. Resident K's clinical record was reviewed on 1/3/23 at 10:05 a.m. Diagnosis included peripheral vascular disease, hypertension and chronic kidney disease. A current physician's order, dated 5/22/23, indicated Resident K had regular diet. During an interview on 1/3/24 at 11:58 a.m., the DON indicated staff had informed her, last night, of the mistakes noted during the lunch observation and her expectation was for staff to not touch food with a bare hand and to don a glove, or to use a fork or napkin, to remove the tops of sandwiches when helping residents at meal times. A current facility policy, revised 6/23, titled General Food Preparation and Handling, provided by the Administrator on 1/3/24 at 2:00 p.m. indicated the following: . 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 observation, interview, and record review, the facility failed to ensure personal protective equipment (PPE) was worn during patient care for 1 of 3 residents with COVID-19 infection reviewed for infection control. (Resident E) Findings include: During an observation and interview, on 1/2/24 at 11:57 a.m., the Resident E's door was open and NA 1 was bent over, assisting the resident. NA 1 did not have on a gown, gloves, or face shield. Upon exiting the room, NA 1 indicated the droplet isolation sign located on outside the resident's room instructed what PPE she should have worn before entering the room to assist this resident. Resident E's clinical record was reviewed on 1/3/24 at 10:45 a.m. Diagnosis included chronic obstructive pulmonary disease (COPD), morbid obesity, and COVID-19. Current physician orders, dated 12/28/23 at 11:48 a.m., indicated, due to having an active infection with highly transmissible pathogens, this resident required droplet isolation related to signs and symptoms of COVID-19. During a follow up interview, on 1/3/24 at 11:58 a.m., the DON indicated the expectation was for staff to don PPE prior to entry and doff the PPE upon exiting the resident's room, per the instructions on the droplet isolation sign. Review of a current, revised policy, reviewed September 2023, titled Standard and Transmission- Based Precautions (Isolation) Policy, provided by the Administrator on 1/2/24 at 2:45 p.m., indicated the following: .Droplet Precautions: refers to actions designed to reduce/prevent the transmission of pathogens spread through close respiratory or mucous membrane contact with respiratory secretions.Use of Personal Protective Equipment- Mask and face protection in addition to gown and gloves: . 3.1-18(a)

Based on interview and record review, the facility failed to resolve resident council concerns related to long call light wait times and missing clothing items. (Residents 5, 47, 4, 87, 59) Findings include: 1. During the Resident Council meeting on 10/4/23 at 11:00 a.m., residents present indicated there were long call light wait times, especially on second shift, and the wait was approximately an hour. There were times when staff members would wear ear buds/headphones while on duty, or turn off the call light without completing care, and this caused continued waiting. Resident 5 indicated during an incident last week, he was left on the toilet for 40 minutes. He could see the clock from the bathroom, since the door was left open. The J Hall staff assigned to his room on H hall were unable to see his call light past the large fire doors. Resident 47 indicated during an incident last week, she was left in a wet brief for approximately one hour. She could see the clock from her bed. Resident 4 indicated during an incident last week, she was left sitting on her bedside commode for approximately one hour. She required staff assistance for this transfer and could see the clock from her bedside commode. During record review on 10/2/23 at 1:47 p.m., the resident council minutes indicated the following: The 6/27/23 minutes indicated residents were concerned about staff use of headphones/ear buds while on duty, agency staff turning call lights off prior to care, and long call light wait times. The included facility follow up, dated 7/3/23, indicated staff education was provided to focus on customer service. The 7/25/23 minutes indicated residents were concerned about agency staff turning call lights off prior to providing care, long call light wait times, and not enough aides on the night shift. The facility follow up, dated 8/1/23, indicated staff education and updating staffing assignment to match census. The 8/30/23 minutes indicated residents were concerned about call lights being turned off prior to care and long call light wait times. The facility follow up record, dated 9/1/23, indicated the facility staff was educated on 8/25/23 and planned additional education on 9/13/23, as well as during daily rounds. The facility would review call light audits and reports. The 9/12/23 and 9/28/23 minutes indicated residents were concerned about staff use of earbuds and cell phones while on duty, call lights being turned off prior to care, and long call light wait times. The facility follow up record, dated 9/13/23, indicated the facility planned to address these issues with a mandatory all staff in-service on 9/13/23. During an interview and record review on 10/6/23 at 3:31 p.m., the Administrator indicated he was new to this facility and he had held a mandatory in-service on 9/13/23. He provided a copy of his outline for this in-service, which included the following main topics: customer care program, survey readiness, abuse/elopement, call light response time, shower sheets, accountability to be increased throughout facility, resident inventory sheets, personal cell phone usage and snacks to be offered to resident's on 2nd shift daily. He provided his contact information to all staff. He provided all the information verbally. A current facility policy, revised 2/20, titled, Resident Council, provided by the Administrator on 10/6/23 at 3:05 p.m., indicated the following: .Policy: The facility will promote and support the residents' right to participate and organize resident council . Procedure: .6. Concerns or suggestions from the meeting will be addressed by the appropriate department. The Executive Director will review all minutes and concerns to ensure through resolution of concerns 2. During the Resident Council meeting on 10/4/23 at 11:00 a.m., members indicated repeated concerns with missing clothing items. Resident 47 indicated she was missing shirts and she was certain her items were labeled. Resident 87 indicated she was missing several labeled shirts. The laundry room had a lost and found where the unlabelled clothing went, but if it was not claimed quickly, the facility donated it or gave it away to other residents. There was to be a special room for only lost and found items, but it had been eliminated due to it being overwhelming. Resident 59 indicated he had spent his own money replacing his shirts lost by the facility. His clothing was labeled and it could take months to see if the facility would reimburse a resident. The 7/25/23 minutes indicated the laundry lost items all the time. The facility follow up, dated 7/26/23, indicated staff were educated to make sure to sort laundry and place unlabelled items into a pile until some one asked for a certain item. The 9/12/23 minutes indicated missing items and wrong clothing placed into wardrobes. The facility follow up, dated 9/12/23, indicated education for laundry staff, labeling instructions, and inventory sheets to be updated. During an interview and record review on 10/6/23 at 3:38 p.m., the Laundry Manager indicated she had completed a laundry employee in-service. She took her staff to an empty room and set up a scenario to test their knowledge on the rules for laundry and return of resident belongings. During an interview on 10/10/23 at 9:14 a.m., Laundry Aide 16 indicated the lost and found was moved from the laundry room onto K Hall last week. She was not aware of this move beforehand. The laundry workers had complained about the labeling of resident clothing and how it should be done with the admission process. During an observation of the lost and found area inside of the K Hall storage room, accompanied by the DON, on 10/10/23 at 9:41 a.m., the DON indicated this was not how the lost and found should be kept and the previous housekeeping manager had made changes that had not worked. The room was a combined storage room with items from multiple departments such as boxes of nursing supplies, wheelchairs, trash cans, toilet risers, a broken toilet, and bed frames. The lost and found clothing was behind the miscellaneous items, in boxes on the floor, under the far left window. During an interview on 10/10/23 at 10:02 a.m., the DON provided a note which indicated the intent to have the resident clothing lost and found moved to an unused office next to the social services office. A current, revised 12/22, facility admission policy, provided by the Administrator on 10/2/23 at 10:00 a.m., indicated the following: .9. Personal Property a. Inventory: Loss or Theft. Resident or Resident Representative agree to furnish, maintain and label clothing and other items .Community is not responsible for items left in Resident's room except to the extent the Community shall exercise reasonable care for the protection of residents property from loss or theft 3.1-3(l)

Based on record review and interview, the facility failed to provide notice of transfer/discharge to a representative of the Office of the State Long-Term Care Ombudsman for 4 of 4 residents reviewed for hospitalization . (Residents 92, 22, 77, and 27) Findings include: 1. The clinical record for Resident 92 was reviewed on 10/3/23 at 3:02 p.m., Diagnoses included chronic respiratory failure, uropathy, chronic pain and abnormal weight loss. The resident was transferred to the hospital on 8/8/23 and returned to the facility on [DATE]. The clinical record lacked documentation of the Ombudsman notification for the transfer/discharge. 42685 2. Resident 22's clinical record was reviewed on 10/3/23 at 3:58 p.m. Diagnoses included obstructive and reflux uropathy and personal history of urinary tract infections. The resident was transferred to the hospital on 8/29/23 and returned to the facility on [DATE]. The clinical record lacked an Ombudsman notification for a transfer/discharge on the above mentioned date. 48146 3. Resident 27's clinical record was reviewed on 10/3/23 at 3:16 p.m. Diagnoses included vascular dementia, left sided hemiplegia, dysphasia, and secondary Parkinson's disease. The resident was transferred to the hospital on 8/2/23 and returned to the facility on [DATE]. The clinical record lacked an Ombudsman notification for a transfer/discharge on the above mentioned date. 4. Resident 77's clinical record was reviewed on 10/6/23 at 9:15 a.m. Diagnoses included unspecified dementia with other behavioral disturbances, heart failure, and type 2 diabetes mellitus with chronic kidney disease. The resident was transferred to the hospital on 9/30/23 and returned to the facility on [DATE]. The clinical record lacked an Ombudsman notification for a transfer/discharge on the above mentioned date. During an interview on 10/10/23 at 11:16 a.m., the SSD indicated he missed sending the August notifications to the Ombudsman at the beginning of September. A current facility policy, revised 4/18, titled, Emergency Transfer Notifications, provided by the SSD on 10/10/23 at 12:38 p.m., indicated the following: .Procedure: .2. Designated facility staff will run the Census Activity Report for Hospital Leave from Matrix at the end of each month. 3. The Census Activity Report will be faxed or mailed to the state Ombudsman each month 3.1-12(a)(6)(A)(iv)

Based on interview, observation, and record review, the facility failed to ensure prompt wound care was provided in a manner to promote resident dignity for 1 of 1 residents reviewed for dignity. (Resident 5) Findings include: During an interview on 10/6/23 at 11:37 a.m., Resident 5 indicated when the wound physician came to evaluate his bilateral leg wounds, he would be asked to sit on the edge of the bed, since that position made it easier for the physician to view his bilateral lower extremities. The physician would remove his dressings, take measurements, and advise him a facility nurse would be in shortly to apply new, clean dressings. There were times where he waited 2 to 3 hours, sitting on the edge of the bed, before the nurse had time to do to his dressings. His wounds were open and stung when left uncovered. He was uncomfortable, but unable to climb back into bed as the open wounds were weeping and bloody, which made a mess of his bedding and his clothing. The contractures in his legs prevented other positions from being manageable for the wound dressing treatments or the time he waited for the dressing to be reapplied. He felt this situation was inappropriate and he should not be asked to deal with multiple visits that caused him pain, since the staff were aware of how much pain he was in. The pain caused from his leg wounds, and these situations with the dressing changes made it difficult to do any activities for himself, such as washing his face or hair. During a wound observation on 10/05/23 at 1:42 p.m., Resident 5 moved to hang his legs off the left side of his bed. The MD removed his dressing to the left leg. Resident 5 asked the MD and DON to reapply his dressing on this leg prior to removing the dressing on the other leg. He indicated his pain was extreme. The MD indicated the ADON would do this as he proceeded to visit the other residents needing wound treatments. The MD indicated he would return to do the right leg. The ADON stayed with the resident to reapply the dressing to his left leg. The clinical record for Resident 5 was reviewed on 10/4/23 at 3:39 p.m. Diagnoses included recurrent cellulitis of the bilateral lower extremities, contractures of the muscle at multiple sites, chronic pain due to trauma, and unspecified anxiety disorder. Resident 5's current physician order, dated 10/2/23, indicated to cleanse left lower extremity including foot with Dakins 0.25% solution, (a solution to clean wounds), one application. Apply Versatel (a wound dressing), cut to fit to wound beds, cover with super absorbent dressing and secure with rolled gauze. Change daily between 2:00 p.m. and 10:00 p.m., and cleanse right lower extremity including foot with Dakins 0.25% solution, one application. Apply Versatel, cut to fit to wound beds, cover with superabsorbent dressing, secure with rolled gauze. Change daily between 2:00 p.m. to 10:00 p.m. A current care plan, revised on 10/2/23, indicated he admitted with venous ulcers to his bilateral legs and to top of feet and to encourage resident to elevate lower extremities as often as possible. An Inter Disciplinary Team (IDT) Weekly Wound Review Note, dated 9/29/23 at 3:44 p.m., indicated Resident 5 had arterial ulcers to his bilateral lower extremities and reported a continuous pain rating of 5 to 7 out a scale of 10. A progress note, dated 10/4/23 at 10:31 a.m., indicated Resident 5 had refused to go to dental appointment scheduled for 10/4/23 due to pain. During an interview on 10/4/23 at 2:23 p.m., Resident 5 indicated he was in pain and his dressing had not been changed yet today. Sometimes it was done so late on second shift, it affected his ability to sleep. He felt the nurses were in a rush and sometimes didn't have the correct materials to do his dressing changes. He thought these should have healed by now and he could have been placed into an assisted living facility. He could not take care of himself like this and it was torture. During an interview, at the bedside on 10/5/23 at 10:48 a.m. with Resident 5 and LPN 12, Resident 5 indicated he would like to prevent a repeat of last week where he waited for hours until a nurse was able to come redress his wounds. LPN 12 indicated the wound team did not reapply the dressing, and she or the ADON would come as quickly as possible to redress his wounds. During a follow-up interview on 10/6/23 at 12:36 p.m., the ADON indicated the wound round process was set by the previous provider. The current MD was an interim team following the practice in place, and the facility nursing staff were aware of the residents being visited during these treatment rounds and should be prepared to follow behind and complete dressings applications as needed. Once her duties with the wound team were completed, she would follow up with the residents to ensure dressings had been replaced. The average time she felt a resident waited was no more than 30 minutes. 3.1-3(t)

Based on observation, interview, and record review, the facility failed to ensure the Minimum Data Set (MDS) assessments were complete and accurate for 1 of 3 residents reviewed for oxygen therapy. (Resident 41) Finding includes: Resident 41's clinical record was reviewed on 10/3/23 at 3:26 p.m. Diagnoses included chronic obstructive pulmonary disease, chronic respiratory failure with hypercapnia, obstructive sleep apnea, and dependence on supplemental oxygen. A current order, dated 9/21/23, indicated the resident required oxygen at two liters per minute via nasal cannula. A current order, dated 5/9/23, indicated the resident required Bi-level Positive Airway Pressure (BiPAP) every shift. A significant change Minimum Data Set (MDS) assessment, dated 8/27/23, lacked indication of specialized treatments for BiPAP and oxygen therapy. An Interdisciplinary Team Note, dated 8/23/23, indicated the resident was dependent on supplemental oxygen. During an interview on 10/4/23 at 3:18 p.m., the resident indicated she had worn continuous oxygen for at least 2 years. She had worn continuous oxygen since she admitted to the facility. Her oxygen therapy was on via nasal cannula during the observation. During an interview on 10/10/23 at 10:58 a.m., MDS Assistant 5 indicated oxygen therapy and BiPAP had been omitted on the above mentioned significant change MDS assessment. During an interview on 10/10/23 at 12:26 p.m., the DON indicated the facility did not have a policy regarding complete and accurate MDS assessments, but followed the Resident Assessment Instrument (RAI) for completion of the MDS assessments. Review of the 2019 RAI manual, retrieved from https://downloads.cms.gov indicated: .Oxygen therapy. Code continuous or intermittent oxygen administered via mask, cannula, etc., delivered to a resident to relieve hypoxia in this item. Code oxygen used in Bi-level Positive Airway Pressure/Continuous Positive Airway Pressure (BiPAP/CPAP) here

Based on record review, observation and interview, the facility failed to ensure pain management was provided during a dressing change when a resident verbally and phyically expressed pain (Resident E) and failed to provided skin tear treatment (Resident D), as ordered for 2 of 2 residents reviewed for ordered treatment in a sample of 3. Findings include: 1. The clinical record for Resident E was reviewed on 10/7/14 at 9:20 a.m. [DIAGNOSES REDACTED]. A physician order, dated 9/26/14, indicated the following, "Santyl ointment. Cleanse wound bed (left heel,right, medial heel, right, lateral, lower leg) with normal saline, pat dry, apply skin prep or barrier cream to periwound. Santyl to wound bed followed by hydrogel fluffed gauze, then cover with dry gauze and secure QD (daily). Change QD." During an observation of the three ordered wound treatments and dressing changes on 10/8/14, Resident E was, continuously, yelling "oow" and pulling away from nurses, indicating pain, from 3:10 P.M., to 3:49 P.M. Resident E occupied a double occupancy room. The privacy curtain was pulled. At 3:10 P.M., the dressing change to the right, lateral, lower leg was started. LPN #11 indicated she would be assisting LPN #16 with the dressing changes. Additionally, she indicated these dressing changes always required two nurses. Two family members of Resident E indicated they wanted to observe the dressing changes, too. LPN #11 lifted the resident's right leg and held it until the wound treatment and dressing change was completed. Resident E displayed anxious behavior and was yelling out in pain throughout the process. Upon hearing the cries of Resident E, the DON came in to the room at 3:13 P.M. During the right leg wound treatment, the resident continued to verbalize his discomfort. At 3:29 P.M., on 10/8/14, the DON asked LPN #16 if pain medication was administered. LPN #16 indicated she administered [MEDICATION NAME] (pain medication) 1 dose (0.25 milliliters), at 2:35 P.M. The DON indicated he could have one more and instructed LPN #16 to get another dose of pain medication. At 3:30 P.M., LPN #16 administered [MEDICATION NAME], 0.25 ml, orally, to Resident E. LPN #16 did not assess for pain level and, at 3:32 P.M., began the dressing change to Resident E's right heel. Resident E continued to complain of pain as LPN # 11 continued to hold up the resident's right leg. The right leg was place on the bed and the dressing change to his right heel was completed at 3:39 P.M. Resident E continued to display anxiety and pain. At 3:40 P.M., the Assistant Director of Nursing (ADON) took over for LPN #11, and held up Resident E's left leg. The resident continued to yell out in pain. The dressing change for the left heel was completed at 3:49 P.M. At 3:56 P.M., on 10/8/14, during an interview, the DON indicated she was very upset regarding the process of the wound treatments and dressing changes. She indicated she expected nursing staff to allow time for a pain medication to take effect and assess and re-assess pain if needed. She indicated LPN #16 did not assess for pain and had to be told to provide an additional dose of pain medication. She expected LPN #16 to stop the dressing changes, administer the additional pain medication dose, and allow time for the pain medication to work. After the resident was assessed as comfortable, the dressing changes could be completed. Additionally, the DON indicated the process of the three wound treatments and dressing changes should not have been painful, should not have taken 45 minutes and should only require one nurse. Too many people were in his room, which, very well, may have have added to his anxiety. 2. On 10/9/14 the record review for Resident D was completed. [DIAGNOSES REDACTED]. The progress notes dated 7/14/14 10:54 p.m., indicated that Resident D had received of a skin tear to his upper left forearm (LUE) when he was with his daughter when he was on Leave of Absence. On 7/15/14 at 8:03 p.m., a progress note indicated the LUE dressing was soiled and changed. The Treatment Administration Record documentation indicated,"...7/14/14-Clean skin tear to left upper arm with sterile water and pat dry, apply [MEDICATION NAME], cover with [MEDICATION NAME] pad and wrap with kerlix every day...." The date boxes were crossed out from 7/1 through 7/14. The boxes for 7/15, 7/17, 7/18, 7/21, and 7/23 had initials inside the boxes. The date boxes of 7/16, 7/19, 7/20, 7/22, and 7/24 were empty. On 10/10/14 at 3:00 p.m., the DNS indicated the boxes that were empty on the TAR indicated the resident had not received the treatment. This Federal Tag relates to Complaint IN 209. 3.1-37(a)