Every finding on record at Rolling Hills Healthcare Center

Based on interview and record review, the facility failed to ensure blood pressure parameters for a resident (Resident B) were followed, as ordered by the physician, for 1 of 3 residents reviewed for quality of care.Findings Include:The clinical record for Resident B was reviewed on 2/23/26 at 10:45 a.m. The resident's diagnosis included, but was not limited to, hypotension (low blood pressure) The physician's order, dated 2/6/26, indicated the resident was to receive Midodrine HCl (hydrochloride) 2.5 mg (milligrams) three times a day at 8:00 a.m.,12:00 p.m., and 4:00 p.m. for hypotension. The medication was to be held if the resident's systolic blood pressure (top number measuring the pressure in arteries when the heart contracts) was above 130. The February 2026 Medication Administration Record (MAR) indicated the resident received his Midodrine, when his systolic blood pressure was over 130, out of parameters on the following dates and times:-On 2/07/26 at 4:00 p.m., the resident received the Midodrine when his systolic blood pressure was 132.-On 2/17/26 at 8:00 a.m., the resident received the Midodrine when his systolic blood pressure was 138.-On 2/17/26 at 12:00 p.m., the resident received the Midodrine when his systolic blood pressure was 138.-On 2/17/26 at 4:00 p.m., the resident received the Midodrine when his systolic blood pressure was 138. During an interview, on 2/23/26 at 2:16 p.m., Registered Nurse (RN) 5 indicated a resident's blood pressure medication should not have been administered when the resident's blood pressure was out of the parameters set by the physician. On 2/23/26 at 2:27 p.m., the Regional Director of Clinical Operations provided a current, undated copy of the document titled Medication Administration. It included, but was not limited to, Definition.Medication Administration Record - the legal documentation for medication administration.Policy.It is the policy of this facility to provide resident centered care.Safety of residents.is a top priority of care.Procedure.Administer medication only a prescribed by the provider. This Citation relates to Intake 2726703 3.1-37

Based on observation, interview and record review, the facility failed to ensure respiratory assessments and respiratory care equipment were in place for a resident (Resident B) who received breathing treatments for 1 of 3 residents reviewed for respiratory care. Findings include:The clinical record for Resident B was reviewed on 2/23/26 at 10:45 a.m. The resident's diagnoses included, but were not limited to, chronic obstructive pulmonary disease (COPD-obstructive lung disease) and emphysema (a chronic, progressive lung disease). During an observation, on 2/23/26 at 10:26 a.m., Resident B was observed with a nebulizer machine (a machine that turns liquid medicine into a mist to be inhaled directly into the lungs) at bedside. The physician's order, dated 2/6/26, indicated the resident was to receive Yupelri (used to treat COPD and emphysema), 175 mcg (micrograms), 3 ml (milliliters) once daily, per nebulizer at 9:00 a.m. for 20 days. Review of the February 2026 Medication Administration Record (MAR) indicated, between 2/6/26 and 2/23/26, the resident received a total of 16 doses of Yuplri. The clinical record lacked documentation of the resident having a pre (before)/post (after) respiratory assessment and cleaning of the equipment after each administration. During an interview, on 2/23/26 at 2:16 p.m., Registered Nurse (RN) 5 indicated a respiratory assessment should be completed before and after each nebulizer treatment. On 2/23/26 at 2:27 p.m., the Regional Director of Clinical Operations provided a current, undated copy of the document titled Nebulizer Treatments. It included, but was not limited to, Definition.Nebulizer.A medication delivery system that creates a fine mist or aerosol that is directly inhaled for delivery of the medication to the bronchial tree.Policy.It is the policy of this facility to provide resident centered care.Procedure.Preparation to provide treatment.Collect data for respirations, pulse, oxygen saturation and lung sounds pre-treatment.Administering treatment.Repeat collection of data for respirations, pulse, oxygen saturation and lung sounds post treatment.Rinse the nebulizer with sterile water and allow it to air dry. 3.1-47(a)(6)

Based on observation, record review, and interview the facility failed to ensure the hot water temperatures were between 100 and 120 degrees. This deficient practice had the potential to affect 82 of 82 residents living in the facility. Findings include: During an observation, on 11/13/25 at 10:00 a.m., the following hot water temperatures were observed:-room [ROOM NUMBER] hot water temperature in the bathroom was 93.6 degrees F.-room [ROOM NUMBER] had no hot water in the bathroom.- room [ROOM NUMBER] hot water temperature in the bathroom was degrees 88.0 FDuring an interview, on 11/13/25 at 10:00 a.m., the Maintenance Director indicated he had not received any complaints from the residents about the lack of hot water. The facility flushed the system every morning.During an interview, on 11/13/25 at 10:30 a.m., Resident B indicated he had not had hot water since September. He informed management that he did not have any hot water in his bathroom. He indicated they recently informed him the sink needed a valve replacement, but he has not had any hot water since September.During an observation, on 11/13/25 at 10:35 a.m., the Maintenance Director indicated the resident's bathroom did not have any hot water. The Maintenance Director allowed the hot water to run, and the water did not get warm. He indicated a valve needed replaced.During an interview, on 11/13/25 at 10:45 a.m., Resident F indicated there were some days she did not have hot water in her bathroom. Most of the time it would take the hot water a long time to warm up. The hot water would come and go.During an interview, on 11/13/25 at 11:00 a.m., the Maintenance Director indicated the hot water does take a while to warm up, but he thought it was related to the lack of running water for a while especially overnight. The water did take some time to warm up.During an interview, on 11/13/25 at 11:15 a.m., Certified Nursing Aide (CNA) 3 indicated the hot water in the resident rooms and the shower room took 5 to 10 minutes to warm up. The farther away the rooms the longer it took for the water to warm up.During an interview, on 11/13/25 at 11:20 a.m., Resident E indicated the hot water in her bathroom took about 10 minutes to warm up. She would wash her hands in cold water because it took too long to even get warm water.During an interview, on 11/13/ 25 at 12:00 p.m., the Executive Director (ED) indicated a couple of weeks ago a Qualified Medication Aide (QMA) called her and indicated there was no hot water. The Maintenance Director flushed the lines on Monday. The farther the rooms were the less the hot water there was, and she indicated it should not take that long for the water to heat up. The boilers were not centralized in one area. Each unit had their own hot water boiler.This citation relates to Intake 2659155.3.1-19(f)(e)

Based on record review and interview, the facility failed to document medication administration for 1 of 5 residents reviewed for pharmacy services. (Resident B) Findings include: The clinical record for Resident B was reviewed on 09/08/25 at 11:36 AM. A Quarterly Minimum Data Set (MDS) assessment, dated 07/09/25, indicated the resident was moderately cognitively impaired . The resident's diagnoses included, but were not limited to, diabetes, hypertension, non-Alzheimer's dementia, anxiety, and depression.A current, open-ended physician's order, with a start date of 03/24/25, indicated the staff were to administer the resident's Lantus (insulin), 30 units, twice a day , in the morning and at bedtime. The August and September 2025, Electronic Medication Administration Record (EMAR) lacked documentation that the resident had received the Lantus medication on the following dates and times: 08/02/25 in the morning; 08/03/25 in the morning; 08/09/25 in the morning; 08/10/25 in the morning, 08/23/25 in the morning; 08/30/25 in the morning; 08/31/25 in the morning; and 09/07/25 in the morning.The clinical record lacked documentation that the resident was out of the building when the resident's medication administration was not documented. During an interview, on 09/08/25 at 2:56 P.M., RN 2 indicated all medications should be initialed in the EMAR. If the medication was not administered there should have been a progress note as to why it wasn't administered. During an interview, on 09/08/25 at 3:05 P.M., Clinical Support Nurse indicated a blank in the EMAR could mean that the medication was not signed out or the medication order had changed. The current facility policy titled, Medication Administration, was provided by the Clinical Support Nurse on 09/08/25 at 3:41 P.M. The policy indicated, .Medications will be charted when given .Medications that are refused or withheld or not given will be documented .Documentation of medication will be current for medication administration .Documentation of medications will follow accepted standards of nursing practice .This citation related to Intake 2609439.3.1-25(b)(3)

Based on record review and interview, the facility failed to ensure an intravenous ( IV) antibiotic was given in a timely manner for 2 of 3 residents reviewed for pharmacy services. (Residents 2 and 4) Findings include: 1. The record for Resident 2 was reviewed on 7/2/25 at 11:17 a.m. The resident's diagnoses included, but were not limited to, dehiscence of the surgical wound and infection following a surgical procedure. The physician's order, dated 5/8/25, indicated the resident was to receive Ceftriaxone Sodium 2 gram intravenously two times a day for post-op craniotomy for 10 Days and use 2 gram intravenously at bedtime for post-op craniotomy for 28 days. The care plan, dated 5/8/25, indicated Resident 2 was currently on intravenous antibiotic therapy for a surgical wound infection. The interventions included, but were not limited to, the resident would be free of signs and symptoms of infection at IV insertion site, administer the IV medications and flushes per the medical provider's orders, and enhanced barrier precautions. The review of the residents' Medication Administration Record (MAR) indicated the resident's p.m. dose was to be administered at 9:00 p.m. The resident MAR indicated the IV antibiotic was given late on the following dates: - On 5/8/25 the resident's p.m. IV antibiotic dose was documented as given late, at 11:48 p.m. - On 5/9/25 the resident's p.m. IV antibiotic dose was documented as given late, at 11:19 p.m. - On 5/19/25 the resident's p.m. IV antibiotic dose was documented as given late, at 11:48 p.m. - On 5/22/25 the resident's p.m. IV antibiotic dose was documented as given late, on 5/23/25 at 12:28 a.m. - On 5/25/25 the resident's p.m. IV antibiotic dose was documented as given late, on 5/26/25 at 12:50 a.m. The resident's clinical record lacked any documented comments to indicate a reason why the resident's medication was administered or why the medication was documented late. 2. The record for Resident 4 was reviewed on 7/2/25 at 12:00 p.m. The resident's diagnoses included, but were not limited to, infection and inflammatory reaction due to the right hip prosthesis. The physician's order, dated 3/14/25, indicated the resident was to receive Ceftriaxone Sodium Solution Reconstituted 2 gm intravenously at bedtime for infection for 35 administrations. The physician's order, dated 4/16/25, indicated the resident was to receive Ceftriaxone Sodium Solution Reconstituted 2 gm intravenously at bedtime for a surgical site infection for 35 administrations. The review of the residents' MAR indicated the resident's p.m. dose was to be administered at 9:00 p.m. The resident MAR indicated the IV antibiotic was given late on the following dates: - On 4/17/25 the resident's p.m. IV antibiotic dose was documented as given late, on 4/18/25 at 4:01 a.m. - On 4/18/25 the resident's p.m. IV antibiotic dose was documented as given late, at 11:25 p.m. - On 4/22/25 the resident's p.m. IV antibiotic dose was documented as given late, at 10:28 p.m. The resident's clinical record lacked any documented comments to indicate a reason why the resident's medication was administered or why the medication was documented late. During an interview, on 6/2/25 at 11:30 a.m., the Director of Nursing (DON) indicated staff should give the medication on time and document correctly if charted late. During an interview, on 6/2/25 at 12:05 p.m., RN 5 indicated the residents' IV medications could be given an hour before and an hour after the medication was due. The IV antibiotics were supposed to be given at a specific time. If a medication was documented as being administered late, she thought it was due to when the nurse documented in the MAR. If a nurse had something come up and could not document the medication as being given on time the nurse could document a comment indicating the medication was given and a reason why the documentation was late. The current Medication Administration policy, included, but was not limited to, .f. Observe the [five rights] in giving each medication: .i. the right resident .ii. the right time .iii. the right medicine .iv. the right dose .v. the right route .ff. Medications will be administered within the time frame of one hour before up to one hour after time ordered This Citation relates to Complaint IN00459358. 3.1-25(a) 3.1-50(a)(2)

Based on observation, record review, and interview, the facility failed to ensure the food was disposed of once expired, the vents were cleaned and repaired, the refrigerator thermostat and drip pan under the stove top were repaired. This had the potential to affect 93 of 95 residents who consume meals from the facility. Findings include: During the initial tour of the kitchen on [DATE] at 9:10 a.m., the following concerns were observed: - On a stand-alone refrigerator, the external temperature was at 38 degrees Fahrenheit (F). No internal thermometer was located. A gallon container of whole milk, which was ,d+[DATE] full, had an expiration date of [DATE]. - The second stand-alone refrigerator, had an external temperature of 37 degrees F. No internal thermometer was located. There was a container of leftover fish, with a use by date of [DATE]. There was another container of tuna, with a use by date of [DATE]. There was a container of lettuce with brown edges, but no serve date or use by date. - The third stand-alone refrigerator, the external temperature read 50 degrees F. There was no internal thermometer. There were 16 prepared glasses of cranberry juice and lemonade on the trays. There were 9 glasses of lemonade and tea on the other side of the stand-alone refrigerator. There were 5 pitchers of orange juice, tea, lemonade, water and cranberry juice, which were half full. [NAME] 3 indicated the drinks were still in use. - Dust was observed on the two vents over the serving counter. The vent over the preparation table had 3 screws holding the vent to the ceiling. The fourth corner of the vent was hanging loose. [NAME] 3 indicated when it rained, the vent would hang down. - The Dietary Manager was observed placing a tray of dessert bars into the trash can from the freezer. The same dessert bars were also on a tray in the stand-alone refrigerator with no date. - One of the 3 drip pans under the cook top had a drip pan stuck with food debris and grease build up, almost up to the underside of the cook top panel, visible through the opening of the pan. The review of the Menu, indicated the fish had last been served on [DATE] for dinner and [DATE] for lunch. During a second kitchen observation, on [DATE] at 10:45 a.m., the instant mashed potatoes were being prepared. [NAME] 3 obtained the gallon container of whole milk, which was ,d+[DATE] full, with a use by date of [DATE], and began pouring it into the instant mashed potatoes. When asked about the date, [NAME] 3 stopped pouring, checked the date and indicated the milk was bad and that it was her fault that she hadn't looked at the use by date. She thought she had grabbed the whole milk with the use by date of [DATE]. She would discard the mashed potatoes and she took it away. [NAME] 3 indicated that the gallon containers were used for cooking and the small containers were for the residents to drink. During a third observation in the kitchen, on [DATE] at 9:18 a.m., the same fish in the container had been re-dated to read a serve date of [DATE] and use by date of [DATE]. The vent over the serving table still had a coating of dust. The vent over the preparation table was still pulled away from the ceiling. The lettuce with the brown edges had been removed from the refrigerator. The tuna in a container had been removed. During an interview, on [DATE] at 9:19 a.m., the Dietary Regional Director of Operation (RDCO) indicated the fish would have been on the menu, on Friday, [DATE]. The Dietary RDCO checked the refrigerators bi-weekly for expired dates. During an interview, on [DATE] at 9:24 a.m., the Dietary Manager indicated she was responsible for monitoring the expiration dates on food items, but all staff should monitor the dates. The Maintenance Director was responsible for cleaning the vents and doing repairs in the kitchen, such as repairing the drip pan and the vent being attached to the ceiling. The current Food Storage and Retention Guide, included, but was not limited to, . Raw Meat/Poultry/Seafood Fish, seafood, ground meat and all poultry Once thawed ,d+[DATE] days . The current Labeling and Dating Inservice, included, but was not limited to, . Purpose: To educate all new hires and current employees on the importance of and guidelines for proper labeling and dating . Guidelines for Labeling and Dating . The use by date as outlined in the attached guidelines . Leftovers must be labeled and dated with the date they are prepared and the use by date . The Maintenance Supervisor Position Description, dated [DATE], included, but was not limited to, . Plan, develop and schedule preventive maintenance for the center. Establish standards for preventive maintenance and cleaning . 3XXX,d+[DATE](i)(3)

Based on record review and interview, the facility failed to ensure the Physician was notified when long acting insulin was held and when blood pressure, cardiac and blood thinner medications were refused for 1 of 3 residents reviewed for notification. (Resident 49) Findings include: The record for Resident 49 was reviewed on 5/5/25 at 1:12 p.m. The resident's diagnoses included, but were not limited to, type 2 diabetes mellitus with diabetic chronic kidney disease, other sequel of nontraumatic untraceable hemorrhage, cerebral edema with right hemicraniectomy, paroxysmal atrial fibrillation, congestive heart failure, hemiplegia and hemiparesis following cerebral infarction, history of venous thrombosis and embolism, and essential hypertension. The Quarterly Minimum Data Set (MDS) assessment, dated 4/9/25, indicated the resident had severe cognitive impairment. On 9/29/23, the physician's order indicated for the resident to receive Metoprolol Tartrate tablet 50 MG (milligram). One tablet by mouth every morning and at bedtime for hypertension. On 9/30/24, the physician's order indicated for the resident to receive Xarelto Oral tablet 20 MG (Rivaroxaban) - give one tablet by mouth in the morning for cerebral vascular accident, hemiplegia and atrial fibrillation. On 6/12/24, the physician's order indicated for the resident to receive Lisinopril tablet - give one tablet by mouth in the morning for hypertension. On 10/4/24, the physician's order indicated for the resident to receive Dilitazem HCI (hydrochloride) tablet 50 MG - give 1 tablet by mouth three times a day for atrial fibrillation. On 2/18/25, the physician's order indicated for the resident to receive Digoxin tablet 62.5 MCG (micrograms) - give one tablet by mouth in the morning for heart failure. The nurse's note, dated 1/21/25 between 12:48 p.m. and 1:02 p.m., indicated the resident refused to take all of his morning medications: Xarelto, Metoprolol Tartrate, Metformin, Lisinopril, Keppra, Dilitazem, and Digoxin, because he did not want his medications crushed. The record lacked documentation of the physician being notified of the resident had refused all his medications, and did not want to have them crushed. On 8/7/24, the physician order indicated to monitor the resident for (s/s) signs and symptoms hypoglycemia/hyperglycemia (IE: sweating, tremor, pallor, tachychardia, palpitations, nervousness, h/a (headache), confusion, light headedness, slurred speech, lack of concentration, irritability, staggering gait etc.) every shift. Although the blood sugars were being monitored, The record lacked documentation of set parameters for when to hold the insulin. On 3/7/25, the physician order indicated to administer Tresiba FlexTouch 100 UNIT/(ML) milliter solution pen-injector - inject 50 unit subcutaneously at bedtime for diabetes. On 5/5/25, the physician order indicated to administer Tresiba FlexTouch 100 UNIT/ML Solution pen-injector - inject 45 units subcutaneously once daily. The review of the nurse's notes, between December 2024 and April 2025, indicated the following: - On 12/2/24 at 8:37 p.m., the Medication Administration Record (eMar): indicated staff were to administerTresiba FlexTouch 100 UNIT/ML Solution pen-injector of 45 units subcutaneously to the resident at bedtime for diabetes. The insulin administration was held due to the resident's blood glucose being 147 (mg/dL) milligram/deciliter. No insulin coverage was required. - On 12/13/24 at 5:01 a.m., the eMar indicated staff were to administer Tresiba FlexTouch 100 UNIT/ML Solution pen-injector of 45 units subcutaneously to the resident at bedtime for diabetes. The insulin administration was held due to to the resident's blood glucose being 109. - On 12/16/24 at 9:17 p.m., the eMar indicated staff were to administer Tresiba FlexTouch 100 UNIT/ML Solution pen-injector of 45 units subcutaneously to the resident's at bedtime for diabetes. The insulin administration was held due to the resident's blood sugar being 97 mg/dL. - On 12/26/24 at 10:25 p.m., the eMar indicated staff were to administer Tresiba FlexTouch 100 UNIT/ML Solution pen-injector of 45 units subcutaneously to the resident at bedtime for diabetes. The insulin administration was held due to the resident's blood glucose being 119. No insulin coverage was required. - On 1/22/25 at 5:08 p.m., the eMar indicated staff were to administer Tresiba FlexTouch 100 UNIT/ML Solution pen-injector of 45 units subcutaneously to the resident at bedtime for diabetes. The insulin administration was held due to the resident's blood glucose being 115. No insulin coverage was required. - On 4/22/25 at 11:19 p.m., the eMar indicated staff were to administer Tresiba FlexTouch 100 UNIT/ML Solution pen-injector of 50 units subcutaneously to the resident at bedtime for diabetes. The insulin administration was held due to the resident's blood glucose being 89 and the resident indicated he did not eat supper. - On 4/25/25 at 11:33 p.m., the eMar indicated staff were to administer Tresiba FlexTouch 100 UNIT/ML Solution pen-injector of 50 units subcutaneously to the resident at bedtime for diabetes. The insulin Administration was held due to the resident's blood glucose being 84. - On 4/27/25 9:33 p.m., the eMar indicated staff were to administer Tresiba FlexTouch 100 UNIT/ML Solution pen-injector of 50 units subcutaneously to the resident at bedtime for Diabetes. The insulin Administration was held due to the resident's blood glucose being 111. The record lacked documentation as to why the long lasting insulin was held and the physician being notified it was being held. The care plan, dated 10/25/21 and reviewed on 4/25/23, indicated the resident had a potential for alteration in mood and behavior related to diagnoses of depression and anxiety. Potential for yelling out, resisting care, hallucinations and refusing medications. The interventions included, but were not limited to, administer medications as ordered. Observe and document signs and symptoms of effectiveness and side effects. Educate the resident or the resident representative of the medication effectiveness and side effects. The care plan, dated 3/1/22, indicated the resident had altered cardiovascular status related to atrial fibrillation, chronic systolic heart failure and hypertension. The goal was for the resident to be free of signs and symptoms of complications of cardiac problems. The interventions included, but were not limited to, administer medications per medical provider's orders. Observe for side effects and effectiveness. Report abnormal findings to medical provider, resident and the resident representative. Provide Digoxin as ordered. Check the pulse prior to administration, do not give if pulse was below 60 beats per minutes. Observe for s/sx of medication side effects: lack of appetite, vomiting, diarrhea, visual disturbances, fast heart rate, elevated Digoxin levels, fatigue, muscle weakness, anorexia, yellow halos around objects. Report any abnormal findings to the medical provider, resident or resident representative. A care plan, dated 3/1/22, indicated the resident had diabetic chronic kidney disease. The interventions included, but were not limited to, administer insulin injections per orders. Administer medications per medical provider's orders. Observe for side effects and effectiveness. Report abnormal findings to the medical provider, resident or the resident representative. Observe for signs and symptoms of hyperglycemia: increased thirst and appetite, frequent urination, weight loss, fatigue, dry skin, poor wound healing, muscle cramps, abdominal pain, kussmaul breathing, acetone breath, stupor, coma. Report any abnormal findings to medical provider, educate resident or the resident representative. Observe for signs and symptoms of hypoglycemia: sweating, tremor, increased heart rate, pallor, nervousness, confusion, blurred speech, lack of coordination, staggering gait. Report any abnormal findings to medical provider, resident or the resident representative. Obtain blood sugars per orders. Report abnormal findings to the medical provider, resident or the resident representative. A care plan, dated 3/1/22, indicated the resident was at risk for abnormal bleeding or hemorrhage due to the anticoagulant related to the cerebral vascular accident; history of noncompliance with use of anticoagulant, atrial fibrillation. The interventions included, but were not limited to, educate the resident and the resident representative on the benefits and potential risks of the anticoagulant drug. Provide the anticoagulant and the antiplatelet medication per medical provider's order. Monitor for effectiveness, and side effects (bleeding, embolism). Report abnormal findings to the medical provider, resident or the resident representative. During an interview with the Regional Director of Clinical Operations (RDCO), dated 5/8/25 at 9:15 a.m., she indicated there should be parameters for when to hold insulin, blood pressure and cardiac medications. At 9:24 a.m., the RDCO indicated because the resident had a long lasting insulin, there would be no set parameters. The resident should not have had his insulin medication held due to it being a long lasting insulin was not usually held except for a specific reason. The physician should have been notified of the resident's insulin being held and the resident's refusal of morning medications due to them being crushed. The review of the facility's current policy Notification of Change in Condition, included, but was not limited to, Policy: It is the policy of this facility to provide resident centered care that meets the psychosocial, physical, and emotional needs of the residents .Compliance Guidelines: The center must inform the resident, consult with the resident's medical practitioner and/or notify the residents' representative, .when there is a change requiring such notification. Circumstances requiring notification included, but not limited to, .3. Circumstances that require a need to alter treatment which may include: a. new treatment; b. discontinuation of current treatment . 3.1-5(a)(3)

Based on record review and interview, the facility failed to ensure a resident received treatment and care in a timely manner for 1 of 5 residents reviewed for quality of care. (Resident 243) Findings Include: The record for Resident 243 was reviewed on 5/5/25 at 11:17 a.m. The resident's diagnoses included, but were not limited to, type 2 diabetes mellitus with diabetic peripheral angiopathy without gangrene, and sepsis due to methicillin susceptible staphylococcus aureus, and hyperglycemia. The physician's order, dated 4/9/25, indicated the resident was to receive Lispro 100 units per mg before meals for diabeties. The staff were to administer the rsident's insulin based on a sliding scale. The staff were to notifiy the physician if the resident's blood surgar level was less the 70 or grater than 400. If the resident's blood sugar level was 151 to 200 staff were to administer 2 units; 201 to 250 administer 4 units; 251 to 300 administer 6 units; 301 to 350 administer 8 units; 351 to 400 administer 10 units, and if the resident's blood sugar was greater than 400 administer 10 units, then recheck the resident's blood sugar in 30 minutes, and notify the physician. The physician's order, dated 4/29/25, indicated the resident was to receive Metformin extended release tablet 500 milligram (mg). Staff were to administer one tablet in the morning. The physician's order, dated 5/2/25, indicated the resident was to receive Tresiba FlexTouch Subcutaneous Solution Pen-injector 100 units/ml (Insulin Degludec). Staff were to administer 25 units subcutaneously to the resident every morning and at bedtime. The review of the residents' blood sugar indicated the following: - On 4/30/25 at 10:38 a.m., the residents' blood sugar was 400.0 (mg/dL) milligrams/deciliters - On 4/30/25 at 4:59 p.m., the residents' blood sugar was 502.0 mg/dL - On 4/30/25 at 5:31 p.m., the residents' blood sugar was 502.0 mg/dL - On 5/1/25 at 7:41 a.m., the residents' blood sugar was 430.0 mg/dL - On 5/1/25 at 9:13 a.m., the residents' blood sugar was 494.0 mg/dL - On 5/1/25 at 9:28 a.m., the residents' blood sugar was 494.0 mg/dL - On 5/1/25 at 12:06 p.m., the residents' blood sugar was 277.0 mg/dL - On 5/1/25 at 3:10 p.m., the resident's blood sugar was 400.0 mg/dL - On 5/2/25 at 10:58 a.m., the resident's blood sugar was 408.0 mg/dL - On 5/2/25 at 4:25 p.m., the resident's blood sugar was 279.0 mg/dL The nurse's note, dated 4/30/25 at 5:31 p.m., indicated the resident's blood sugar was 502 mg/dL at dinner time. The nurse tried to call the physician and left a message. The resident's blood sugar had been high all day. The nurse called the Director of Nursing (DON) and documented she was told by the DON to give 10 units of the sliding scale insulin and recheck the blood sugar in 30 minutes. The review of the resident's blood sugars, dated 4/30/25 at 5:31 p.m., indicated the resident's blood sugar was 502 mg/dL. The record indicated the resident's blood sugar wasn't rechecked again until 5/1/25 at 7:41 a.m., and his blood sugar was 430 mg/dL. The review of the resident's blood sugar, dated 5/1/25 at 3:10 p.m., indicated the resident's blood sugar was 400.0 mg/dL. The resident's blood sugar wasn't rechecked again until 5/2/25 at 10:58 a.m. The nurse's note, dated 5/2/25 at 10:58 a.m., indicated the resident's blood sugar was 408 mg/dL. The Nurse Practitioner (NP) was notified and gave orders to administer 10 units of sliding scale insulin and recheck. The resident's blood sugar wasn't rechecked again until 4:25 p.m. During an interview, on 5/7/25 at 10:15 a.m., the Regional Director of Clinical Operations (RDCO) indicated the DON told the RN to give the 10 units of the sliding scale insulin and call the NP. She indicated she had talked to the NP this morning and the NP indicated she was made aware of the resident's high blood sugars. The RDCO agreed the clinical record lacked documentation the NP was notified and the blood sugar was rechecked. During an interview, on 5/7/25 at 10:25 a.m., the DON indicated the RN called her and she instructed her to give the 10 units according to the sliding scale and call the NP. She indicated the night shift nurse called her later and told her the resident's blood sugar was down to 300 mg/dL. During an interview, on 5/8/25 at 8:37 a.m., the NP indicated she was made aware the resident's blood sugars were high on 4/30/25. She added a note on 5/1/25 that indicated she increased the resident's insulin. The NP contacted the pharmacy on 5/7/25 and requested the resident's (IV) intravenous antibiotics to be mixed with normal saline instead of dextrose (sugar) due to elevated blood sugars. The clinical documentation standards policy, dated 2014, included, but was not limited to, .Nurses will follow the basic standard of practice for documentation including but not limited to providing a timely and accurate account of resident information in the medical record . Cross reference F842 3.1-37

Based on observation, interview and record review the facility failed to ensure interventions and treatments were completed for 1 of 4 residents reviewed for pressure ulcers. (Resident 53). Findings included: The record for Resident 53 was reviewed on 5/7/25 at 12:29 p.m. The resident's diagnoses included, but were not limited to, type 2 diabetes mellitus, morbid obesity, osteomyelitis of vertebra, sacral and sacrococcygeal region, and chronic embolism and thrombosis. A physician's order, dated 1/13/25, indicated staff were to obtain the resident vitals every shift for 72 hours and then daily to establish baselines. The record lacked documentation to indicate the resident's vital signs were being completed. The last recorded blood pressure was on 1/28/25 at 95/66 (mm/hg) millimeters of mercury. Vital sign monitoring was an intervention in the care plans of actual skin impairment and osteomyelitis. The care plan, dated 1/14/25, indicated the resident had actual impaired skin integrity that included, a Stage 4 pressure ulcer to the sacrum and unstageable wound to right hip. On 3/17/25, the area to the right hip was classified as stage 4 pressure ulcer. The interventions included, but were not limited to, low air loss mattress to bed per manufacturer guidelines, monitor the area for signs of infection, monitor the area for signs of progression, encourage turning and repositioning, and provide wound care per treatment orders. The Wound Assessment report, dated 1/14/25, indicated the resident had a stage 4 pressure injury to the sacrum, measuring 5 cm (centimeters) in length, by 2 cm in width by 3 cm in depth with serosanguineous drainage with subcutaneous tissue, bone and adipose tissue present. The wound was not acquired in house. The treatment was to cleanse the wound with NS (Normal Saline) cleanser, then apply NS wet to moist rolled gauze to the wound bed, and cover with a bordered gauze dressing every 12 hours and as needed until resolved On 2/4/25, the wound assessment indicated the sacrum wound measured 5 cm in length, by 1 cm in width by 2.7 cm in depth. On 3/6/25, the wound assessment indicated the wound measured 4.8 cm in length, by 1 cm in width, by 2 cm in depth. On 4/22/25, the wound assessment indicate wound measured 4.6 cm in length, by 1.2 cm in width by 2 cm in depth. The resident was on antibiotics to treat a wound infection, and the status indicated the wound was improving with complications. On 5/6/25, the wound assessment indicated the wound measured 4.5 cm in length, by 1.2 cm in width by 2 cm in depth. A physician's order, dated 1/14/25, indicated that a low air loss mattress should be applied, which should be checked every shift for proper placement and function. The care plan, dated 1/22/25, indicated that the resident had a history of osteomyelitis. The interventions included, but were not limited to, observe the resident for any signs of infection, monitoring of vital signs, and administer antibiotics per the medical provider's orders. A nurse's note, dated 2/28/25, indicated during wound care on the sacrum the resident alerted the nurse that a previously scabbed area to the side of her right thigh was bothering her. The nurse observed the right thigh had an open area with a small amount of drainage. The nurse notified the provider and received an order for wound care. The resident was encouraged not to sit in her wheelchair as frequently to promote healing of both wounds. The Wound Assessment report, dated 3/6/25, indicated the resident had an unstageable pressure injury to the right hip, measuring 3 cm in length, by 2.5 cm in width by 0.1 cm in depth with no drainage and subcutaneous tissue exposed. The wound was in house acquired. Treatment included to cleanse the wound with NS cleanser, apply medical grade honey to the wound bed, and cover with a bordered gauze dressing until resolved daily and as needed. On 3/13/25, the wound assessment indicated the resident had an unstageable pressure injury to the right hip, measuring 2.8 cm in length, by 2.2 cm in width by 0.1 cm in depth with no drainage and subcutaneous tissue was exposed. On 4/1/25, the wound assessment indicated that the resident had a Stage 3 pressure injury to the right hip, measured 2 cm in length, by 1.7 cm in width by 2.4 cm in depth with a moderate amount of serosanguineous drainage and subcutaneous tissue and the dermis were exposed. On 4/22/25, the wound assessment indicated the resident had a Stage 3 pressure injury to the right hip measured 1.1 cm in length, by 1.6 cm in width by 2.4 cm in depth with a moderate amount of serosanguineous drainage and subcutaneous tissue and dermis were exposed. On 5/6/25, the wound assessment indicated the resident had a Stage 3 pressure injury to the right hip measured 1.1 cm in length, by 1.6 cm in width by 1.7 cm in depth with a moderate amount of serosanguineous drainage and subcutaneous tissue and dermis were exposed. The peri-wound was intact, but fragile. A skin note, dated 3/6/25, indicated that the resident was seen for wound rounds. The sacrum was stable at that time. The wound to the right hip was noted to be a pressure ulcer. The area was suspected of being caused by the resident's previous wheelchair, and the wheelchair had been replaced. A physician's order, dated 3/6/25, indicated to cleanse the area to the side of the right thigh with wound cleanser and pat dry. The order read to apply silver collagen to the wound bed and place saline wet to moist gauze over the wound and cover it with a dry dressing daily and as needed. A nurse's note, dated 4/2/25, indicated that during a dressing change the nurse observed the wound to resident's sacrum had green drainage along with a very strong foul odor. Neither drainage or odor was documentated previously during the dressing changes. The NP was notified and gave orders for Doxycycline 100 mg twice daily for 7 days, probiotic twice daily for 10 days and for a wound culture to be obtained on next dressing change. A nurse's note, dated 4/7/25, the resident was seen by the wound care center. The wound center obtained a wound culture during the visit. The nurse then called the wound center to notify the physician that the resident was currently on an antibiotic for wound infection. A nurse's note, dated 4/14/25, indicated the wound center ordered amoxicillin for 10 days and for the resident to return to the wound center on 4/28/25. A nurse's note, dated 4/22/25, indicated that the resident had refused further use the low air loss mattress, and the resident was encouraged to turn and reposition while in bed. The intervention was not removed from the resident care plans. The May 25 (EMAR/ETAR) Electronic Administration Record/Electronic Treatment Administration Record indicated that the order was still on the EMAR/ETAR and was to be checked every shift for proper placement and function. This was completed by nursing staff every shift despite the removal of the mattress on 4/22/25. A physician's order, dated 4/29/25, indicated to cleanse the area to the sacrum with wound cleanser and pat dry, apply silver collagen to the wound bed, place a fluffed normal saline, wringing out the excess saline, collagen in place, and cover the area with a bordered gauze daily for wound care. The April and May 25 EMAR/ETAR indicated the resident record lacked documentation of the daily wound assessment to the right thigh wound on 4/7/25, 4/11/25, 4/23/25, 5/2/25, and 5/3/25. The record lacked documentation of wound care and dressing changes on the right thigh on 4/9/25 and 5/2/25. The record lacked docunentation of wound care and dressing changes to the sacrum on 4/9/25, 4/28/25, and 5/2/25. The record lacked documentation of a daily assessments to the sacral wound on 5/2/29. The Braden Assessment scores completed for the resident included a low-risk score for skin breakdown 1/27/25, 2/3/25, and 5/4/25. For the month of May 2025, the resident consistently rated her pain at 4 to 5 out of 10. The pain scale indicated 10 being severe. The resident received pain medication twice daily. During an observation, 5/8/25 at 10:00 a.m., Licensed Practical Nurse (LPN) 10 performed hand hygiene. The resident stood up with assistance and bent over the chair for completion of the wound care. The right hip wound had redness on the tissue surrounding the wound, The wound was tunneling with a small amount of slough and a moderate amount of serosanguineous exudate. The wound was cleaned with wound cleanser, packed with prism collagen, a wrung out 4 x 4 was placed on top of the wound and covered with bordered gauze. The nurse removed her gloves and performed hand hygiene. The nurse completed wound care to the sacrum. A dressing was then removed, cleaned with wound cleanser, packed the prism collagen and packed a normal saline soaked gauze. The wound was then covered with bordered gauze. Neither dressing to the right hip or sacrum was dated. During an interview, 5/8/25 at 10:15 a.m., the resident indicated that she does not have any pain due to having routine pain medication. She had a pressure cushion on the wheelchair. The pressure reducing mattress was removed due to the resident was not comfortable on the mattress. She went to bed 2 to 3 times per day, and turned and repositioned herself while in bed. She reported that she was finished with the antibiotics for a sacrum wound infection. During an interview, on 5/8/25 at 10:20 a.m., LPN 10 indicated the resident was not comfortable on the air loss mattress, so it was removed. The resident did have an air loss cushion on her wheelchair. The resident was good at turning and repositioning herself every 2 hours while in bed. If a resident refused any intervention, the physician or the NP would be notified. A wound care policy was not received from the facility. 3.1-40

Based on record review and interview, the facility failed to ensure sufficient information related to a resident's blood sugar was rechecked; and physician notification and verbal orders were documented in the resident's clinical record for 1 of 21 residents reviewed for Documentation. (Resident 243) Findings include: The record for Resident 243 was reviewed on 5/5/25 at 11:17 a.m. The resident's diagnoses included, but were not limited to, type 2 diabetes mellitus with diabetic peripheral angiopathy without gangrene, and sepsis due to methicillin susceptible staphylococcus aureus, and hyperglycemia. The physician's order, dated 4/9/25, indicated the resident was to receive Lispro 100 units per mg before meals for diabeties. The staff were to administer the rsident's insulin based on a sliding scale. The staff were to notifiy the physician if the resident's blood surgar level was less the 70 or grater than 400. If the resident's blood sugar level was 151 to 200 staff were to administer 2 units; 201 to 250 administer 4 units; 251 to 300 administer 6 units; 301 to 350 administer 8 units; 351 to 400 administer 10 units, and if the resident's blood sugar was greater than 400 administer 10 units, then recheck the resident's blood sugar in 30 minutes, and notify the physician. The review of the residents' blood sugar indicated the following: - On 4/30/25 at 10:38 a.m., the residents' blood sugar was 400.0 mg/dL(milligrams/deciliters) - On 4/30/25 at 4:59 p.m., the residents' blood sugar was 502.0 mg/dL - On 4/30/25 at 5:31 p.m., the residents' blood sugar was 502.0 mg/dL - On 5/1/25 at 7:41 a.m., the residents' blood sugar was 430.0 mg/dL - On 5/1/25 at 9:13 a.m., the residents' blood sugar was 494.0 mg/dL - On 5/1/25 at 9:28 a.m., the residents' blood sugar was 494.0 mg/dL - On 5/1/25 at 12:06 p.m., the residents' blood sugar was 277.0 mg/dL - On 5/1/25 at 3:10 p.m., the resident's blood sugar was 400.0 mg/dL The nurse's note, dated 4/30/25, at 4:59 p.m., indicated the physician was called for a blood sugar of 502 mg/dL. The nurse's note, dated 4/30/25, at 5:31 p.m., indicated the resident's blood sugar was 502 mg/dL at dinner time. The nurse tried to call the physician and left a message. The resident's blood sugar had been high all day. The nurse called the Director of Nursing (DON) and documented she was told by the DON to give 10 units of the sliding scale insulin and recheck the blood sugar in 30 minutes. The record lacked documentation indicating the physiucian/Nurse Practitioner (NP) received the left message, a recheck of the resident's blood sugar was completed, or any verbal NP orders were received. During an interview, on 5/7/25 at 9:55 a.m., RN 8 indicated the resident's blood sugar was 502 mg/dL and she tried to call the physician without success. She called the DON and was told to call the NP on call because she would probably order 10 units of insulin. She indicated she took a verbal order from the NP to give the insulin. The RN was unable to locate a verbal order from the NP in the resident's medical record. During an interview, on 5/7/25 at 10:15 a.m., the Regional Director of Clinical Operations (RDCO) indicated the DON told the RN to give the 10 units of the sliding scale insulin and call the NP. She indicated she had talked to the NP this morning and the NP indicated she was made aware of the resident's high blood sugars. The RDCO agreed that the record lacked documentation the NP was notified, and the blood sugar was rechecked. During an interview, on 5/7/25 at 10:25 a.m., the DON indicated the RN called her and she instructed her to give the 10 units according to the sliding scale and call the NP. She indicated the night shift nurse called her later and told her the resident's blood sugar was down to 300 mg/dL. During an interview, on 5/8/25 at 8:37 a.m., NP indicated she was made aware the resident's blood sugars were high. She added a note on 5/1/25 that indicated she increased the resident's insulin. The NP indicated on 5/7/25 she called the pharmacy and requested the resident's Intravenous (IV) antibiotics be mixed with normal saline instead of dextrose (sugar). During an interview, on 5/8/25 at 8:50 a.m., the RDCO indicated the nurse had given the 10 units according to the sliding scale and his blood sugar came down to 300 mg/dL. She indicated there should have been documentation the nurse called the NP and documented the blood sugar and what time it was taken. The clinical documentation standards policy dated 2014, included, but was not limited to, .a. The primary purpose of the medical record (s) is to provide continuity of care 1. Clinical evidence of care and treatment records as evidence of care iv. Document the status of the resident including changes i. The medical record will reflect the current status of the resident a. Chart in [real time] when an event is occurring or shortly thereafter, as is practicable . 3.1-3(o)(r)

Based on observation, interview and record review, the facility failed to ensure narcotic medications were not signed out prior to administration times for 7 of 11 residents reviewed for medication storage. (Resident E, Resident M, Resident N, Resident R, Resident S, Resident T and Resident U) Findings include: On 1/27/25 at 11:24 a.m., during an observation of the 400 hall controlled drug administration records with LPN (Licensed Practical Nurse) 6, the following narcotic medications had been signed out but not administered: -Resident E - Hydrocodone-APAP 5-325 mg (milligrams) signed out on 1/27/25 at 1:00 p.m. -Resident M - Oxycodone IR 5 mg (2 tabs to equal 10 mg) signed out on 1/27/25 at 2:00 p.m. -Resident N - Oxycodone IR 10 mg signed out on 1/27/25 at 2:00 p.m. -Resident R - Oxycodone IR 10 mg signed out on 1/27/25 at 1:00 p.m. -Resident S - Hydrocodone-APAP 5-325 mg signed out on 1/27/25 at 1:00 p.m. -Resident T - Oxycodone-APAP 5-325 mg signed out on 1/27/25 at 1:00 p.m. -Resident U - Hydrocodone-APAP 10-325 mg signed out on 1/27/25 at 1:00 p.m. During an interview on 1/27/25 at 11:24 p.m., LPN 6 indicated she had already signed out her 1:00 p.m. and 2:00 p.m. medications but had not given them yet. She was aware that she should not sign the medications out ahead of time. 1. The clinical record for Resident E was reviewed on 1/27/25 at 12:09 p.m. The diagnoses included, but were not limited to, major depressive disorder, right above the knee amputation and left hand contracture. The physician's order, dated 1/7/25, indicated the resident was to receive Hydrocodone-Acetaminophen 5-325 mg three times a day for pain. During an interview on 1/28/25 at 9:55 a.m., Staff Member 11 indicated the controlled drug administration record should be signed when pulled from the card to administer. On 1/28/25 at 12:30 p.m., the Regional Director of Clinical Operations provided a current, undated copy of the document titled Chain of Custody for Controlled Substances. It included, but was not limited to, Policy .It is the policy of this facility to provide resident centered care .Safety of residents .is a top priority .Nurses will sign both the MAR (medication administration record) and the Drug Count sheet when administering a controlled substance to a resident On 1/28/25 at 12:30 p.m., the Regional Director of Clinical Operations provided a current, undated copy of the document titled Medication Administration. It included, but was not limited to, MAR: Medication Administration Record - the legal documentation for medication administration .Policy .It is the policy of this facility to provide resident centered care .Procedure .Narcotic will be signed out when given 2. The clinical record for Resident M was reviewed on 1/28/25 at 11:04 a.m. The diagnosis included, but was not limited to, stage 4 sacral pressure ulcer (wound that extends through all layers of the skin, reaching the underlying muscle, tendon or bone). The physician's order, dated 1/14/25 indicated the resident was to receive Oxycodone HCl 10 mg every 4 hours as needed for pain. 3. The clinical record for Resident N was reviewed on 1/28/25 at 11:24 a.m. The diagnoses included, but were not limited to, diabetes with neuropathy and rheumatoid arthritis. The physician's order, dated 1/22/25, indicated the resident was to receive Oxycodone HCl 10 mg every 8 hours as needed for pain. 4. The clinical record for Resident R was reviewed on 1/28/25 at 2:01 p.m. The diagnoses included, but were not limited to, malignant neoplasm of the laryngeal cartilage and recurrent depressive disorder. The physician's order, dated 1/2/25, indicated the resident was to receive Oxycodone HCl 10 mg three times a day for pain. 5. The clinical record for Resident S was reviewed on 1/28/25 at 1:40 p.m. The diagnosis included, but was not limited to, depression. The physician's order, dated 1/15/25, indicated the resident was to receive Hydrocodone-Acetaminophen 5-325 mg three times a day for pain. 6. The clinical record for Resident T was reviewed on 1/28/25 at 2:10 p.m. The diagnoses included, but were not limited to, depression, anxiety and congestive heart failure. The physician's order, dated 12/30/24, indicated the resident was to receive Oxycodone-Acetaminophen 7.5-325 mg three times a day for pain. 7. The clinical record for Resident U was reviewed on 1/28/25 at 2:17 p.m. The diagnoses included, but were not limited to, peripheral vascular disease, diabetes and depression. The physician's order, dated 1/1/25, indicated the resident was to receive Hydrocodone-Acetaminophen 10-325 mg three times a day for pain. This Citation relates to Complaint IN00450462 3.1-25(a)

Based on interview and record review, the facility failed to ensure medication administration records reflected the administration of narcotic medications for 4 of 11 residents reviewed for medical records. (Resident M, Resident N, Resident O and Resident V) Findings include: 1. The clinical record for Resident M was reviewed on 1/28/25 at 11:04 a.m. The diagnosis included, but was not limited to, stage 4 sacral pressure ulcer (wound that extends through all layers of the skin, reaching the underlying muscle, tendon or bone). The physician's order, dated 1/14/25, indicated the resident was to receive Oxycodone (narcotic pain medication) HCl (hydrochloride) 10 mg (milligrams) every 4 hours as needed for pain. The January 2025 controlled drug administration record indicated the resident received the medication on the following dates and times: - 1/20/25 at 6:00 a.m., 10:00 a.m. and 2:00 p.m. - 1/21/25 at 6:00 a.m., 10:00 a.m., 2:00 p.m. and 8:00 p.m. - 1/22/25 at 6:00 a.m., 10:00 a.m., 3:00 p.m. and 8:00 p.m. - 1/23/25 at 1:00 a.m., 6:00 a.m., 10:00 a.m. and 2:00 p.m. - 1/24/25 at 8:00 a.m. and 5:00 p.m. The January 2025 medication administration record (MAR) lacked documentation of the administration of the medication. During an interview on 1/28/25 at 9:55 a.m., Staff Member 11 indicated when as needed medications are administered, the MAR should be signed to show the medication was administered. 2. The clinical record Resident N was reviewed on 1/28/25 at 11:24 a.m. The diagnoses included, but were not limited to, diabetes with neuropathy, osteoarthritis and rheumatoid arthritis. The physician's order, dated 1/22/25, indicated the resident was to receive Oxycodone HCl 10 mg every 8 hours as needed for pain. The January 2025 controlled drug administration record indicated the resident received the medication on the following dates and times: - 1/22/25 at 9:00 p.m. - 1/23/25 at 6:00 a.m. and 2:00 p.m. - 1/25/25 at 8:00 a.m. The January 2025 MAR lacked documentation of the administration of the medication. 3. The clinical record for Resident O was reviewed on 1/28/25 at 11:44 a.m. The diagnosis included, but was not limited to, depression. The physician's order, dated 1/20/25, indicated the resident was to receive Morphine Sulfate (narcotic pain medication) 0.25 ml (milliliters) every 4 hours as needed for pain or shortness of air. The January 2025 controlled drug administration record indicated the resident received the medication on the following dates and times: - 1/22/25 at 8:45 a.m. and 12:45 p.m. - 1/23/25 at 6:00 a.m., 11:00 a.m. and 3:00 p.m. - 1/26/25 at 12:00 p.m. The January 2025 MAR lacked documentation of the administration of the medication. 4. The clinical record for Resident V was reviewed on 1/28/25 at 2:28 p.m. The diagnoses included, but were not limited to, left femur fracture, diabetes and depression. The physician's order, dated 12/19/24, indicated the resident was to receive Norco (narcotic pain medication) 7.5-325 mg every 6 hours as needed for pain. The January 2025 controlled drug administration record indicated the resident received the medication on the following dates and times: - 1/20/25 at 7:00 a.m., 1:00 p.m. and 8:00 p.m. - 1/21/25 at 7:00 a.m., 1:00 p.m. and 8:00 p.m. - 1/22/25 at 7:00 a.m., 1:00 p.m. and 8:00 p.m. - 1/23/25 at 7:00 a.m., 1:00 p.m. and 8:00 p.m. - 1/26/25 at 5:00 p.m. The January 2025 MAR lacked documentation of the administration of the medication. On 1/28/25 at 12:30 p.m., the Regional Director of Clinical Operations provided a current, undated copy of the document titled Medication Administration. It included, but was not limited to, MAR: Medication Administration Record - the legal documentation for medication administration .Policy .It is the policy of this facility to provide resident centered care .Procedure .Medications will be charted when given This Citation relates to Complaint IN00450462 3.1-50(a)(2)

Based on observation, interview and record review, the facility failed to ensure Indwelling catheter care orders were implemented for 1 of 3 residents reviewed for Indwelling catheters. (Resident M) Findings include: On 1/28/25 at 11:29 a.m., the resident was observed sitting in a chair in her room with an Indwelling catheter in place. The clinical record for Resident M was reviewed on 1/28/25 at 11:04 a.m. The resident's diagnosis included, but was not limited to, stage 4 sacral pressure ulcer (wound that extends through all layers of the skin, reaching the underlying muscle, tendon or bone). The care plan, dated 1/13/25, indicated the resident had an Indwelling catheter and to provide catheter care every shift. The clinical record lacked documentation of any Indwelling catheter care for Resident M. During an interview on 1/28/25 at 9:55 a.m., Staff Member 11 indicated Indwelling catheter care orders should be implemented upon admission. On 1/28/25 at 2:44 p.m., the Regional Director of Clinical Operations provided a current, undated copy of the document titled Catheter Care. It included, but was not limited to, Policy .It is the policy of this facility to provide resident centered care .Catheter care is performed twice daily on residents that have indwelling catheters, for as long as the catheter is in place 3.1-41(a)(2)

Based on interview and record review, the facility failed to ensure behaviors were care planned and monitored for 3 of 4 residents reviewed for behavior management. (Residents B, D, and G) Findings include: 1. The clinical record for Resident B was reviewed on 12/19/24 at 1:24 p.m. The resident's diagnoses included, but were not limited to, dementia with agitation and schizoaffective disorder. During an interview on 12/19/24 at 10:15 a.m., the Memory Care unit manager indicated Resident B would actively seek out Resident C and had done so for a couple of months. She did not know if the resident had been care planned for the behavior. During an interview on 12/19/24 at 10:24 a.m., the Director of Nursing indicated she and the Executive Director had went back to the unit. As they were going down the hallway, there were two females (Residents B and D) in Resident C's room. One was standing up and the other was sitting on the bed. She inquired about the two females in the male resident's room and the staff reported that there was nothing going on. It was not appropriate for females to be in a male residents room and she had the staff remove them and told the staff that visiting needed to be done in a social areas of the unit. Review of Resident B's care plan lacked documentation related to the behavior of the resident seeking out Resident C. 2. The clinical record for Resident D was reviewed 12/19/24 at 1:41 p.m. The resident's diagnoses included, but were not limited to, dementia with behavioral disturbance and vascular dementia with psychotic disturbance. During an interview on 12/19/24 at 10:15 a.m., the Memory Care unit manager indicated Resident D would actively seek out Resident C and had done so for a couple of months. She did not know if the resident had been care planned for the behavior. Review of Resident D's care plan lacked documentation related to the behavior of the resident seeking out Resident C. 3. The clinical record for Resident C was reviewed on 12/18/24 at 2:15 p.m. The resident's diagnosis included, but was not limited to, dementia with agitation. The care plan, dated 10/6/20, indicated Resident C had a potential behavior related to sexually acting out. The interventions included, but were not limited to, anticipate and meet resident's needs, assist in developing more appropriate methods of coping and interacting such as encouraging more male friends in group/public areas with male/female setting; observe and discourage resident wanting to focus continually on one female; encourage to be in eye sight of staff when out of room. 4. The clinical record for Resident G was reviewed on 12/18/24 at 3:00 p.m. The resident's diagnoses included, but were not limited to, alcohol induced persisting dementia and dementia with behavioral disturbance. The care plan, dated 10/14/24, indicated the resident had a behavior problem as follows: known to have bowel movements in inappropriate places, yelling/demanding food at all times, verbal aggression towards staff and sexual comments towards others and to monitor behavioral episodes. Review of the November 2024 behavior tracking log lacked documentation of behavior monitoring for day shift on the following days: 11/7/24, 11/8/24, 11/10/24, 11/16/24, 11/22/24, 11/23/24, 11/28/24 and 11/29/24. Review of the December 2024 behavior tracking log lacked documentation of behavior monitoring for day shift on the following days: 12/2/24, 12/8/24, 12/11/24 and 12/18/24. During an interview on 12/20/24 at 12:39 p.m., Qualified Medication Aide (QMA) 13 indicated all behaviors should be documented on the behavior log in the medication demonstration record regardless of whether they have those behaviors or no behaviors. The medication administration record will bring up a list of behaviors for the residents and we click on the behavior if any and, if no behaviors, click a zero to show no behaviors. On 12/20/24 at 11:36 a.m., the Regional Director of Clinical Operations provided a current, undated copy of the document titled 'Behavior Management General. It included, but was not limited to, Policy .It is the policy of the facility to identify and safely manage residents who are exhibiting behaviors .Residents will be provided with a resident centered behavior management care plan to safely manage the residents and others .Document the assessment of the behavior in electronic medical record .Complete a care plan This Citation relates to Complaint IN00448446 3.1-43(a)(1)

Based on observation, interview and record review, the facility failed to ensure affective interventions were in place for a resident with increased sexually inappropriate behaviors for 1 of 8 residents reviewed for dementia care. (Resident C) Findings include: 1. The clinical record for Resident C was reviewed on 12/18/24 at 2:15 p.m. The resident's diagnosis included, but was not limited to, dementia with agitation. The care plan, dated 10/6/24, indicated the potential for behavior problem related to a history of sexually acting out. The interventions included, but were not limited to, assist in developing more appropriate methods of coping and interacting and to encourage more male friends and group/public areas with male and female setting; discourage resident wanting to focus continually on one female per family recommendation; encourage the resident be in in eye sight of staff when out of room and if reasonable, discuss behaviors; intervene as necessary to protect the rights and safety of others. The progress note, dated 10/27/24 at 8:42 p.m., indicated the resident continued to be on one-on-one supervision (one staff to one resident supervision) due to inappropriate behaviors observed. The psychiatric note, dated 10/28/24 at 8:10 a.m., indicated the resident had attempted sexually inappropriate behaviors with another female resident with staff intervention. The progress note, dated 10/20/24 at 6:36 a.m. indicated the resident continued to be on one-on-one supervision. The progress note, dated 11/3/24 at 8:19 p.m., indicated the resident continued to be on one-on-one supervision. The progress note, dated 11/4/24 at 5:44 p.m., indicated the resident had attempted to be inappropriate to a female resident in the dining area. The resident waved a staff member away and told the staff member to mind their own business when the staff member attempted to intervene. The female resident had to be taken to a different area. The resident was then observed next to another female resident with his hand located on her lap. Staff immediately approached the two residents and relocated the female resident to her room. The staff had observed that the resident expressed increased behaviors when met with authority or correction pertaining to the female residents. The resident continued to seek female company when exiting his room or in the dining room. One on one supervision continued as needed while the resident was out of his room. During an interview on 12/19/24 at 9:20 a.m., Staff Member 5 indicated Resident C would always get close to Resident B and try to put his hand down her brief. She had witnessed Resident C kiss Resident D. She would always report incidents and was just told to separate the residents and that was what she did. During an interview on 12/19/24 at 9:28 a.m., Staff Member 7 indicated she had witnessed Resident C kiss Resident B. She removed Resident C away from Resident D and reported the incident to her nurse. During an interview on 12/19/24 at 9:31 a.m., Staff Member 6 indicated Resident C was a toucher, would rub the ladies back and things like that. He was a ladies man. During an interview on 12/19/24 at 10:09 a.m., the Social Services on the Memory Care unit indicated Resident C did have inappropriate behaviors, although not consistently. He talked to the ladies a lot. During an interview on 12/19/24 at 10:15 a.m., the Memory Care Unit Manager indicated Resident C was very friendly with the men and women. He liked to sit beside them, comfort them, give them a kiss and we would separate. He was just a little too loving at times. During an interview on 12/20/24 at 10:40 a.m., Staff Member 12 indicated she had witnessed Resident C rub Resident B's thighs and kiss the following residents: Resident B, Resident D, Resident F, Resident H and Resident L. Staff member 12 would intervene and separate, however, Resident C would be right back at it. Once the resident was placed on one on one supervisor she had not observed the behaviors. The clinical record for Resident B was reviewed on 12/19/24 at 1:24 p.m. The resident's diagnosis included, but was not limited to, dementia with agitation. The clinical record for Resident D was reviewed on 12/19/24 at 1:41 p.m. The resident's diagnoses included, but were not limited to, dementia with behavioral disturbance and vascular dementia with psychotic disturbance. The clinical record for Resident F was reviewed on 12/19/24 at 2:11 p.m. The resident's diagnoses included, but were not limited to, dementia and cognitive communication deficit. The clinical record for Resident H was reviewed on 12/19/24 at 2:24 p.m. The resident's diagnoses included, but were not limited to, Alzheimer's with early onset, dementia with agitation and bipolar. The clinical record for Resident L was reviewed on 12/20/24 at 12:10 p.m. The resident's diagnoses included, but were not limited to, disorganized schizophrenia, schizoaffective disorder of the bipolar type and dementia with agitation. On 12/19/24 and 12/20/24, Residents B, D, F, H, and L were all observed on the unit. The residents were pleasantly confused and showed no signs of any psychosocial distress. On 12/20/24 at 11:41 a.m., the Regional Director of Clinical Operations provided a current, undated copy of the document titled Dementia Care Resident Rights and Privileges. It included, but was not limited to, Policy .It is the policy of this facility to provide resident centered care .Safety is a primary concerns .Residents with dementia and/or dementia-related diagnosis will be treated with the same respect and dignity and afforded the same resident rights regardless This Citation relates to Complaint IN00448446 3.1-37(a)

Based on interview and record review, the facility failed to ensure the anti-psychotic medication was documented as administered (Resident G) and failed to ensure resident's (Resident C and Resident E) medication administration records reflected the administration of narcotic medication for 3 of 5 residents reviewed for medical records. Findings include: 1. The clinical record for Resident G was reviewed on 12/18/24 at 3:00 p.m. The resident's diagnosis included, but was not limited to, dementia with behavioral disturbance. The physician's order, dated 10/28/24, indicated the resident was to receive Divalproex Sodium (mood stabilizer) delayed release, 125 mg (milligrams) three times a day in the morning, afternoon and at bedtime. The November 2024 medication administration record (MAR) indicated the medication was not signed out as given on the following scheduled administration times: - On 11/12/24 in the morning - On 11/18/24 in the morning On 11/25/24, the Divalproex Sodium was discontinued and a new order was implemented for Divalproex Sodium 500 mg three times a day in the morning, afternoon and at bedtime. The November 2024 and December 2024 MAR indicated the medication was not signed out as given on the following scheduled administration times: - On 11/25/24 at bedtime - On 11/28/24 at bedtime - On 11/29/24 at bedtime - On 12/06/24 at bedtime - On 12/08/24 at bedtime - On 12/11/24 in the afternoon and bedtime 2. The clinical record for Resident C was reviewed on 12/18/24 at 2:15 p.m. The resident diagnosis included, but was not limited to, pain. The physician's order, dated 10/4/24, indicated the resident was to receive Hydrocodone-Acetaminophen (narcotic pain medication) 5-325 mg in the morning, afternoon and at bedtime. The October 2024 controlled drug record indicated the medication was administered on 10/26/24 in the afternoon. The October 2024 MAR lacked documentation of the administration of the resident's medication. 3. The clinical record for Resident E was reviewed on 12/19/24 at 2:03 p.m. The resident's diagnoses included, but were not limited to, pain and anxiety. The physician's order, dated 5/29/24, indicated the resident was to receive Lorazepam (narcotic anxiety medication) 0.75 ml (milliliters) every 4 hours for anxiety at 12:00 a.m., 4:00 a.m., 8:00 a.m., 12:00 p.m., 4:00 p.m. and 8:00 p.m. The November 2024 controlled drug record and the November 2024 MAR lacked documentation of the administration of the narcotic medication at 4:00 p.m. on 11/12/24. The December 2024 controlled drug record indicated on 12/8/24 at 4:00 p.m., the medication was administered to the resident. The December 2024 MAR lacked documentation of the administration of the resident's medication on 12/8/24 at 4:00 p.m. The physician's order, dated 6/18/24, indicated the resident was to receive Morphine Sulfated (narcotic pain medication) 0/25 ml every 4 hours for pain at 12:00 a.m., 4:00 a.m., 8:00 a.m., 12:00 p.m., 4:00 p.m. and 8:00 p.m. The November 2024 controlled drug record and the November 2024 MAR lacked documentation of the administration of the narcotic medication at 4:00 p.m. on 11/12/24. The December 2024 controlled drug record indicated on 12/8/24 at 4:00 p.m., the medication was administered to the resident. The December 2024 MAR lacked documentation of the administration of the resident's medication on 12/8/24 at 4:00 p.m. During an interview on 12/20/24 at 12:39 p.m., Qualified Medication Aide (QMA) 13 indicated the MAR and controlled drug record should be signed off to show the medications and narcotics were administered. On 12/20/24 at 11:36 p.m., the Regional Director of Clinical Operations provided a current, undated copy of the document titled Medication Administration. It included, but was not limited to, MAR: Medication Administration Record - the legal documentation for medications administration .Policy .It is the policy of this facility to provide resident centered care .Procedure .Medications will be charted when given This Citation relates to Complaint IN00448446 3.1-50(a)(2)

Based on observation, interview and record review, the facility failed to ensure fall interventions were in place for 1 of 3 residents reviewed for accident hazards. (Resident C) Findings include: The clinical record for Resident C was reviewed on 8/28/24 at 12:50 p.m. The resident's diagnoses included, but were not limited to, Parkinson's disease and epilepsy. The care plan, dated 3/4/22, indicated the resident was at risk for falls and to apply non-skid strips to the left side of the bed. During an observation with the DON (Director of Nursing) on 8/28/24 at 2:53 p.m., the care planned intervention of non-skid strips to the left side of Resident C's bed were not in place. During an interview on 8/28/24 at 2:43 p.m., the DON indicated if the intervention was on the resident's plan of care, they should be in place. On 8/29/24 at 10:10 a.m., the Executive Director provided a current, undated copy of the document titled Fall Prevention and Management. It included, but was not limited to, It is the policy of this facility to provide resident centered care that meets the .needs .of the residents. Fall prevention .is the process of identifying risk factors that can minimize the potential for falls and also a process to manage a resident's care if a fall occurs This Citation relates to Complaint IN00440995 3.1-45(a)(2)

Based on observation, record review, and interview, the facility failed to ensure the resident's call lights were within reach for 10 of 108 residents observed for call light placement. (Residents 20, 77, 256, 60, 47, 91, 11, 38, 46 and 94) Findings include: 1. During an observation on 5/10/24 at 8:15 a.m., Resident 20's call light was laying on the floor underneath the resident's bed. No staff were present in the resident's room. The record for Resident 20 was reviewed on 5/16/24 at 9:18 a.m. The resident's diagnoses included, but were not limited to, COPD (chronic obstructive pulmonary disease), major depressive disorder, difficulty walking, muscle wasting and atrophy, the need for assistance with personal care, cognitive communication deficit, dysphagia and dementia. The Quarterly MDS (Minimum Data Set) assessment, dated 3/18/24, indicated the resident was rarely or never understood. The resident required the use of a wheelchair for mobility. 2. During an observation on 5/9/24 at 8:30 a.m., Resident 77's call light was laying on the floor underneath the resident's bed. No staff were present in the resident's room. During an observation and interview on 5/10/24 at 8:15 a.m., Resident 77's call light was laying underneath the resident's pillows out of reach from the resident. No staff were present in the resident's room. The record for Resident 77 was reviewed on 5/16/24 at 9:20 a.m. The resident's diagnoses included, but were not limited to, the need for assistance with personal care, unsteadiness on her feet, muscle weakness, difficulty walking, the need for assistance with personal care, and cognitive communication deficit. The Quarterly MDS assessment, dated 2/27/24, indicated the resident was severely cognitively impaired. The resident required the use of a wheelchair for mobility. 3. During an observation on 5/9/24 at 9:40 a.m., Resident 256's call light was at the foot of his bed between the mattress and the foot board. No staff were present in the resident's room. The record for Resident 256 was reviewed on 5/16/24 at 9:00 a.m. The resident's diagnoses included, but were not limited to, type 2 diabetes mellitus with neuropathy, cardiac implants and grafts, atrial fibrillation, the use of anticoagulants, a history of transient ischemic attach and cerebral infarction, pulmonary emboli, and cognitive communication disorder. The Quarterly MDS (Minimum Data Set) assessment, dated 2/6/24, indicated the resident was cognitively intact. The resident required the use of a wheelchair for mobility. The resident had upper and lower extremity functional limitations on one side. 4. During an observation on 5/9/24 at 9:30 a.m., Resident 60's call light was at the head of his bed out of reach from the resident. No staff were present in the resident's room. The record for Resident 60 was reviewed on 5/16/24 at 9:00 a.m. The resident's diagnoses included, but were not limited to, nontraumatic intracerebral hemorrhage, acute respiratory failure, cerebral edema, hemiplegia (partial paralysis on one side of the body) and hemiparesis following a cerebral infarction affecting the left non- dominant side, the need for assistance for personal care, and dementia. The Quarterly MDS assessment, dated 2/6/24, indicated the resident was cognitively intact. The resident required the use of a wheelchair for mobility. The resident had upper and lower extremity functional limitations on one side. 5. During an observation and interview on 5/9/24 at 9:30 a.m., Resident 47's call light was clipped to the privacy curtain and hid behind the curtain. The resident indicated he was in a lot of pain. He was waiting for someone to come into his room so he could tell them he needed pain medication. No staff were present in the resident's room. During an observation and interview on 5/10/24 at 8:16 a.m., the call light for Resident 47 was underneath his bed laying on the floor. He indicated a call light would come in handy. Right now he just yells out if he needs anything. The resident wasn't aware he had a call light. No staff were present in the resident's room. The record for Resident 47 was reviewed on 5/16/24 at 9:00 a.m. The resident's diagnoses included, but were not limited to, hemiplegia and hemiparesis following a cerebral infarction, acquired absence of the right leg below the knee, type 2 diabetes mellitus, the need for assistance with personal care, dysphagia, and cognitive communication disorder. The Quarterly MDS assessment, dated 3/27/24 indicated the resident was moderately cognitively intact. The resident required the use of a wheelchair for mobility. The resident had upper and lower extremity functional limitations on one side. During an interview on 5/16/24 at 12:00 p.m., CNA (Certified Nursing Aide) 3 indicated the residents' call lights should always be within the residents reach. If a resident could not use their call light, staff would still put the call light within their reach and check on the resident frequently. During an interview on 5/16/24 at 12:15 p.m., CNA 6 indicated the residents' call lights should always be within the residents reach. The call light should never be clipped to the privacy curtains or on the floor out of reach. 15251 6. During an observation of resident call light placement on 5/9/24 between 9:30 a.m. and 10:15 a.m., Resident 91 was sitting in his wheelchair with his upper legs propped up his on bed. The resident's call light was hanging on the wall across from his bed out of reach. No staff were present in the resident's room. The record for Resident 91 was reviewed on 5/10/24 at 1:00 p.m. The resident's diagnoses included, but were not limited to, bilateral below the knee amputations, peripheral vascular disease, amputation of right index finger to knuckle, depression and anxiety. The Quarterly MDS assessment, dated 3/29/24, indicated the resident was alert and oriented. The resident required the use of a wheelchair for mobility. 7. During an observation of resident call light placement on 5/9/24 between 9:30 a.m. and 10:15 a.m., Resident 11 was asleep in her bed. The resident's call light was underneath the top of the mattress at the head of the bed out of the resident's reach. No staff were present in the resident's room. During an observation of resident call light placement on 5/9/24 between 1:45 p.m. and 2:10 p.m., Resident 11 was asleep in her bed. There was no call light in sight or staff present in the resident's room. During an observation of resident call light placement on 5/16/24 between 8:30 a.m. and 8:45 a.m., Resident 11 was laying in her bed with her eyes open and at times looking around. The resident's call light was on the floor under the bed. No staff were present in the resident's room. The record for Resident 11 was reviewed on 5/10/24 at 12:30 p.m. The resident's diagnoses included, but were not limited to, Parkinson's disease without dyskinesia, bipolar disorder, Alzheimer's disease, and major depressive disorder. The Quarterly MDS assessment, dated 3/7/24, indicated the resident had severe cognitive impairment. The resident had lower extremity functional limitations on both sides. 8. During an observation of resident call light placement on 5/9/24 between 9:30 a.m. and 10:15 a.m., Resident 38 was observed asleep in her bed. The resident's call light was hanging off the side of the bed towards the floor. The resident's call light was out of the reach of the resident. No staff were present in the resident's room. During an observation of resident call light placement on 5/9/24 between 1:45 p.m. and 2:10 p.m., Resident 38 was asleep in her bed. the resident's call light was on the side rail below the level of the mattress out of the resident's reach. No staff were present in the resident's room. The record for Resident 38 was reviewed on 5/9/24 at 2:00 p.m. The resident's diagnoses included, but were not limited to, Alzheimer's disease, dementia, anxiety, depression, and chronic obstructive pulmonary disease. The Significant Change MDS assessment, dated 2/17/24, indicated the resident had severe cognitive impairment. The resident required the use of a wheelchair for mobility. 9. During an observation of resident call light placement on 5/9/24 between 9:30 a.m. and 10:15 a.m., Resident 94 was observed lying on his bed looking around. The resident's call light was on the floor behind his bed. No staff were present in the resident's room. During an observation of resident call light placement on 5/9/24 between 1:45 p.m. and 2:10 p.m., Resident 94 was lying awake in his bed. The resident's call light was laying across the nightstand out of reach of the resident. No staff were present in the resident's room. During an observation of resident call light placement on 5/16/24 between 8:30 a.m. and 8:45 a.m., Resident 94 was laying in his bed with his eyes open. The resident's call light was on the floor by the bed. No staff were present in the resident's room. The record for Resident 94 was reviewed on 5/13/24 at 9:15 a.m. The resident's diagnoses included, but were not limited to, diabetes mellitus, dementia and depression. The Admission MDS assessment, dated 1/31/24, indicated the resident had moderate cognitive impairment. The resident had upper extremity functional limitations on one side. 10. During an observation of resident call light placement on 5/9/24 between 1:45 p.m. and 2:10 p.m., Resident 46's was asleep in her bed. the resident's call light was on the floor under her roommate's bed. No staff were present in the resident's room. During an observation of resident call light placement on 5/16/24 between 8:30 a.m. and 8:45 a.m., Resident 46 was asleep in her bed. The resident's call light was under the roommate's bed. No staff were present in the resident's room. The clinical record for Resident 46 was reviewed on 5/15/24 at 1:22 p.m. The resident's diagnoses included, but were not limited to, Alzheimer's disease. mood disorder, chronic obstructive pulmonary disease, major depression and cognitive communication deficit. The Significant Change MDS, dated [DATE], indicated the resident had severe cognitive impairment. The resident had lower extremity functional limitations on one side. On 5/14/24 at 1:06 p.m., the Executive Director (ED) presented a copy of the facility's current policy titled Resident Rights. The policy included, but was not limited to, Policy: It is the policy of this facility to provide resident centered care that meets the psychosocial, physical and emotional needs and concerns of the residents. Safety of residents, .is a top priority. The purpose of this policy is to guide employees in the general principles of dignity and respect of caring for residents, including the .safety of other residents, visitors and staff .Procedure: 1. The residents will be treated with dignity and respect including but not limited to: .c. To have a method to communicate needs to staff: i. Call light or bell access will be within reach of the resident as one method to communicate needs to staff . Cross Reference F565 3.1-19(u)(1)

Based on interview and record review, the facility failed ensure Administration was taking resident concerns seriously or being visible to the residents for 11 of 13 Resident Council meetings (3/23, 4/23, 5/23, 6/23, 7/23, 9/23, 10/23, 1/24, 3/24. 4/24, and 5/24). This deficient practice had the potential to affect 108 of 108 residents currently residing in the facility. Findings include: 1. The Resident Council meeting held on 3/21/23, the residents indicated their concerns were not resolved or acted upon for the following: - There was no improvement in Administration taking the resident's concerns seriously. The residents heard the same excuse over and over. - Nothing was being done about the lack of staff. - The resident's indicated they saw nursing staff walking past the resident's rooms who needed assistance. It was hard to get a nurse to come and see what residents needed at night. - The meals were not being balanced out with the residents' diet. When the ticket said double portions, they were not getting it every meal. The residents were still hungry. The residents were receiving the same meals over and over. - The laundry was not putting the clothes in the right closet and they were not getting their clothes back. The documentation lacked a response from the responsible department heads. 2. The Resident Council meeting held on 4/18/23, the resident concerns indicated the following were not resolved or acted upon: - Issues continued with the nursing staff. - The nurses were telling the residents they did not have time to make appointments for them. - Housekeeping was not mopping the floor or cleaning the restroom. - The clothes were missing and had bleach marks on them. The response given to the nursing concerns indicated a daily 10:00 a.m. meeting would be held to discuss issues. The documentation lacked a response from Laundry or Housekeeping related to the other concerns. 3. The Resident Council meeting held on 5/23/23, the residents indicated the following concerns were not resolved or acted upon: - Nursing shortage. - The food was cold and if someone ordered an alternate, it was not served. - The resident's clothes were missing. The Dietary Manager responded to the food concern on 5/24/23. She indicated food temperatures were taken at every meal, but the food carts were seen sitting in the hallway for 30 minutes, which meant the heat bases had stopped working. The nursing staff were to come to the kitchen instead of sending the resident to get the requested items. The Director of Nursing (DON) was present in this Resident Council meeting, but no response was given to address the staff shortage. The documentation lacked a response from Laundry on the missing clothes. 4. The Resident Council meeting held on 6/20/23, the residents indicated the following concerns were not resolved or acted upon: - The CNAs (Certified Nurse Aides) and nursing talked bad to the residents. - There was a nursing shortage. - Housekeeping would not empty the trash cans. - The clothes were not being put back into the right closets. The documentation lacked a response from the department heads. 5. The Resident Council meeting held on 7/11/23, the resident's indicated the following concerns were not resolved or acted upon: - The residents felt that Administration needed to get to know the residents needs. - The residents felt that dietary needed to go around and ask what the residents wanted to eat, because they were not getting what they ordered. The documentation lacked a response from the department heads. 6. The Resident Council meeting held on 9/19/23, the residents indicated the following concerns were not resolved or acted upon: - There was too much turnover of nursing staff; some of the CNAs were lazy. - The food was nasty; they were served too much fish. - The laundry never brought the clothes back, they lost the clothing, and they mixed the clothing up. - The nurses and CNAs were talking nasty. - The night shift was not answering the call lights. - The nursing staff were talking while standing by the 100 Hall doors, which bothered the residents who were trying to sleep. The documentation lacked a response from the department heads. 7. The Resident Council meeting held on 10/18/23, the resident's indicated the following concerns were not resolved or acted upon: - The CNAs and nurses were yelling down the halls at each other and it woke the residents up. - A nurse was giving the residents the wrong medication. - The food was cold and tasted awful. The DON responded to the concern on 10/18/23 and indicated a staff inservice had been completed. The Dietary Manager responded to the concern on 10/18/23 and indicated the manager will do audits daily on meal service to ensure proper food temperatures and taste. 8. The Resident Council meeting held on 1/16/24, the residents indicated the following concerns were not resolved or acted upon: - The kitchen served whatever they wanted. - The resident's clothes were missing. The Activity Director responded during the meeting that the kitchen had to go by a menu and that if the residents did not want what was on the menu, there were alternatives they could have. The residents were asked what clothes were missing and that the facility would replace the items for them. 9. The Resident Council meeting held on 3/19/24, the residents indicated the following concerns were not resolved or acted upon: - The resident's clothes were missing and the residents were receiving other people's clothes. The Activity Director responded to the residents during the meeting that the facility was checking on the missing clothes to see if they could find them. She further indicated all of Administration were going to be invited to the next meeting so the residents could know who they were and be able to answer any questions they may have. 10. The Resident Council meeting held on 4/24/24, the residents indicated the following concerns were not resolved or acted upon: - The resident's clothes were missing. The Activity Director responded during the meeting that she spoke with Laundry about the missing clothes and the facility would replace them. Some of the clothing was found. Activities and Laundry were going to take the residents' down to Laundry and look through the items to see if any of the clothing was theirs. The residents invited members of the Administration to attend the meeting and they failed to do so. 11. The Resident Council meeting held on 5/12/24, the residents indicated the following concerns were not resolved or acted upon: - A night shift aide could be verbally abusive. The aide was often found sleeping on the job or off their assigned hall looking in resident rooms on other halls. Administration was spoken to about the aide, but it was just brushed aside. - Resident 31 was supposed to be one on one at all times, but on several occasions had been left to roam the halls by himself. The resident was physically aggressive with both staff and other residents, including Resident 71. Administration was aware of the problems, but nothing was done about it. - No satisfaction from Management when concerns were voiced. A bunch of nonsense was given and the issue was not resolved. - The nursing staff told the residents they had to pass all the trays and feed all the residents who needed assistance before they would go to the kitchen to obtain a substitute meal and heat the food up for them. - The food was cold, tasted poorly, and was not very appealing when served. Bread was soggy from the vegetable juice on the same plate. Resident 71 showed a picture he took of a meal, which showed the baked beans and tomatoes and okra on the same plate with the juices surrounding the sloppy joe bun. - There was not enough snacks for everyone to have, they were not always offered, or the tray of snacks went to one particular hall and was never seen again. - They sometimes ran out of food. The didn't always get the substitutes the residents asked for because they were out of the item. - The nursing staff were not always making appointments for the residents. - The nurses were not assisting the residents when they need to be changed. They would tell the residents it was not their job and they would have to find an aide to help. - The call lights were not being answered timely. It took 1/2 hour to 2 hours to be answered. The staff would come in and turn off the light and indicated they would be right back, but did not return. The Activity Director indicated the 12 residents who attended this Resident Council meeting were alert and oriented. The review of the individual resident Grievance Logs between March 2023 and May 2024 indicated missing clothes, bleach on clothes, and not answering call lights were reported. 35732 During an interview on 5/9/24 at 12:42 p.m., Resident 66 indicated she did not have any of her clothes. Laundry and staff had not been able to find them, and she didn't have any more clothes to wear that fit. She indicated her name was inside her clothing and she needed her clothes. During an observation and interview, on 5/14/24 at 8:30 a.m., Resident 66 had 3 pairs of pants and 3 shirts in her closet. The resident indicated she had 8 short sleeve shirts missing, 3 outfits she received for Christmas, and 3 pairs of pants were missing. Her name was on her clothing and the laundry had not found them. During an interview on 5/14/24 at 8:45 a.m., the Housekeeping Supervisor indicated they had been looking for Resident 66's clothing. At that time she was unable to find them. The resident told her she was missing pants and shirts. She had a lost and found and she was going to go through it to see if the resident had any clothing in it. Laundry would take the clothing and see if the resident could identify them. She indicated the facility would replace her clothing if they could not be found. The review of the Grievance/complaint Log, dated 5/14/24 at 11:00 a.m., indicated Resident 66's missing clothing were found and staff took them to the resident. During an interview 5/15/24 at 9:23 a.m., Resident 66 indicated she was told yesterday the staff had found her clothing and they were going to bring them to her. She indicated no one had found or brought her clothes to her. On 5/14/24 at 1:06 p.m., the Executive Director (ED) presented a copy of the facility's current policy titled Resident Council, dated effective 4/22/21. The policy included, but was not limited to, Policy: .2. Duties of the Resident Council include: .c. Helping identify concerns; .e Helping individuals speak out about what's bothering them and helping to overcome fear of retaliation; f. Improving the atmosphere of the facility .4 .Any concerns voiced at the meeting should be documented on the Concern Form and distributed to the appropriate Department Head. 5. Facility should follow the Resident Grievance Procedure for any concerns identified. The ED also presented a copy of the facility's current policy titled Resident Grievance Indiana, dated effective 6/19/18. The policy included, but was not limited to, : .Policy: It is the policy of this facility to provide resident centered care that meets the psychosocial, physical and emotional needs and concerns of residents. This facility will provide a venue for residents .to voice concerns, complaints, or grievances to facility leadership and external parties .Procedure: 1. Prevent Ongoing Violations: a. Upon receipt of an oral, written or anonymous grievance submitted by a resident, the Grievance Official will take immediate action to prevent further potential violations of any resident right while the alleged violation is being investigated, if indicated .3. Investigation: a. The Grievance Official will complete an investigation of the resident's grievance .4. Time Frame: a. The grievance review will be completed in a reasonable time frame consistent with the type of grievance but not to exceed 30 days. 5. Grievance Decision: a. Upon completion of the review, the Grievance Official will complete a written grievance decision that includes the following: i. The date the grievance was received. ii. A summary of the statement of the resident's grievance. iii. The steps taken to investigate the grievance .vi. Whether any corrective action was or will be taken. vii. If corrective action was or will be taken, a summary of the corrective action. If corrective action will not be taken, then an explanation of why such action is not necessary .6. Resident Notification: a. The Grievance Official will meet with the resident and inform the resident of the results of the investigation and how the resident's grievance was resolved or will be resolved, if applicable . Cross reference F804 and F558 3.1-3(l)

Based on record review and interview, the facility failed to ensure the CNAs (Certified Nurse Aides) tested for their licensure, prior to 120 days after of employment and worked past the 120 days for 6 of 33 CNAs reviewed. (CNAs 13, 14, 16, 15, 19, and 17) Findings include: During the review of the employee records on 5/15/24 at 11:10 a.m., the following was identified: -CNA 14 was hired on 9/6/23. -CNA 13 was hired on 8/2/23. Date of hire on the employee records indicate 5/3/23. -CNA 16 was hired on 2/10/20. -CNA 15 was hired on 8/2/23. -CNA 19 was hired on 3/29/23. -CNA 17 was hired on 6/29/23. -CNA 20 was hired on 6/21/23. During an interview on 5/15/24 at 1:25 p.m., the ED (Executive Director) indicated there wasn't a HR (Human Resources) person up to 4/5/24 and the ED looked at all staff for licenses. She found that 8 facility staff who were licensed in Kentucky had not taken their CNA licensure test in the 120 days required in Indiana. All 8 staff were taken off of the work schedule until they passed their CNA licensure test. -CNA 13's 120th day was 11/29/23. She worked 70 days past her 120th day between 11/30/23 and 4/2/24. -CNA 14's 120th day was 1/3/24. She worked 21 days past her 120th day between 11/13/23 and 2/5/24. -CNA 16's 120th day was 7/26/23. She worked 137 days past her 120th day between 7/26/23 and 3/30/24. -CNA 15's 120th day was 11/29/23. She worked 51 days past her 120th day between 11/29/23 and 4/4/24. -CNA 19's 120th day was 7/26/23. She worked 102 days past her 120th day between 7/29/23 and 4/4/24. -CNA 17's 120th day was 10/26/23. She had worked 10/27/23. During an interview on 5/16/24 at 9:15 a.m., the ED indicated the facility had mobile HR 12, who came in 2 times weekly. On 5/16/24 at 9:32 a.m., the ED provided the last staff which was HR 11. Her hire date was 1/8/24 and she left the position on 2/6/24. The Frequently Asked Questions: Certified Nurse Aides, included, but was not limited to, . 5. What steps area needed to certify an out-of-state certified nurse aide in Indiana? . Aide is allowed to work in Indiana for 120 days until they are on the Indiana registry . The Past noncompliance began on the hire date of each CNA and the deficient practice was corrected by 4/5/24 after the facility implemented a systemic plan that included the following actions: The facility changed the process for monitoring staff for licensure, by placing the CNAs license on monthly planners. This citation relates to Complaint IN00432743 3.1-14(c)(1)

Based on interview and record review, the facility failed to ensure appropriate interventions were implemented for a resident (Resident B) with a moderate risk for impaired skin integrity which resulted in a stage 3 pressure ulcer (full thickness skin loss) to the sacrum, an unstageable pressure ulcer (full thickness skin loss either covered by extensive necrotic tissue or by eschar) to the upper sacrum, and a deep tissue injury (localized area of discolored skin caused by damage to underlying tissue from pressure and/or shear) to the right heel, and to ensure pressure ulcer treatments were completed for residents (Resident B and H) for 2 of 3 residents reviewed for pressure ulcers. Findings include: 1. The clinical record for Resident B was reviewed on 6/7/22 at 12:37 p.m. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly MDS (Minimum Data Set) assessment, dated 1/23/22, indicated the resident's cognition was severely impaired. The resident required one physical staff member's assistance with bed mobility. The Braden Observation Tool, dated 12/7/21, indicated the resident was at a moderate risk for pressure ulcers due to slightly limited sensory perception, very moist skin exposure, chairfast, slightly limited mobility, and a problem with friction/shearing. Potential interventions for those at a moderate risk for pressure ulcers included an actual turning schedule as the resident allowed'/tolerated, wedge support for 30 degree side positioning, and heel protection. The care plan, dated 2/9/22, indicated the resident had impaired skin integrity and at risk for altered skin integrity related to immobility, diabetes, and [CONDITION(S)]. The interventions included to administer medications as ordered, complete treatments as ordered, apply barrier creams post incontinent episodes, complete skin at risk assessments, complete weekly skin checks, and obtain labs as ordered. The care plan, dated 2/9/22, indicated the resident had actual impaired skin integrity that included a stage 3 to the coccyx, a deep tissue injury to the right heel, and an unstageable pressure ulcer to the sacrum. The interventions included to evaluate ulcer characteristics, measure ulcer at regular intervals, provide wound care per treatment orders, notify provider if no signs of improvement on current wound regimen, and to monitor or signs of infection, wound progression or wound declination. The wound evaluation report, dated 2/1/22, indicated the resident had a new stage 3 pressure ulcer to the sacrum, acquired in house, which measured 5.06 cm (centimeters) in length, 8.14 cm in width with a depth of .10 cm. Staff were to ensure compliance with turning protocol and a wedge/foam cushion for offloading. The wound evaluation report, dated 2/1/22, indicated the resident had a new area to the right heel, acquired 2/1/22, which measured 0.64 cm in length, 0.74 cm in width with no depth. Staff were to elevate the resident's legs regularly and a wedge/foam cushion for offloading. The skin/wound evaluation note, dated 2/1/22, indicated the pressure reduction and turning precautions were discussed with staff at the time of visit, which included heel protection and pressure reduction to bony prominences. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the February 2022 indicated the treatment to the coccyx was not completed on 2/2/22 and the treatment to the right heel was not completed on 2/2/22 (day shift) and 2/8/22 (night shift). The nurse practitioner note, dated 2/7//22 at 11:42 a.m., indicated the resident had a deep tissue injury to the right heel, a stage 3 pressure ulcer to the sacrum, and that the resident refused to get out of bed. The progress note, dated 2/9/22 at 1:06 p.m., indicated the resident currently had a low air loss mattress in place. The wound evaluation report, dated 2/10/22, indicated the stage 3 to the sacrum measured 3.04 cm in length, 3.06 cm in width with a depth of .01 cm. Staff were to ensure compliance with turning protocol and a wedge/foam cushion for offloading. The wound evaluation report, dated 2/10/22, indicated the deep tissue injury to the right heel measured 0.47 cm in length, 0.39 cm in width with no depth. Staff were to elevate the resident's legs regularly and a wedge/foam cushion for offloading. The wound evaluation report, dated 2/10/22, indicated the resident had a new area to the upper sacrum which measured 2.15 cm in length, 1.5 cm in width with no depth. Staff were to ensure compliance with turning protocol, wedge/foam cushion for offloading, and specialty bed. The clinical record lacked documentation of turning/repositioning, offloading heels, or any refusal to turn, reposition, or offload heels. During an interview on 6/8/22 at 12:10 p.m., the Director of Nursing indicated the resident acquired the wounds due to actively dying and refused to move or get up out of bed. A confidential interview, during the survey process, indicated Resident B was sent to the hospital on 2/11/22 for evaluation. The resident had stage 3 pressure sores which required multiple skin grafts during her stay at the hospital. The resident was discharged , after approximately 5 days in the hospital, to an out of State skilled nursing facility per family request. They were aware the resident was in the new skill nursing home for a couple of months after discharging from the hospital. 2. The clinical record for Resident H was reviewed on 6/8/22 at 12:54 p.m. The diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The admission MDS assessment, dated 3/11/22, indicated the resident was admitted with a stage 4 pressure ulcer to the coccyx. The care plan, dated 3/8/22, indicated the resident had a stage 4 pressure ulcer to the coccyx and to provide wound per treatment orders. The wound evaluation report, dated 5/6/22, indicated the resident had a stage 4 wound to the coccyx which measured 8 cm in length, 5 cm in width with a depth of 0.2 cm. The May 2022 treatment administration record indicated staff were to cleanse the resident's coccyx wound with normal saline, pat dry, pack wound areas with calcium alginate with silver and cover with a dry dressing daily. Review of the May 2022 treatment administration record indicated the treatment was not completed on 5/15/22 or 5/26/22. The wound evaluation report, dated 6/3/22, indicated the resident's stage 4 wound measured 6.5 cm in length, 4.6 cm in width with a depth of .10 cm. The June 2022 treatment administration record indicated to cleanse the coccyx wound with normal saline, pat dry, pack left side of the wound with collagen and calcium alginate with silver, apply collagen to exposed wound bed, and cover with a dry dressing daily. Review of the June 2022 treatment administration record indicated the treatment was not completed on 6/6/22. On 6/9/22 at 11:45 a.m., LPN (Licensed Practical Nurse) 3 indicated when a treatment was completed, the nurse should initial the treatment record to show it was completed. On 6/9/22 at 11:05 a.m., the Executive Director provided a current copy of the document titled Skin Care & Wound Management Overview dated 7/2016. It included, but was not limited to, Policy .The facility staff strives to prevent resident/patient skin impairment and to promote the healing of existing wounds .implement interventions to prevent .potential skin integrity issues .Implementation of prevention strategies to decrease the potential for developing pressure ulcers .Develop a care plan with individualized interventions to address risk factors This Federal tag relates to Complaint IN 335 3.1-40(a)(1) 3.1-40(a)(2)

Based on observation, record review, and interview, the facility failed to ensure appropriate interventions were identified and implemented to prevent accidents for 3 of 10 residents (Residents C, D, and E) reviewed for accidents, which resulted in Resident C and Resident E sustaining fractures to their wrists. Findings include: 1. During an observation, on 2/14/22 at 10:00 a.m., Resident C was observed in a high-backed wheelchair with anti-tippers in his room. The resident would attempt to converse with nonsensical speech and was only oriented to person. The head of his bed was against the wall, with both sides open to the room. There were no skid-strips observed anywhere in the resident's room or bathroom. The clinical record for Resident C was reviewed on 2/17/21 at 11:11 a.m. Diagnoses included, but were not limited to, cerebral infarction, [CONDITION(S)], dementia, non-displaced fracture of right ulna styloid process, muscle weakness, unsteadiness on feet, need for assistance with personal care, difficulty walking, and [CONDITION(S)] following cerebral infarction. The Admission MDS (Minimum Data Set) assessment, dated 9/3/21, indicated the resident was severely cognitively impaired, could not recall, required extensive assistance of 1 person with all ADL's (activities of daily living) including bed mobility, transfer, walking, locomotion, toileting and personal hygiene. His balance during transitions from seated to standing position, walking, turning when walking, and moving on or off the toilet was not steady and only able to stabilize with human assistance. He used a wheelchair. He was frequently incontinent of both bowel and bladder. He had a fall in the last month prior to admission and had one fall since admission. The nurse's note, dated 9/1/21 at 12:27 p.m., indicated the resident was returned to his room by therapy and left sitting next to his bed in his wheelchair. A CNA (Certified Nurse Aide) went into the room and the resident was unable to hold his position in his chair and slid out onto floor. The CNA indicated the resident did not hit his head. There was no injury. The IDT (Interdisciplinary Team) follow-up note, dated 9/2/21 at 11:46 a.m., indicated the root cause of the incident was the resident being unable to maintain his trunk control. An intervention for OT (occupational therapy) to evaluate the resident's need for a possible high-back wheelchair was put into place. The note indicated the care plan was updated. The care plan, dated 9/3/21, indicated the resident was at risk for falls related to gait and balance problems, impaired cognition, incontinence, medications, safety awareness, difficulty in walking, and unsteadiness on his feet. The only interventions listed on the care plan were for staff to assess risk for falls on admission, readmission, quarterly, and as needed, observe medication for side effects that may increase risk for falls, and physical and occupational therapy to evaluate as needed. The physician's note, dated 11/22/21 at 7:50 p.m., indicated the resident had been found at 7:30 p.m., sitting on the floor after an unwitnessed fall. The resident indicated he was trying to transfer himself. His right elbow was swollen and painful, which he rated a 7 out of 10 on a numerical pain scale. His right elbow had a large contusion, at least 10 cm (centimeters) in diameter. The resident was sent to the hospital to rule out a right upper extremity fracture. The nurse's note, dated 11/22/21 at 11:00 p.m., indicated the nurse heard a noise and went down the hallway. The resident was observed sitting upright on the floor beside his bed leaning against the night table. He was alert, talkative, and stated, I hurt my arm. His right arm was swollen. He was able to move all extremities well, but it was painful to move his right arm. The resident was sent to the hospital. The hospital report, dated 11/22/21, indicated the resident presented with a hematoma and pain to his right forearm and wrist. He had a nondisplaced fracture to the distal tip of the ulnar styloid. The physician's note, dated 11/22/21 at 11:50 p.m., indicated the resident returned from the hospital with a diagnosis of fracture to the right wrist and was wearing a splint. The IDT follow-up note, dated 11/23/21 at 12:11 p.m., indicated the root cause of the resident's fall was self-transferring. The note indicated an intervention of skid strips and bed against the wall was put into place, and the care plan was updated. The nurse's note, dated 1/24/22 at 5:43 p.m., indicated the nurse was notified by therapy of the resident having a black eye. Upon investigation the resident did have a black eye to the right side. The area was observed to be black and dark blue in color, circling the entire right eye. The resident did not have any complaints of pain or trouble with vision at the time. The resident also showed the nurse a small, raised area to the right forearm. He stated he was going to the bathroom on his own and caught himself against the bar in the bathroom but did not fall. The IDT follow-up note, dated 1/25/22 at 10:07 a.m., indicated the resident was taking himself to the bathroom and lost his balance, catching himself on the railing. The root cause of the incident was the resident not asking for help with bathroom assistance. The note indicated the intervention put into place was to encourage the resident to ask for help with toileting and to use the call light in the bathroom, and the care plan was updated. During an interview, on 2/18/22 at 5:52 p.m., the RDCO (Regional Director of Clinical Operations) indicated if a resident was not able to comprehend direction education, then education would not be an appropriate intervention. If an intervention specified for the bed to be against wall, the resident's non-dominant side would be placed against the wall, not the head of the bed. Interventions should be implemented immediately, and they should be added to the care plan. 2. The clinical record for Resident E was reviewed on 2/18/21 at 10:00 a.m. Diagnoses included, but were not limited to, acute [CONDITION(S)], [CONDITION(S)], and congestive heart failure. The baseline 48 hour care plan, indicated the resident required supervision with bed mobility and transfers, extensive assistance of one person with toileting and personal hygiene. The admission note, dated 1/5/22 at 8:00 p.m., indicated the resident was admitted with a chief complaint of weakness, she walked occasionally during the day, but for very short distances with or without assistance and spent the majority of each shift in the bed or chair. The nurse's note, dated 1/5/22 at 8:00 p.m., indicated the resident required supervision to the bathroom and with ADL's. She was continent of bowel and bladder. The skin/wound note, dated 1/6/22 at 3:07 p.m., indicated the resident reported a history of weakness and gait instability, and she had impaired mobility. The post-fall evaluation, dated 1/8/22 at 3:00 a.m. indicated the resident required minimum assist with a gait belt, had a balance problem while walking, and had fallen attempting to go to the restroom. She slid from her bed to the floor due to instability with self transfers, she was wearing non-skid socks at the time of the fall. The resident was placed in bed with assistance of 2 staff members, and offered a bed pan due to instability. The nurse's note, dated 1/8/22 at 3:10 a.m., indicated the resident was observed to be sliding out of bed when attempting to transfer to the bathroom. The writer watched the resident slide to the floor from the bed, no injuries were observed. The resident stated she was trying to go to the bathroom. While staff assisted the resident back to bed, her knees began to buckle under her when placed in a standing position. The bedpan was offered due to the resident's instability on her feet. The IDT follow-up note, dated 1/10/22 at 11:14 a.m., indicated the root cause of the fall was a slick surface. The new intervention was to add skid strips to the left side of the bed, and the care plan was updated. The nurse's note, dated 1/12/22 at 1:34 a.m., indicated the resident was very needy and turned on her call light frequently for numerous wants and needs, . like can you hand me a glass of water when bedside table is right there within reach, can you move my leg in bed, but resident gets up to go to the bathroom and can move extremities just fine . The resident was continent of bowel and bladder, alert and oriented. The post-fall evaluation, dated 1/12/22 at 3:00 a.m., indicated the resident had an unwitnessed fall with a head injury and a nosebleed. The resident had impaired walking with difficulty rising from the chair. Her ability to transfer was identified as a sit to stand lift for transfers and she was non-ambulatory. She was unable to stand alone. She fell attempting to get to the bathroom, in her wheelchair. The suspected root cause indicated, n/a (not applicable). The nurse's note, dated 1/12/22 at 4:22 a.m., indicated the resident's roommate came out into the hallway and reported the resident had fallen. The resident was found sitting in the floor with a laceration to the bridge of her nose. She indicated she was getting up to go the bathroom. The resident's family requested staff to put a brief on her so she wouldn't get up in the middle of the night to use the restroom and the resident agreed. The nurse's note, dated 1/12/22 at 10:45 a.m., indicated the resident's family was requesting the resident to be sent to the hospital because they believed she had a urinary tract infection and wanted her sent out. Staff explained labs could be obtained in the facility, but her family insisted the resident be sent out. The resident was sent to the hospital. The nurse's note, dated 1/12/22 at 6:14 p.m., indicated the resident was admitted to the hospital with a left radial fracture and [CONDITION(S)]. The resident did not return to the facility. During an interview, on 2/18/22 at 5:52 p.m., the RDCO indicated skid-strips would not have been an appropriate intervention if the resident's knees were buckling, and it would not have been appropriate to document afterwards that the resident could move her extremities just fine. The root cause should have been identified and addressed, with her complaints of not being able to move her legs, there should have been an assessment, notification to the nurse practitioner for further guidance, and interventions to assist the resident with her needs. 3. The clinical record for Resident D was reviewed on 2/16/22 at 2:42 p.m. Diagnoses included, but were not limited to, [CONDITION(S)], cognitive communication deficit, muscle weakness, difficulty walking, abnormalities of gait and mobility, lack of coordination, dementia, spondylosis, and spinal stenosis. The Quarterly MDS assessment, dated 12/28/21, indicated the resident was moderately cognitively impaired, required extensive assistance with bed mobility, transfers, toileting and personal hygiene, and had one fall with injury since her last quarterly assessment. The care plan, dated 10/6/20, indicated the resident was at risk for falls related to diminished safety awareness with [CONDITION(S)] and dementia, use of walker with mobility, and daily use of [CONDITION(S)] medications which added to fall risk. Interventions included, but were not limited to, one-quarter side rails to bed for mobility, anticipate and meet the resident's needs, call light within reach, encourage gripper socks at all times, encourage resident to lie in the middle of the bed, encourage resident to wear new full cam boot with gripper at all times, encourage resident to use assistive devices when ambulating, follow facility fall protocol, keep adjustable bed in low position for safe transfers, and lock bed brakes. The nurse's note, dated 11/11/21 at 8:30 a.m., indicated the resident was found next to her bed by a housekeeper. She indicated she slipped on a blanket which was wrapped around her feet. Staff educated the resident on importance of ensuring area around feet and walker were clear. The nurse's note, dated 11/11/21 at 12:00 p.m., indicated the resident was showing signs of increased confusion and lethargy. The Nurse Practitioner was in the building and ordered stat labs including a CBC (complete blood count), BMP (basic metabolic panel), and a U/A (urinalysis), as well as a onetime dose of [MEDICATION(S)] 25 mg, Tylenol 650 mg q 6 hours for fever, and covid-19 testing. The SBAR (situation background assessment recommendation) note, dated 11/11/21 at 12:45 p.m., indicated the resident had an altered mental status and abnormal vital signs. Orders were given to send the resident to the hospital. The nurse's note, dated 11/11/21 at 3:12 p.m., indicated the resident was transported to the hospital. The nurse's note, dated 11/11/21 at 11:46 p.m., indicated the resident returned to the facility alert and oriented. The IDT follow-up note, dated 11/12/21 at 12:14 p.m., indicated the root cause of the resident's fall was an unsteady gait. New interventions included a medical workup and occupational therapy to evaluate. The nurse's note, dated 11/19/21 at 2:09 p.m., indicated the resident had a witnessed fall. She was attempting to get up from her chair and grab her walker, lost her balance, and fell forward rolling onto her side. She had no injury and did not hit her head. She indicated she didn't know why she kept falling. The IDT follow-up note, dated 11/19/21 at 2:23 p.m., indicated the root cause of the fall was the resident holding her pants up with one hand. A new intervention to have family bring in new pants for the resident was put into place. The physician's note, dated 12/4/21 at 10:03 a.m., indicated the resident was assessed for falling twice that morning. She seemed to be more confused but had tried to get up twice and slid to the floor. She was fairly oriented and following commands. Orders were given to obtain a urinalysis. The nurse's note, dated 12/4/21 at 10:10 a.m. indicated the resident had fallen twice that morning within 5 minutes. She could not walk on her own, was incontinent, had increased confusion. New orders were given to hold her pain medication, obtain U/A, and obtain vitals every 4 hours. The IDT follow-up note, dated 12/6/21 at 11:18 a.m. indicated the root cause was identified as confusion, new interventions included a medical workup and U/A. The nurse's note, dated 12/8/21 at 11:30 a.m., indicated the resident had increased lethargy and was altered. The NP (Nurse Practitioner) ordered a onetime dose of intramuscular [MEDICATION(S)] due to pending U/A culture. The nurse's note, dated 12/8/21 at 2:55 p.m., indicated the resident was found on the floor next to her bed. She continued with lethargy and was unable to form words. The NP ordered to send the resident to the hospital. The nurse's note, dated 12/8/21 at 11:33 p.m., indicated the resident returned to the facility. She was pleasant, but still very confused. The nurse's note, dated 12/9/21 at 11:35 a.m., indicated the resident was still increasingly confused and disoriented. The resident's family requested she be seen in the hospital again, due to decline. She was requiring 4 lpm (liters per minute) of oxygen, was incontinent of bowel and bladder, and unable to walk with walker. The NP ordered to send the resident to the hospital. The admission note, dated 12/10/21 at 5:00 p.m., indicated the resident returned to facility with an admitting chief complaint of [CONDITION(S)] due to [CONDITION(S)]. The IDT follow-up, indicated on 12/9/21 a review of the resident's fall was conducted. The root cause was identified as increased confusion and weakness. The intervention was the resident sent to the hospital for evaluation related to increased confusion and weakness. The nurse's note, dated 12/25/21 at 1:50 a.m., indicated a QMA (Qualified Medication Aide) found the resident on the floor. She fell trying to get up to the restroom and hit her head. There was a baseball size hematoma to back of her head, and she was sent to the hospital for evaluation. The nurse's note, dated 12/25/21 at 10:10 a.m., indicated the resident's radiology results were negative and she was being sent back to the facility. The IDT follow-up note, dated 12/28/21 at 12:04 p.m., indicated the root cause of the resident's fall was slick flooring. A new intervention of skid strips to the bed was put into place. The nurse's note, dated 1/6/22 at 6:18 p.m., indicated a CNA was alerted by the resident's roommate, the resident was on the floor. The resident slid out of bed trying to get something. Her bed was at a high level, and she had regular socks on. The nurse's note, dated 1/6/22 at 8:30 p.m., indicated the resident had another fall at 8:00 p.m. She was unable to follow directions or answer questions about the situation, or correctly answer when asked about the date and time. The physician was notified and ordered to send to the hospital. The nurse's note, dated 1/7/22 at 6:40 a.m., indicated the resident was admitted for a urinary tract infection and altered mental status. The nurse's note, dated 1/8/22 at 3:04 p.m., indicated the resident was readmitted to the facility alert and oriented times two. The nurse's note, dated 1/8/22 at 7:15 p.m., indicated the nurse heard a loud noise from the resident's room followed by a yell for help. The resident was found lying across the floor in the direction of the bathroom with her right arm under her body and legs extended out. She stated she was going to the bathroom and forgot to ask for help. The nurse and QMA mechanically lifted the resident back to bed, as she was unable to assist with getting up. The IDT follow-up note, dated 1/10/22 at 2:29 p.m., indicated the root cause of the resident fall, was the bed at a height where her feet were not on the floor, and she couldn't balance herself. The new intervention indicated the resident was educated on proper bed height. The IDT follow-up note, dated 1/10/22 at 2:32 p.m., indicated the root cause of the resident fall, was the resident was being treated for a [CONDITION(S)], forgetting to ask for help, and not using her wheelchair to get to the bathroom. The new intervention indicated the resident was placed back in bed and educated on asking for assistance with toileting. During an interview, on 2/18/22 at 5:52 p.m., the RDCO indicated if a resident was not able to comprehend direction, education would not be appropriate. If a resident was confused and falling when trying to get to the restroom, she would consider interventions such as toileting plans. During an interview, on 2/21/22 at 1:55 p.m., the SDC (Staffing Development Coordinator) indicated she was a part of the IDT team, and she did participate in fall reviews. The IDT team tried to do the review by the day after the fall, for instance if the fall was on a Saturday, they would review it on Monday. Interventions were supposed to be put into place immediately. Skid strips should be put into place by maintenance the same day. For an intervention of bed against the wall, they would place the long part, or side of the bed against the resident's wall as soon as possible. If a resident was confused educational approaches would not be appropriate, they would consider interventions such two hour toileting, therapy consult for a reaching device, it really just depended on what they were doing when they fell . They could do a medical workup to see where the confusion is coming from. If the fall was due to weakness, they would look at therapy case load, put an assist with them with transferring, if they're buckling they would recommend skid strips, but if staff were having to assist the resident and their legs were still buckling it would probably not be appropriate to do that as an intervention. During an interview, on 2/21/22 at 2:55 p.m., Unit Manager 10 indicated prior to November, Resident 73 had been alert and oriented on a regular basis, but between November and January she'd had a change from her baseline and was very hit and miss. They sent her out, but she never bounced back. She was talking out of her head, mumbling, and had slurred speech. She would bounce back momentarily and then decline again; it wouldn't take but a week for her to decline. She did not feel when the resident was confused, she would have been able to be educated. She was requiring more assistance, normally she would get to the chair by herself, but towards the end she was an assist of 1, sometimes even an assist of 2, it depended on her mental state that day. The Fall Prevention and Management Policy, dated 5/25/21, provided on 2/17/22 at 3:30 p.m., by the RDCO, included, but was not limited to, . Post Fall Intervention: Attempt to put an intervention in place that could prevent further falls such as: if the resident was going to the bathroom, assist them to toilet . Attempt to identify why the resident fell and put an immediate intervention in place . The IDT team should review all information for all falls at the next Daily Clinical Meeting . A deep root cause investigation should be discussed. The care plan should be reviewed to identify if interventions are appropriate or if the new interventions should be added . This Federal tag relates to Complaint IN 056. 3.1-45(a)(1) 3.1-45(a)(2)

Based on record review and interview, the facility failed to ensure comfort medication orders were obtained in a timely manner for a hospice patient who was displaying signs of anxiety and pain for 1 of 5 residents reviewed for hospice services. (Resident 107) Findings include: The clinical record for Resident 107 was reviewed on 3/9/20 at 1:10 p.m. The resident's [DIAGNOSES REDACTED]. The care plan, dated 12/16/19, indicated the resident was on palliative and end of life care due to a [DIAGNOSES REDACTED]. The goal included, the resident would be cared for with respect and dignity and would be comfortable during end of life process. The Social Services note, dated 12/11/19 at 8:27 a.m., indicated the resident signed a Do Not Resuscitate (DNR) and wished to be on hospice services. The nurse's note, dated 12/16/19 at 3:29 p.m., indicated the resident was complaining of pain, 7 out of 10, involving her bilateral lower extremities and back. She was having difficulty sleeping at night and performing her normal every day activities. The nurse reminded the resident she had PRN (as needed) Tylenol and the resident indicated the Tylenol did not help her pain. A look back over the past 7 days indicated the resident had not taken any Tylenol. The DON (Director of Nursing) was made aware. The clinical record lacked documentation of any notification to the physician at that time of the resident's pain or the lack of pain relief from the Tylenol. The nurse's note, dated 12/16/2019 at 3:57 p.m., indicated hospice had given new orders to discontinue some of the resident's medications. No new orders were given for pain or anxiety medications. A nurse's note, dated 12/18/19 at 11:38 p.m., indicated the resident was very restless and was twitching from side to side in the bed. The hospice nurse indicated she would try to get orders for medications to address pain and anxiety. No medications were ordered at that time. A nurse's note, dated 12/19/19 at 1:10 a.m., indicated the resident was thrashing and continued to be very restless. The hospice nurse was notified and said she would come in to visit the resident. No new orders were given at that time. A nurse's note, dated 12/19/19 at 3:19 a.m., indicated the hospice nurse had left messages for the hospice physician, however no return call had been received. No new prescriptions had been received. A nurse's note, dated 12/19/2019 at 3:44 a.m., indicated the hospice nurse had left the facility and would call when she received new orders from the physician. A nurse's note, dated 12/19/19 at 12:30 p.m., indicated the resident's family members were present and requested medications for the resident's pain and anxiety for the resident's comfort. No new orders were written at that time. The MAR (medication administration record) indicated the resident did not receive a dose of [MEDICATION NAME] sulfate 100 mg/5 mL (milligrams per milliliter) until 12/19/19 at 2:04 p.m. A nurse's note, dated 12/19/19 at 3:30 p.m., indicated hospice was in the facility and had written orders for [MEDICATION NAME] 0.25 mL (milliliters) every two hours as needed for shortness of breath or pain, and Tylenol 650 mg (milligrams) rectal suppository every four hours as needed for fever or pain. No orders to address anxiety were written at that time. A nurse's note, dated 12/20/19 at 5:49 a.m., indicated the resident had been placed on concentrated [MEDICATION NAME] every four hours as needed for anxiety or shortness of breath. The pharmacy had been contacted several times, but could not provide the authorization codes to pull the medication. The pharmacy would send the medication after 7:00 a.m. The MAR indicated [REDACTED] During an interview on 3/9/20 at 11:17 a.m., Unit Manager 4 indicated the resident did not take the Tylenol because she indicated it did not help her. She had not initially been given any pain medication or anxiety medication due to her history of [MEDICAL CONDITION], however once she went on hospice, due to the restlessness she would have needed medications to address pain and anxiety. During an interview on 3/9/20 at 11:27 a.m., The hospice RN indicated the resident's order for pain and anxiety medications should have been written upon admission to hospice. The hospice physicians were available 24 hours a day, 7 days a week, and normally responded quickly. During an interview on 3/9/20 at 1:56 p.m., the DON (Director of Nursing) indicated the resident was observed with pain and restlessness on 12/16/19, when she went onto hospice and said her Tylenol did not work. He did not know why it took so long to get pain and anxiety medications for the resident. During an interview on 3/10/20 at 2:55 p.m., the DON indicated he did not have a policy regarding hospice services.

Based on observation, interview, and record review, the facility failed to ensure appropriate treatments were in place for a resident (Resident C and Resident E) for 2 of 3 residents, which resulted in the worsening of a pressure ulcer (Resident E). Findings include: 1. The clinical record for Resident E was reviewed on 8/8/18 at 10:00 a.m. [DIAGNOSES REDACTED]. On 8/8/18 at 1:05 p.m., the resident was observed in bed with his eyes open. The resident's left foot was resting on the bed and not elevated. On 8/8/18 at 1:48 p.m., the wound to the left outer heel was observed to be a dark brown in color and measured 3 cm (centimeters) by 4 cm with no depth. The left back heel was observed to be dark brown in color and measured 8.3 cm by 5 cm with no depth observed. The Unit Manager indicated the wounds were debrided (removal of tissue) on 8/6/18. The admission observation tool, dated 6/1/18 at 5:17 p.m., indicated the resident had a suspected deep tissue injury of the left heel, which measured 8 cm in length and 3.5 cm in width with no depth, and a surgical wound to the front of the right thigh which measured 8 cm in length by 1 cm in width. The hospital discharge summary, dated 6/1/18 at 2:50 p.m., indicated to apply [MEDICATION NAME] (wound treatment) 10% (percent) to the resident's wound twice daily. The care plan indicated the resident had pressure ulcers upon admission, to complete treatments as ordered, and follow facility policies and protocols for the prevention and treatment of [REDACTED]. The (MONTH) (YEAR) MAR (Medication Administration Record) indicated to cleanse the left thigh wound, apply Dakin's (wound debridement solution) wet to dry dressing, and cover with a dressing. The (MONTH) (YEAR) MAR indicated [REDACTED] -6/11/18 - due to absent from home -6/12/18 - due to resident at [MEDICAL TREATMENT] -6/13/18 - blank -6/16/18 - blank -6/18/18 - due to 'hold' -6/20/18 - blank The (MONTH) (YEAR) MAR indicated [REDACTED]. There was no documentation to indicate the treatment was completed between 6/1/18 and 6/27/18. The skin grid pressure sheets for the left outer heel indicated the following measurements: 6/04/18 - 1.9 cm x 2.0 cm x 0.1 cm, classified as a stage 2 6/11/18 - 1.6 cm x 0.9 cm x 0.1 cm, classified as a stage 2 6/18/18 - 5.5 cm x 5.0 cm x 0.1 cm, classified as a stage 2 6/25/18 - 5.5 cm x 5.0 cm x 0.1 cm, classified as a stage 2 The skin grid pressure sheets for the left heel indicated the following measurements: 6/04/18 - 3.7 cm x 3.5 cm x 0.1 cm, classified as a stage 2 6/11/18 - 3.6 cm x 3.5 cm x (no depth listed), classified as a stage 2 6/18/18 - 6.9 cm x 6.0 cm x 0.1 cm, classified as a stage 2 6/25/18 - 6.9 cm x 6.0 cm x 0.1 cm, classified as a stage 2 During an interview on 8/8/18 at 1:40 p.m., RN (Registered Nurse) 3 indicated staff sign off on the MAR/TAR (treatment administration record) to show they have completed treatments. On 8/8/18 at 3:46 p.m., the Director of Nursing provided a copy of the document titled Skin Management & Wound Management dated (MONTH) (YEAR). It included, but was not limited to, the following: Definition: A pressure is defined as a localized injury to the skin .Policy .The facility staff strives to prevent resident .skin impairment and to promote the healing of existing wounds. The interdisciplinary team works with the resident .to identify and implement interventions to prevent and .treat potential skin integrity issues .Skin care and wound management program includes .Application of treatment protocols based on clinical best practice: standards for promoting wound healing .Treatment .2. Review and select the appropriate treatment for [REDACTED]. Obtain a physician's order .5. Document treatment on the Treatment Administration Record (TAR) 2. The clinical record for Resident C was reviewed on 8/6/18 at 2:22 p.m. [DIAGNOSES REDACTED]. The care plan, indicated potential for alteration in skin integrity. Interventions included, but were not limited to, pressure reducing mattress, follow physician orders for wound care, turn and reposition as allows, and to follow the facility policies and protocols for the prevention/treatment of [REDACTED]. The skin pressure grid, dated 7/2/18, indicated the resident had a house acquired wound to the left buttock, which measured 2 cm in length, 3 cm in width, and a depth of .25 cm. During an interview, on 8/7/18 at 12:42 p.m., LPN (Licensed Practical Nurse) 4 indicated she treats the wound with triple antibiotic ointment. On 8/7/18 8/7/18 at 12:50 p.m., the wound to the left gluteal fold was 3 cm in length, 3 cm in width, and a depth of .2 cm. The wound bed edges were pink and the center of the wound was a yellowish and white color. LPN 4 cleansed the pressure area with saline from a syringe, applied triple antibiotic ointment to the 4 by 4 dressing and placed over the wound. The clinical record lacked documentation of any treatment completed or treatment order for the resident's pressure ulcer for (MONTH) 2 through (MONTH) 7, (YEAR). During an interview, on 8/7/18 at 1:05 p.m., the Director of Nursing indicated there was no active order in place for the resident's wound. This Federal tag relates to Complaint IN 824. 3.1-40(a)(2)

Based on observation, interview, and record review, the facility failed to ensure interventions and treatments were in place for one resident who was at an increased risk for developing pressure ulcers and developed, in house, one unstageable pressure ulcer to the left heel and one stage four pressure ulcer to the left medial foot which resulted in an above knee amputation of the left leg (Resident B); one resident with a healed pressure ulcer that reopened to a stage 3 pressure ulcer on the coccyx (Resident E); and one resident who developed a stage 3 pressure ulcer in the right gluteal fold acquired in the facility (Resident H) for 3 of 3 resident reviewed for pressure ulcers. The Immediate Jeopardy began on 9/17/17 at 6:48 p.m. when an area to the left heel was identified by staff and the facility failed to ensure interventions and treatments were in place. The Administrator and Regional Nurse Consultant were notified of the Immediate Jeopardy on 1/19/18 at 3:15 p.m. Findings include: 1. The clinical record for Resident B was reviewed on 1/18/18 at 12:28 p.m. [DIAGNOSES REDACTED]. The five day Admission MDS (Minimum Data Set) assessment, dated 8/16/17, indicated the resident had intact skin, was at risk for pressure ulcers, required an extensive two person assistance with bed mobility, and had functional range of motion impairment to both upper and lower extremities. The Braden Scale for Predicting Pressure Sore Risk, dated 8/17/17 at 2:08 a.m., indicated Resident B was bedfast with very limited mobility which signified the inability to make frequent or significant changes in body position without assistance. The care plan, dated 8/10/17, indicated a potential for pressure ulcer development due to decreased mobility, dementia, incontinence, and the need for hands on staff assist with activities of daily living. The interventions included administer treatments as ordered, follow the facility policies/protocols, remind/assist to turn/reposition at least ever 2 hours, use of pressure reducing mattress on bed, cushion in wheel chair, and weekly full body skin assessments. The progress note, dated 9/17/17 at 6:48 p.m., indicated the family notified staff of a wound on the resident's left heel, which was discolored, intact, and very mushy to touch. Notification was placed in the physician's binder for further evaluation, and a heel protector boot was placed on the left foot to aid in protection. The September 2017 treatment administration record lacked documentation of a weekly skin assessment on 9/22/17 and 9/29/17 or any new treatment orders for the identified area on the heel. The September 2017 shower sheets indicated the resident had no skin areas of concern. The progress note, dated 10/18/17 at 5:52 p.m., indicated the resident had an open area on the left heel which measured 5 cm (centimeters) in diameter with a moderate amount of drainage and a foul smelling odor. The physician order, dated 10/18/17 at 6:14 p.m., indicated to cleanse the left heel wound with wound cleanser, apply opticell (treatment for [REDACTED]. The October 2017 treatment administration record indicated the treatment was not completed to the wound on the left heel on 10/19/17, 10/22/17, 10/23/17, and 10/30/17. The record lacked documentation of a weekly skin assessment on 10/13/17 and 10/27/17. The October 2017 shower sheets indicated the resident had no skin areas of concern. The Nurse Practitioner note, dated 11/6/17, indicated to send the resident for an evaluation at the wound care center. The progress note, dated 11/10/17 at 1:14 p.m., indicated the wound on the inner aspect of the foot was 3 cm x 2.5 cm with red/black/slough. The left heel was approximately 5 cm x 3.6 cm, which was all black. The progress note, dated 11/13/17 at 1:53 p.m., indicated the left heel had yellow drainage with an odor and a new order was received to obtain an x-ray and wound culture during the next dressing change. The progress note, dated 11/15/17 at 3:53 p.m., indicated the wound culture was obtained. The radiology report, dated 11/13/17 at 6:59 p.m., indicated no evidence of osteomylitis but an MRI (magnetic resonance imaging) was more sensitive. The left heel wound culture, dated 11/18/17 at 1:35 p.m., [MEDICAL CONDITION] ([MEDICAL CONDITION] resistant staphyloccoccus aureus) with heavy growth. The progress noted, dated 11/18/17 at 6:31 a.m., indicated a full head to toe skin assessment was completed on 11/17/17 and the resident was noted with an unstageable pressure area to the left heel and inner bony prominence. A new treatment order for Santyl (wound debridement agent), cover with dry dressing, and wrap with kerlix daily was received. The progress note, dated 11/18/17 7:23 p.m., indicated the the Nurse Practitioner was notified and to start Cipro, 500 mg (milligrams) twice daily. The care plan, initiated 11/18/17, indicated the resident had unstageable pressure ulcers to the left heel and inner left bony prominence related to decreased mobility, to complete treatments as ordered, and to apply heel protectors to bilateral feet. The skin grid pressure sheet, dated 11/18/17 at 3:54 p.m., indicated the resident had an unstageable area to the left heel, first observed on 10/19/17, house acquired, with risk factors of impaired/decreased mobility and contracture of the left knee. The area measured 5 cm x 3 cm. The skin grid pressure sheet, dated 11/18/17 at 7:05 p.m., indicated the resident had an area to the left foot, first observed on 10/19/17, was house acquired, with risk factors of impaired/decreased mobility and contracture of the left knee. The area measured 2.5 cm x 2 cm and the area was not staged. The clinical record lacked documentation of any other skin grid pressure sheets prior to 11/18/17 and thereafter. On 1/19/18 at 9:48 a.m., LPN (Licensed Practical Nurse) 3 indicated wounds were measured weekly and the information was put on the skin grid pressure sheets. The November 2017 treatment administration record indicated on 11/17/17 to discontinue the current treatment to the left heel and start Santyl, apply to left heel and left inner bony prominence after cleansing with normal saline then cover with a dry dressing and wrap with kerlix daily. The treatment record also indicated, on 11/18/17, the resident was to have heel protectors to bilateral feet. The November 2017 treatment administration record lacked documentation of a weekly skin assessment on 11/29/17, heel protectors in place on 11/22/17 and 11/27/17, and wound treatment completed on 11/18/17, 11/22/17, and 11/27/17. The November 2017 shower sheets indicated no skin areas noted. The progress note, dated 11/30/17 at 2:26 p.m., indicated the resident had a wound consult at the wound care center on 12/13/17. The wound care center assessment report, dated 12/13/17 at 9:00 a.m., indicated the left heel measured 4 cm x 2 cm x 0.3 cm and was classified as an unstageable area. The left medial foot measured 2.5 cm x 2.5 cm x 0.2 cm and was classified as a stage 4. The wound center progress note, dated 12/13/17 at 9:00 a.m., indicated the left heel was an unstageable pressure injury, the base was soft black necrotic tissue, and the lateral aspect had an area open with surrounding ecchymosis. The area needed to be offloaded. The progress note, dated 12/19/17, indicated the resident had an appointment at the wound center and was directly admitted to the hospital from the wound center. The wound center progress note, dated 12/19/17 at 3:30 p.m., indicated the left heel measured 4.5 cm x 4.5 cm x 0.3 cm and was classified as an unstageable area. The left medial foot measured 2.5 cm x 2.5 cm x 0.2 cm and was classified as a stage 4. The December 2017 treatment administration record indicated the heel protectors to bilateral feet, wound treatment to the left heel, and left medial foot were discontinued on 12/2/17. The December 2017 MAR (medication administration record) indicated, between 12/9/17 and 12/11/17, to apply Santyl to the left heel topically every day shift, at which time the treatment was discontinued. The physician order, dated 12/11/17 at 11:25 a.m., indicated to apply Santyl to the left heel and left foot bony prominence (medial) topically every day shift for wound care. The December 2017 MAR indicated [REDACTED]. There was also no documentation of weekly skin assessments. The December 2017 shower sheets indicated there were no skin areas noted. During an interview on 1/19/18 at 12:47 p.m., RN (Registered Nurse) 2 and LPN 3 indicated they did not have an answer as to why there were no wound measurements documented prior to 11/18/17 and thereafter, when the medial left foot wound was first identified; why it took so long to set up a wound evaluation at the wound care center; or why it took so long for a treatment to be started on the identified wounds. The hospital history and physical, dated 12/20/17 at 12:18 p.m., indicated the following: Plan of Care .Assessment .infected decubitus left heel/foot. The hospital infectious disease consultation report, dated 12/20/17, indicated the resident was admitted due to a worsening left heel ulcer which was necrotic, very deep and had a foul odor. The hospital operation report, dated 1/2/18, included, but was not limited to, the following: Date of Procedure .1/2/18 .Preoperative Diagnoses: [REDACTED].Postoperative [DIAGNOSES REDACTED].Procedure Performed .Above Knee Amputation . During an interview on 1/19/18 at 1:55 p.m., Resident B's primary care physician at the facility indicated he was unaware of the resident's wounds until he was admitted to the hospital on [DATE] and had the wounds been identified and properly treated, the resident likely would not have lost his leg and the clinical course would have been different. On 1/19/18 at 10:10 a.m., the Unit Manager provided a copy of the document titled Skin Care & Wound Management, dated 7/2016. It included, but was not limited to, the following: Policy .The facility staff strives to prevent resident/patient skin impairment and to promote the healing of existing wounds .Treatment .1. Select and complete the appropriate form .a. Pressure Ulcer Documentation. Complete for all pressure ulcers .2. Review and select the appropriate treatment for [REDACTED]. Obtain a physician's orders [REDACTED]. Monitor and document progress .7. Evaluate effectiveness of interventions during the clinical meeting . 2. The clinical record for Resident E was reviewed on 1/19/18 at 2:48 p.m. [DIAGNOSES REDACTED]. The care plan, dated 7/7/6 and revised on 1/19/18, indicated the resident had a pressure ulcer due to often sitting for extended periods of time, was admitted with a stage 2 pressure ulcer which was healed, and had reopened as a stage 3 pressure ulcer. The interventions, included but were not limited to, administer treatments as ordered, assess/record/monitor wound healing weekly, measure weekly, and weekly skin assessments. On 11/23/18 at 11:35 a.m. Resident E's wound was observed to be approximately 2.5 cm (centimeters) in length, 1.5 cm in width, and 0.1 cm in depth. The wound bed was white/yellowish in color. The September 2017 TAR (treatment administration record) indicated to cleanse the coccyx with wound cleanser, pat dry, apply Opti-foam treatment to the wound bed, and cover with a dry dressing every day shift. The TAR for September 2017 indicated the weekly skin assessments were discontinued on 9/18/17 and lacked documentation of a treatment completed on 9/1/17, 9/2/17, 9/4/17, 9/5/17, and 9/12/17. The October 2017 treatment administration record lacked documentation of weekly skin assessments. Review of the pressure grid sheets indicated the wound was assessed and measured on 8/23/17 and not again until 9/22/17, and on 10/11/17 and not again until 1/18/18. During an interview on 1/19/18 at 12:47 p.m., RN 2 indicated skin checks are completed weekly and nursing staff initial the treatment administration record when they are done. During an interview on 1/23/18 at 12:28 p.m., LPN 8 indicated once a treatment was completed, it was initialed by the nurse on the treatment administration record to verify it was completed. 3. The clinical record for Resident H was reviewed on 1/22/18 at 1:40 p.m. [DIAGNOSES REDACTED]. The annual MDS assessment, dated 1/2/18, indicated the resident had impaired cognition and required extensive two person physical assistance with bed mobility. On 1/23/18 at 11:13 a.m., Resident H's wound to the right gluteal fold was observed to be approximately 3 cm length by 3 cm width and 0.3 cm depth. The wound bed a dark grayish/black color. The care plan, dated 3/27/17, indicated the resident had the potential for pressure ulcer development due to decreased mobility, sitting for extended periods of time, incontinence, and need for staff assistance with activities of daily living. The interventions included to administer treatments as ordered, remind/assist to turn/reposition at least every 2 hours, and weekly full body skin assessments. The Braden Scale for Predicting Pressure Sore Risk, dated 9/24/17, indicated the resident was chairfast and at a low risk for pressure ulcers. The Braden Scale for Predicting Pressure Sore Risk, dated 1/19/18, indicated the resident was chairfast, very limited mobility, problem with friction/shearing, and at a moderate risk for pressure ulcers. The December 2017 treatment administration record indicated a weekly skin assessment on 12/26/17 was not completed. The progress note, dated 1/2/18 at 11:44 a.m., indicated RN 10 was alerted, during report at start of shift, that Resident H had a spot on his right buttock, and, upon assessment, there was an area which measured 2.8 cm in length by 2.5 cm in width and 0.1 cm in depth. The physician order, dated 1/3/18, indicated to cleanse the right buttock with wound cleanser/normal saline, apply triple antibiotic ointment and cover with a dry dressing daily. The order was discontinued on 1/13/18. The progress note, dated 1/4/18 at 10:36 a.m., indicated the area did not appear to be pressure related and was an abrasion. The Nurse Practitioner note, dated 1/4/18, indicated the resident has had no changes per the nurse. The weekly skin check note, dated 1/10/18 at 5:10 a.m., indicated the resident had an abrasion to the right buttock due to diaper rubbing the right fold of the buttock. The December 2017 treatment administration record indicated a weekly skin assessment on 12/26/17 was not completed. The physician order, dated 1/13/18, indicated to cleanse the right buttock with wound cleanser/normal saline, apply [MEDICATION NAME] and cover with borderfoam every day shift. The skilled documentation note, dated 1/15/18 at 12:14 p.m., indicated the resident had a stage 2 to the right buttock. The care plan, dated 1/19/18, indicated the resident had a stage 3 pressure ulcer to the right buttocks The January 2018 treatment administration record lacked documentation of a skin assessment on 1/2/18 and wound treatments on 1/5/18, 1/8/18, 1/14/18, 1/15/18, and 1/16/18. The Immediate Jeopardy that began on 9/17/17 at 6:48 p.m. was removed on 1/23/18 at 12:02 p.m. when the facility completed staff education/inservices on daily wound monitoring, identifying skin impairment, pressure ulcer prevention, at risk residents, weekly skin assessments, pressure and non pressure skid grid documentation, and abuse and neglect. The Immediate Jeopardy was removed on 1/23/18, but noncompliance remained at the lower scope and severity of isolated, no actual harm with potential for more than minimal harm that is not Immediate Jeopardy because not all staff had been educated on daily wound monitoring, identifying skin impairment, pressure ulcer prevention, at risk residents, weekly skin assessments, pressure and non pressure skid grid documentation, and abuse and neglect. This Federal tag relates to Complaint IN 002 3.1-40

Based on interview and record review, the facility failed to immediately and completely investigate an observation of a sexual encounter between two cognitively impaired residents (Resident E and Resident G) and failed to provide adequate supervision to prevent a second encounter from occurring (Resident E and Resident F) for 2 of 3 residents reviewed for abuse. This deficient practice resulted in an Immediate Jeopardy. The Immediate Jeopardy began on 6/5/17 at 6:30 p.m. when a staff member observed a sexual encounter between two cognitively impaired residents (Resident E and Resident G) and failed to provide adequate supervision to prevent a second encounter from occurring (Resident E and Resident F). The Health Facility Administrator, Director of Nursing, and District Director of Clinical Operations were notified of the Immediate Jeopardy on 6/12/17 at 4:19 p.m. The Immediate Jeopardy was removed on 6/14/17 at 2:55 p.m., but noncompliance remained at the lower scope and severity of isolated, no actual harm with potential for more than minimal harm that is not Immediate Jeopardy. Findings include: 1. The clinical record for Resident E was reviewed on 6/12/17 at 10:50 a.m. [DIAGNOSES REDACTED]. The quarterly MDS (Minimum Data Set) assessment, dated 5/15/17, indicated a BIMS (Brief Interview of Mental Status) score of 10, which signified moderately impaired cognition. During an interview with the DNS (Director of Nursing Services) on 6/12/17 at 4:40 p.m., she indicated on 5/31/17 another BIMS was conducted on Resident E with a score of 3, which signified severely impaired cognition. The clinical record for Resident G was reviewed on 6/12/17 at 3:45 p.m. [DIAGNOSES REDACTED]. The quarterly MDS assessment, dated 5/6/17, indicated severely impaired cognition. The behavior note, dated 6/5/17 at 7:40 p.m., indicated staff noted Resident E to be attempting inappropriate sexual behavior with a female resident (Resident G). The behavior note, dated 6/6/17 at 12:56 a.m., indicated the resident (Resident E) continues to ask staff to get in bed with him. Review of the ISDH (Indiana State Department of Health) reportable, dated 6/6/17 at 7:30 p.m., indicated a staff member reported to the DNS that last night (6/5/17) Resident G was found sitting on the bed of Resident E who had his pants down and his genitalia out. The abuse investigation worksheet, dated 6/6/17 at 5:00 p.m., indicated on 6/5/17 at about 6:30 p.m. Resident E came very close to Resident G with an exposed erect penis. CNA (Certified Nursing Assistant) 4 was passing Resident E's room and saw him standing on the side of the bed with his curtain mostly pulled. She went to his side of the room to check on him and saw Resident G sitting on the side of the bed. Resident E had an erect penis and was nearly touching Resident G's forehead with one hand on her shoulder. During a telephone interview on 6/12/17 at 1:36 p.m., CNA 4 indicated after dinner on 6/5/17 she was coming down the hall, looked into Resident E's room, and saw him standing with his back to the door and the privacy curtain pulled. I went in and found (Resident G) sitting on his bed. He had his hands down the back of her shirt rubbing her back and his erected penis was out of his pullup and right at her forehead. I removed (Resident G) and reported the incident to the Social Services Director (SSD 5). During an interview on 6/12/17 at 12:58 p.m., the DNS indicated on 6/5/17 around 6:30 p.m. she had several people at her door and the SSD on the dementia unit reported there was an incident with Resident E. I heard the word penis, but don't recall the details of what she told me. What I got was everything was ok. After about 10 minutes, I went back to talk with (the SSD) and asked what we were going to do and we decided to send (Resident E) for a psychiatric evaluation, and after that, I left. At this point, we did not know the severity of the first incident. During this interview, the Administrator indicated Resident E was monitored well. During an interview on 6/12/17 at 1:42 p.m., SSD 5 indicated on 6/5/17, CNA 4 reported to her that Resident G was sitting on Resident E's bed. He was standing in front of her with his privates out. I immediately notified (the DNS) and started the process to have the resident transferred out to the hospital. I started 15 minute checks, and when I left at 2:00 a.m. on 6/6/17, handed the paperwork to the nurse. She could not locate the 15 minute checks. The clinical record for Resident E lacked documentation of increased supervision after the first incident occurred on 6/5/17 at 6:30 p.m. up to the second incident on 6/6/17 at 3:30 p.m. On 6/12/17 at 10:13 a.m., the Administrator provided a current copy of the document titled Abuse, dated 8/31/12. It included, but was not limited to, the following: Policy .sexual .neglect .are strictly prohibited .All alleged violations involving .abuse .are reported immediately to the administrator .Rationale: Patients have the right to be free of .sexual .abuse .14 .If the alleged violation is verified, appropriate corrective action must be taken 2. The clinical record for Resident F was reviewed on 6/12/17 at 3:20 p.m. [DIAGNOSES REDACTED]. The quarterly MDS assessment, dated 3/12/17, indicated severely impaired cognition. The ISDH reportable, dated 6/6/17 at 4:30 p.m., indicated Resident E was found in the doorway of his room with his hand down Resident F's shirt. The abuse investigation worksheet, dated 6/6/17 at 3:30 p.m., indicated Resident E was found in the doorway of his room leaning over the wheelchair of Resident F. He had his hand down her shirt and was apparently rubbing her chest. CNA 3 reported she saw Resident F in her wheelchair backed up into the doorway of Resident E's room. He had his hand inside her shirt rubbing her right shoulder and chest area. During a telephone interview on 6/12/17 at 1:24 p.m., CNA 3 indicated on 6/6/17 around 3:30 p.m. she was in the dining room charting when Resident E's call light came on. She went into his room and Resident F was sitting in her wheelchair facing the hallway. Resident E was behind/beside her with his hand down the front of her shirt rubbing all over. I asked him to remove his hand and he refused, so I removed it. He said he was trying to get her in bed. (Resident F) was crying and I took her up to the nurses station and reported the incident to the nurse and DNS. Prior to the incident, Resident E kept trying to come out of his room with only a t-shirt and brief on and kept saying I need a woman. During an interview on 6/12/17 at 12:47 p.m., the Administrator indicated the first incident occurred around 7:00 p.m. on 6/5/17. The DNS reported Resident E was in his room with his pants down and a female resident (Resident G) wandered into his room. The next incident occurred on 6/6/17 at 3:30 p.m. when Resident E was found with his hand down another female resident's (Resident F) shirt. While the facility was investigating the second incident, they found out the first incident was more severe than previously thought. The Administrator indicated increased supervision was put into place after the first incident, however, it was not in the form of 15 minute checks or 1 on 1 supervision. The Immediate Jeopardy that began on 6/5/17 at 6:30 p.m. was removed on 6/14/17 at 2:55 p.m. when the facility completed staff education/in-services on abuse and abuse prevention and management education on immediate abuse investigation and implementation of adequate supervision to prevent reoccurrence of significant events. The Immediate Jeopardy was removed on 6/14/17, but noncompliance remained at the lower scope and severity of isolated, no actual harm with potential for more than minimal harm that is not Immediate Jeopardy because not all staff had been educated on abuse and abuse prevention and implementation of adequate supervision to prevent reoccurrence of significant events. This Federal tag relates to Complaint IN 990 3.1-45(a)(2)

Based on observation, interview and record review, the facility failed to ensure fall risk was evaluated and interventions were in place according to an individualized plan of care for 3 of 5 residents reviewed in a sample of 8 residents who met the criteria for falls. This failure resulted in a fall with hip fracture for Resident #D. (Residents #D,# E, and #F ) Findings include: 1. Interview with LPN #9 on 8/18/14 at 2:40 p.m., indicated Resident #D had fallen the previous week and sustained a fractured right hip. The clinical record was reviewed on 8/20/14 at 11:15 a.m. [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment, dated 7/31/14, indicated the resident had cognitive impairment, and needed the limited assistance of one person for transfers and walking in the room. The resident needed the extensive assistance of one person for walking in the corridor. The resident's balance for all transitions and walking was assessed as not steady and the resident was only able to stabilize with human assistance. These were the same assessments as found on the 5/5/14 quarterly assessment. The care plan indicated the resident was at risk for falls related to unsteady gait, poor balance, poor communication/comprehension, and dementia. The goal for this problem was for the resident to have no significant injuries through the next review. The interventions for the problem of falls was to ensure proper footwear when out of bed and encourage gripper socks when not in shoes, non-skid strips in the residents bathroom for safety, and to place a pressure sensitive alarm on the bed to alert staff of attempts to transfer without assist. physician's orders [REDACTED]. 5/18/14 Check resident for proper footwear while out of bed related to recent fall. 5/24/14 Resident to wear gripper socks while abed (in bed). 6/30/14 Gripper sock on at bedtime and while in bed. 7/18/14 Non skid strips next to bed for safety. 8/9/14 Have non skid strips placed in resident bathroom for safety. The record indicated the resident had falls on 4/18/14, 5/24/14, 6/30/14, 7/18/14 and 8/9/14. The 8/9/14 fall resulted in a fractured hip. Observation of the resident in her room in bed, on 8/20/14 at 11:20 a.m., indicated she did not have gripper socks on her feet. The socks were plain white. Interview with CNA #1 at 11:24 a.m., indicated she did not know the resident was to have gripper socks on when in bed. The assignment sheet was provided at that time and did not indicate the resident was to wear gripper socks. Observation with LPN #3 in the resident's bathroom on 8/20/14 at 11:20 a.m. indicated there were no non-skid strips on the floor in front of the toilet. Review of Fall Investigations on 8/21/14 at 8:40 a.m., indicated the facility did not use the Root Cause Analysis to document the evaluation of the fall for the underlying reasons the resident fell . For example, the Root Cause Analysis for the 8/9/14 fall included: What was missing or weak? "CP (care plan) Intervention" was written with no explanation of what care plan intervention was missing. What steps contributed to the event? "CP Intervention." with no explanation. "What do we do now to prevent failure at the step?" "New intervention: Res (resident) sent to ER (emergency room ) and admitted , CP will be updated when readmitted to facility." Action Plan: Care Plan Interventions, "Resident sent to ER (with) later being admitted . Will update CP when resident is readmitted to facility." "What are the details of the event? Resident fell from w/c while attempting to transfer self into bathroom." "Where or when did the event(s) occur? Resident Bathroom 8/9/14 at 9:30 a.m." The resident had been identified as having the inability to sustain balance with transfers on the MDS assessment. The problem of the resident not having adequate supervision to prevent falls was not identified as a potential reason for the fall. On 7/8/14, the resident had an unwitnessed fall without injury. The resident was found in her room on the floor without shoes and attempting to put self to bed at 9:10 p.m. The Root Cause Analysis for this fall included: "What was missing or weak? CP Intervention." There was no explanation of what care plan intervention was missing. "What do we do now to prevent failure at the step? "Non skid strips to be placed next to bed for safety." "CP intervention added." On 6/30/14, the resident had an unwitnessed fall without injury. The resident was found beside the bed on the floor with regular socks. On 5/24/14, the resident had an unwitnessed fall on the floor of the bedroom when she attempted to self transfer. The invention was to assure proper footwear. Interview with the DON (Director of Nursing) on 8/22/14 at 10:40 a.m. indicated the falls are reviewed by the interdisciplinary team and new interventions are written for the resident. The documentation for these meeting was kept in their Quality Assurance (QA). The QA record for the 8/9/14 fall was provided by the DON and indicated, "Resident assisting self to toilet, non slip socks in place, was able to transfer self, c/o pain, sent to ER, with revision of CP to be updated when resident returns." 2. Interview with LPN #9 on 8/18/14 at 2:50 p.m., indicated Resident #E had falls on 7/20/14, 7/28/14 and 8/2/14. Injuries were limited to skin tears and bruising. Clinical record review on 8/20/14 at 3 p.m., the Minimum Data Set (MDS) assessment, dated 2/18/14, indicated the resident had cognitive impairment, needed the extensive assistance of one for transfer and toileting, and did not walk. The most recent quarterly MDS assessment, dated 6/2/14, indicated the resident needed the extensive assistance of one for bed mobility, transfers, toileting and personal hygiene. The resident required limited assistance of one for ambulation in room, but extensive assistance of one for ambulation in the corridor. The resident was assessed as having difficulty with balance in all areas of transitions and walking and was not steady and only able to stabilize with human assist. The care plan identified the resident's risk for falls and noted impaired vision due to glaucoma. The intervention was to ensure glasses were washed and clean prior to application. The goal for this problem of falls was for the resident to not sustain serious injury. "(Resident E) is at risk for falls r/t (related to) vision problems, gait/balance problems, incontinence, diminished safety awareness, history of falls, psychoactive drug use. Often walks w/o (without) shoes and walker and will trip over her own feet, refusal to wear shoes or use walker at times." "7/11/2014-transfers independently even when unsteady-refuses to ask for or accept assistance." Interventions included: "Anticipate and meet needs 5/6/14." "Be sure the call light is within reach and encourage to use it for assistance as needed." "bed alarm" "Encourage to use gripper socks when not in shoes." Encourage/remind to use walker when ambulating. If refuses to use walker notify nurse and monitor closely for safety 6/3/14." Follow facility fall policy." "She needs to be in the falling star program. 5/6/14" "Ensure that she is wearing appropriate footwear or gripper socks. Encourage to wear 1 or the other." Observation of Resident #E, on 8/20/14 at 11:34 a.m., with CNA 3# indicated the resident was in bed in her room and had no socks on her feet. She was barefooted. The CNA provided the assignment sheet which failed to include this intervention. Review of the Root Cause Analysis forms, the facility failed to look for the underlying cause of the falls. For example, the 8/1/14 unwitnessed fall when the resident was found between the bathroom and the bed resulted in the new intervention of bed alarms and hipsters while out of bed. The facility failed to identify this resident with problems with balance had not been adequately supervised in order to provide the assistance needed. The 7/28/14 witnessed fall when the resident was standing in the hallway and lost balance and feel to floor resulted in a therapy evaluation and hipsters while out of bed. The facility failed to identify the resident was allowed to be ambulating in the hall without assistance. The 5/25/14 unwitnessed fall when the resident was found prone on the floor at 12:30 a.m., resulted in the intervention of the resident to wear gripper socks while in bed. Interview with CNA #1 on 8/20/14 at 11:24 a.m., indicated the resident had glasses but did not wear them. Interview with the Social Service Director, on 8/22/14 at 10 a.m., indicated the resident's daughter had taken glasses home. There was no intervention for the resident's loss of vision besides having her glasses in place. During lunch observation, on 8/19/14 at 11:50 a.m., the right arm of the wheel chair (w/c) Resident #E sat in had a black arm rest that was unattached at the place wear the residents hand rested. The black plastic piece swung sidewise on the chair. CNA #4 noted the broken w/c arm. Observation on 8/21/14 at 3 p.m., indicated the resident sat in hallway in her w/c. Two CNA's were with the resident. The right arm to the w/c was off to the side and only attached at the back. This appeared the same as it was on 8/19/14. Neither CNA were aware if the broken chair arm had been reported so it could be fixed. Review of the Fall Response and Management policy provided by the DON on 8/22/14 at 10:40 a.m. indicated, "Patients who have fallen are assessed to determine if there is injury while maintaining the safety of the patient. Post fall, patients are assessed to attempt to determine the cause of the fall and implement individualized patient intervention to reduce the risk of a fall occurrence. Any staff member finding a patient who has fallen is responsible for remaining with the patient and being part of the investigation." 3. On 8/21/14 at 10:23 a.m., the Resident #F was observed sitting in the dining room at a table eating a snack. The resident was wearing shoes with thin white socks. On 8/21/14 at 10:50 a.m., the resident was observe up in the dining room sitting at a table for activities. The resident was wearing shoes on her feet with thin white socks. On 8/21/14 at 1:39 p.m., the resident was observed in the dining room sitting at a table, playing with a flower. The resident was wearing shoes and thin white socks. The resident's record was reviewed on 8/21/14 at 8:44 a.m. The resident's [DIAGNOSES REDACTED]. The Physician order [REDACTED]. A Physician order, dated 6/14/14 at 5:45 a.m., indicated remove shoes while in bed an keep gripper socks on at all times. Monitor bruise and hematoma on forehead till healed every shift. A Quarterly Minimum Data Set (MDS) Assessment, dated 6/3/14, indicated there had been 2 or more falls since the last admission, none since last assessment. A Quarterly MDS Assessment, dated 7/28/14, indicated, there had been falls since the last admission and one fall since the last assessment. The following Fall Risks Assessments were completed: 5/11/14 - a score of 15 which was a low risk for a fall, 5/27/14 - a score of 50 which was high risk for falls, 6/01/14 - a score of 65 which was high risk for falls, 6/14/14 - a score 75 which was high risk for falls, 7/14/14 - a score of 40 which was medium risk for falls, 7/21/14 - a score of 75 which was high risk for falls, 8/01/14 - a score of 65 which was a high risk for falls, 8/05/14 - a score of 75 which was a high risk for falls, 8/14/14 - a score of 75 which was a high risk for falls. A Care Plan, initiated on 4/21/14 and updated on 5/7/14, indicated a problem of risk for falls related to confusion, poor communication/comprehension, gait/balance problems, incontinence, fall risk assessment score, diminished safety awareness, [DIAGNOSES REDACTED]. The intervention included, but were not limited to, transfer with one assist, anticipate and meet the resident's needs, be sure call light is in reach, bed against the wall, encourage to take off shoes while in bed, ensure resident is wearing appropriate footwear and shoes are tied, evaluate resident's surroundings when ambulating to avoid trip hazards, alarm in place to bed, frequent check on resident while in bed to make sure resident is not tangled up in sheet, gripper socks on at all times and shoes on while ambulating, non skid socks or shoes on at all times. Review of a Post Fall Assessment, dated 5/27/14, indicated, the resident fell on [DATE] at 5:10 a.m. The fall was unwitnessed and there was no injury. The assessment indicated a loud noise was heard by the CNA and the resident was found sitting on the floor beside her bed with her back against the wall under the window in the resident's room. The resident was confused and unable to tell what happened. The resident's speech was disoriented and non-sensible. Interventions to be put into place were no objects with wheels were to be left in the residents room by her bedside. Review of a Post Fall Assessment, dated 6/1/14, indicated, the resident fell on [DATE] at 1605 (4:05 p.m.) The fall was unwitnessed and there was no injury. The resident was found on the floor in the dining room. The interventions to be put into place were the resident's bed was to be against the wall, staff were to assure her shoe laces were tied, non-skid strips by the bed, and a perimeter mattress to the bed. Review of a Post Fall Assessment, dated 6/14/14, indicated, the resident fell on [DATE] at 5:00 a.m. The fall was unwitnessed and there an injury. The resident was found on the floor laying on the right side facing the bed with feet wrapped in in the covers. The resident was fully dressed with socks and shoes on. The resident had a bruise with a hematoma present on the forehead. The interventions to be put into place were to remove the resident's shoes while in bed even if the resident was napping and be sure the resident wore gripper socks were on at all times. A Post Fall Assessment, dated 7/21/14, indicated, the resident fell on [DATE] at 0000 (12:00 a.m.) The fall was witnessed and there was no injury. The resident was grabbed by another falling resident and went to the floor. Review of a Health Service Event Report, dated 7/14/14 at 8:00 p.m., indicated, the interventions put into place were to provide more activities to decrease wandering. A Post Fall Assessment, dated 8/1/14, indicated, a fall occurred on 8/1/4 at 4:35 a.m. that was unwitnessed with an injury. The resident got out of bed and was ambulating gin the room and was found laying on her right side in front of the bathroom door. The interventions were to assess the resident and help get back to bed. A Post Fall Assessment, dated 8/5/14, indicated, a fall occurred on 8/5/14 at 1803 (6:03 p.m.) which was witnessed with no injury. The resident was ambulating through the dining room and tripped over another residents anti-rollback mechanism on the wheelchair. The resident tripped and fell into another resident. The interventions was a review in medications and a decrease in Buspar. A Health Service Reporting Form, dated 8/5/14 at 6:30 p.m., indicated, to decrease the resident's medications and rearrange the furniture to allow for more free space. A Post Fall Assessment, dated 8/11/4, indicated, the resident fell on [DATE] at 7:10 a.m. The fall was unwitnessed with no injury. The resident was transferring from bed. The resident was to be checked on frequently while in bed to make sure she was not tangled in the sheets. A Health Services Event Reporting Form, dated 8/11/14 at 7:10 a.m., indicated, the resident was trying to get out of bed and became tangled up in sheets which caused the fall. She had no non-skid socks, non-skid strips by the bed. The resident was to have her shoes removed when she was in bed. Interview with LPN #51, on 8/21/14 at 1:46 p.m., indicated the resident had on regular socks. She would need to see the bottom of the resident's sock to be sure, however the resident refused to all the nurse to take off her shoes. Interview with CNA #52, on 8/21/14 at 2:05 p.m., indicated the resident had on regular socks and just gripper socks were used when the resident was in bed. She provided her a Care Report Sheet which indicated the resident was to be encouraged to not wear shoes while in bed and to wear non-skid socks. It also indicated non-skid socks. Interview with the SDC (Staff Development Coordinator), on 8/21/14 at 3:59 p.m., indicated in regards to the resident having on gripper socks at all times the intervention needed to be worded better. On 8/22/14 at 8:30 a.m. in an interview with the DON, it was indicated a new Activities staff member was added to the unit. The staff member started on 8/4/14. This Federal tag relates to Complaint IN 896. 3.1-45(a)(1) 3.1-45(a)(2)

Based on record review and interview, the facility failed, for 1 of 3 residents (Resident B) reviewed for prevention of falls, to implement appropriate transfer techniques designed to prevent a resident from falling during transfer. Finding includes: A facility submitted State of Indiana Incident Report, dated 6/8/14, indicated CNA (Certified Nursing Assistant) #1 was involved in transferring Resident B from a bed to a chair in the resident's room. The report indicated "the resident's legs became weak and she was assisted to the floor per CNA." The report further indicated that while no injuries were found during assessment immediately after the fall and the resident verbalized no pain, 4.5 hours later the resident's "left knee was swollen", and "x-rays indicated bilateral knee fractures." Resident B's clinical record was reviewed 6/25/14 at 3:00 P.M. Resident B's Annual Minimum Data Set (MDS) assessment, dated 9/12/13, indicated the resident had "extensive" needs with transfers and required a two person physical assistance with transfers. On 6/25/14 at 3:15 P.M. the facility provided for review an "Interdisciplinary Team Falls Review," dated 6/9/14, which indicated that on 6/8/14 Resident B had a "witnessed fall" which resulted in the resident being discharged to a hospital after x-rays were obtained and indicated "bilat knee fx (bilateral knee fractures)." A "Root Cause Analysis" attached with the IDT Falls Review indicated "CNA states lowered resident to the ground." The analysis also indicated the "CNA transferred resident by herself-resident 2 assist (resident is a two-person assist with transfers), not using gait belt." The analysis further indicated the "CNA needs education about transfers, gait belt, CNA assignment sheet." Interview on 6/25/14 at 3:40 P.M. with the facility's Staff Development Coordinator indicated that policies and procedures regarding CNA assignment sheets are reviewed with employees during orientation. The Staff Development Coordinator provided the attendance rosters and the orientation agendas for 5/21/14 and 5/22/14 indicated CNA #1 attended and participated with orientation training at hiring. CNA #1's name was on the sign in sheet for day of the initial orientation. Interview with the facility's Director of Nursing (DON) on 6/25/14 at 3:45 P.M. indicated CNA #1 was immediately suspended pending investigation following the fall and that the CNA indicated during interview with the DON during the investigation that she didn't refer to the facility's CNA care assignment sheet prior to the transfer. The DON indicated after the investigation, CNA #1 was reinstated, on 6/16/14, following a meeting where corrective action was implemented and an inservice on using CNA care sheets, proper use of transfers and use of gait belts was provided. Review of the corrective action, dated 6/11/14, provided by the DON, indicated CNA "attempted to transfer a 2 person assist by herself." The corrective action, which was signed by CNA #1, indicated the CNA was educated on the above expectations during orientation." The DON indicated CNA #1 returned to work on 6/16/14, but one week later resigned her position with the facility. CNA #1 was unavailable for interview regarding the above incident. This Federal tag relates to Complaint IN 573. 3.1-45(a)(2)