Every finding on record at Rolling Meadows Health Care Center

Based on observation, interview and record review, the facility failed to implement immediate interventions to prevent future falls for 2 of 3 residents reviewed for falls. (Residents B and C). This deficient practice resulted in Resident B sustaining a right hip fracture during a subsequent fall following a fall resulting in a wrist fracture. Findings include: 1. Resident B's clinical record was reviewed on 5/30/25 at 10:55 a.m. Diagnoses included fracture of the left wrist, fracture of the right femur, dementia, muscle weakness, difficulty walking and the need for personal assistance with care. Current physician orders included bed alarm for safety 5/28/25, check placement of splint to left wrist, watch for signs and symptoms of swelling, metoprolol succinate (antihypertensive) 25 milligrams (mg) daily and Rivastigmine tartrate (dementia) 1.5 mg daily. A fall risk assessment, dated 3/20/25, indicated Resident B was at high risk of falls for reasons including intermittent confusion, previous falls in the past three months, and gait/balance problems. A current care plan, initiated on 9/23/24, indicated Resident B was at risk for falls related to poor decision making and impaired balance. Interventions included a bed alarm would be used to reminded Resident B to ask for staff assistance for bed mobility and transfers (5/27/25), hourly rounding initiated for the next 72 hours to help establish any new habits or routines resident may have (5/20/25), wearing proper footwear or nonskid footwear when Resident B was up (9/23/24), personal items within reach (4/15/25), an alternating air mattress with bolsters (5/27/25), call light within reach (9/23/24), care plan would be updated upon Resident B's return from the hospital (5/19/25), and remind Resident B to change positions slowly (4/15/25). A 4/9/25, quarterly, MDS assessment indicated Resident B was cognitively impaired. Resident B required supervision or touching staff assistance when rolling to the left and right. Resident B required partial/moderate assistance with toilet transfers. Resident B was independent when walking 10,50, and 150 feet. A 5/19/25, quarterly, Minimum Data Set (MDS) Assessment indicated Resident B was cognitively impaired. Resident B required substantial/ maximal staff assistance with toileting hygiene and when rolled to the left and right. Resident B required partial/moderate staff assistance with chair/bed to chair transfer and toilet transfers. Resident B was independent when walking 10, 50, and 150 feet. A progress note, dated 5/19/25 at 2:23 a.m., indicated Resident B was in the bathroom being toileted by the CNA. The CNA turned toward the sink to grab towels, when Resident B ran out of the bathroom with her pants around her ankles. As Resident B turned to face the CAN, Resident B lost her balance and fell hitting the back of her head on the wall. The nurse assessed Resident B for injuries. Resident B was noncompliant with staff attempting to help her up off the floor. The nurse and CNA were able to assist Resident B back to her bed. The nurse was unable to obtain vital signs due to Resident B's combativeness. Neurological checks were initiated. A progress note, dated 5/19/25 at 5:43 a.m., indicated Resident B's left wrist was bruised and swollen. The DON and physician was notified. On 5/19/25 at 5:58 a.m., indicated an order was obtained for a left wrist x-ray if the resident's representative agreed. On 5/19/25 at 7:57 a.m., indicated Resident B's left wrist appeared swollen, bruised and painful. The NP was notified. A new order was placed for a left wrist x-ray and hydrocodone if the resident's representative agreed. The resident's representative was notified and indicated the facility could do what was needed including sending Resident B to the hospital. The NP was notified and advised to send Resident B to the emergency room for evaluation. On 5/20/25 at 4:30 p.m., indicated Resident B returned from the hospital. Left wrist x-ray results indicated acute left wrist fracture status post fall. Resident B was seen by orthopedics, who placed a cast on Resident B's left wrist. No immediate interventions were implemented to prevent further falls. On 5/25/25 at 2:55 p.m., indicated Resident B was found on the floor between the two beds in her room, lying on her right side. A skin tear was noted to Resident B's right elbow and a bruise was noted to her right eyebrow. Neurological checks were initiated. The NP was notified and recommended sending Resident B to the emergency room for a CT scan if Resident B's representative agreed. On 5/25/25 at 3:05 p.m., indicated Resident B's representative was notified and declined sending the resident to the emergency room at this time. On 5/25/25 at 10:18 p.m., indicated Resident B was shifting weight off her right hip while groaning and rubbing her hip. Pain medication was administered. Pain medication was effective for a short time. Resident B appeared uncomfortable when toileted a short time later. The NP was notified, and a new order was received for a right hip x-ray. Resident B's representative was notified and declined to send Resident B to the emergency room. On 5/26/25 at 3:00 p.m., indicated Resident B's right hip x-ray showed a right femur fracture. On 5/26/25 at 3:30 p.m., Resident B's representative was notified of the x-ray results. Resident B's representative declined sending Resident B to the hospital for evaluation and treatment of her right hip fracture. During an interview, on 5/30/25 at 11:03 a.m., LPN 30 indicated, prior to the fall on 5/25/25, Resident B had been resting in bed. Staff found the resident between the two beds in the room maybe 45 minutes later, following shift change. A medication review was requested due to the resident recently starting taking hydrocodone (opiate pain medication). During an interview, on 5/30/25 at 11:10 a.m., RN 5 indicated CNA 35 came and notified her on 5/25/25 that Resident B had fallen. Resident B was assessed by RN 5. RN 5 and the CNA lifted Resident B off the floor and placed Resident B into bed. Resident B's immediate fall intervention was bed in the lowest position and increased supervision during neurological checks. CNA 35 was unavailable for interview during the survey on May 30 and June 2, 2025. On 5/30/25 at 11:43 a.m., RN 6 indicated after a resident experienced a fall, the immediate intervention would be put into place by the nurse. The Interdisciplinary Team (IDT) would later review the fall and update the care plan On 5/30/25 at 1:00 p.m., the DON indicated neurological checks were a nursing measure and not an immediate intervention to a fall. Immediate interventions after a fall would be documented in the residents' progress note and in a 24-hour report. The resident care plan should be updated with immediate interventions. On 5/30/25 at 1:14 p.m., CNA 7 indicated, on 5/19/25, he heard a noise and saw Resident B walking down the hallway. He assisted Resident B to the bathroom. CNA 7 turned to grab towels from the bathroom sink when Resident B ran behind him out of the bathroom with her pants and brief around her ankles. When Resident B turned around, Resident B tripped and fell, hitting her head against the wall. CNA 7 went and got RN 5. CNA 7 and RN 5 assisted Resident B into bed after the RN completed her assessment. No immediate intervention was put into place. 2. Resident C's clinical record was reviewed on 5/30/25 at 10:55 a.m. Diagnoses included Parkinson's disease without dyskinesia (abnormal, involuntary movements), unspecified dementia, muscle weakness, and need for assistance with personal care. A fall risk assessment, dated 12/5/24, indicated Resident C was at moderate risk for falls. A 3/11/25, quarterly, MDS assessment indicated the resident had moderate cognitive impairment. Moderate assistance was needed for toileting hygiene, footwear, and personal hygiene. Supervision was needed for rolling left and right, going from sitting to standing, chair/bed to chair transfers, and toilet transfers. A walker was used as a mobility device and the resident needed supervision for walking 10 feet. The resident had two falls without injury since the prior MDS assessment. A current care plan for falls, dated 12/20/23, indicated the resident was at risk for falls due to the resident not always using assistive devices, having impaired balance and coordination, and having an unsteady gait. Interventions included the following: additional anti-skid strips placed in front of recliner (03/24/2025), educate and remind the resident to use the call light, even for standby assistance (03/03/2025), have personal items that the resident uses frequently within his reach (12/20/23), call light within reach (12/20/23), reminder signs will be placed within view in my room to remind me to use the call light for assistance (per POA request) (12/23/24), falling leaf program (6/4/24), wear proper footwear or non-slip footwear when resident is up (12/20/23), assistive devices will be kept within resident's reach (3/24/25), and resident will sit on non-skid mat in my recliner (12/5/24). An Interdisciplinary Team (IDT) note, dated 1/7/25 at 2:51 p.m., indicated Resident C fell on 1/6/25 at 3:30 p.m. as he attempted to transfer without assistance. The resident pulled the call light cord and facility staff found him sitting on the bathroom floor. The intervention implemented was to re-educate the resident on the importance of using the call light for staff assistance with ambulation to and from the bathroom, hygiene, and dropped items off of the floor. The clinical record lacked a nurse's note for a fall on 1/6/25. A risk management form, provided by RN 3, on 6/2/25 at 10:25 a.m., indicated the immediate action taken was that Resident C was educated on the importance of call light usage. The call light was placed with personal belongings in reach of the resident while in his recliner. A fall investigation worksheet, provided by RN 3, on 6/2/25 at 10:25 a.m., indicated that Resident C was on the bathroom floor, holding onto the railing. The resident took self to the toilet and pulled the call light. The new interventions put into place were 4 P's (position, personal needs, pain, placement), educate resident on call light, and call light in reach. A 4 P's flow sheet, provided by RN 3, on 6/2/25 at 10:25 a.m., indicated a lack of documentation on 1/7/25 from 10:00 a.m. to 1:00 p.m. and on 1/8/25 from 6:00 a.m. to 5:00 p.m. A progress note, dated 3/2/25 at 11:55 p.m., indicated Resident C used his call light and was found sitting on his bedroom floor beside his bed. The resident slid from the edge of his bed as he reached to move his walker closer. Facility staff assisted the resident from the floor back into bed. No immediate interventions were implemented to prevent further falls. An IDT note, dated 3/3/25 at 11:38 a.m., indicated Resident C fell on 3/2/25 at 10:45 p.m. The resident was organizing his walker and bedside table; he leaned further than anticipated and slid to the floor. The resident indicated to IDT staff that he continues to do as much as he can on his own, but sometimes his body disagrees. The intervention implemented was call lights were to be in reach and resident education was provided about natural decline of body and encouraged to use the call light for assistance, even to have a staff member present for stand by assistance. A risk management form, provided by RN 3, on 6/2/25 at 10:25 a.m., indicated the immediate action taken was Resident C was assisted to standing position, using two staff members, and assisted back into bed. A fall investigation worksheet, provided by RN 3, on 6/2/25 at 10:25 a.m., indicated Resident C was organizing his walker and bedside table and leaned farther than expected and slid to the floor. The new interventions put into place were resident education provided on call light use, even if to have a staff member present for standby assist. A 4 P's flow sheet, provided by RN 3 on 6/2/25 at 10:25 a.m., indicated a lack of documentation on 3/3/25 from 3:00 p.m. to 9:00 p.m. and on 3/4/25 from 4 p.m. to 9:00 p.m. A fall risk assessment, dated 3/7/25, indicated Resident C was at moderate risk for falls. A progress note, dated 3/21/25 at 9:45 p.m., indicated Resident C was found lying on his back with his head facing the closet and his feet towards the bed. The resident had previously been in his recliner. His walker was beside him. Staff observed blood on the floor after assisting the resident to a standing position. The resident was found to have had two abrasions to his right buttock. No immediate interventions were implemented to prevent further falls. An IDT note, dated 3/24/25 at 3:40 p.m., indicated Resident C had a fall on 3/21/25 at 9:25 p.m. The resident had been transferring without assistance and had attempted to get up from the recliner. During a post fall interview, the resident indicated that he had Parkinson's and falling was expected. The fall intervention implemented was to add additional anti-skid strips in front of Resident C's recliner, provide education, and offer encouragement to use the call light for assistance. A risk management form, provided by RN 3, on 6/2/25 at 10:25 a.m., indicated the immediate action taken was Resident C was assessed for injuries. A fall investigation worksheet, provided by RN 3, on 6/2/25 at 10:25 a.m., indicated that Resident C had attempted to get up from recliner. The new interventions section of form was incomplete and did not list an intervention. A 4 P's flow sheet, provided by RN 3 on 6/2/25 at 10:25 a.m., showed lack of documentation on 3/21/25 through 3/25/25 until 2:00 p.m. A progress note, dated 4/30/25 at 7:45 p.m., indicated Resident C had fallen in his room. He was found lying on the floor with his head towards the door and his feet towards the window. His walker was laying on the floor beside him. The resident had two skin tears to his right arm. The immediate intervention was that the resident went to bed and he was encouraged to use the call light and ask for staff assistance. An IDT note, dated 5/1/25 at 2:06 p.m., indicated Resident C had a fall on 4/30/25 at 7:45 p.m. The resident attempted to transfer without assistance. The resident indicated that he had lowered himself to the floor and he did not fall. The intervention implemented was that staff will encourage the resident to increase fluids and have a urinal within his reach. A risk management form, provided by RN 3 on 6/2/25 at 10:25 a.m., indicated the immediate action taken was Resident C was encouraged to use call light and have staff help with transfers. A fall investigation worksheet, provided by RN 3 on 6/2/25 at 10:25 a.m., indicated that Resident C lost his balance. The new interventions put into place was staff would keep urinal within resident reach. A 4 P's flow sheet, provided by RN 3 on 6/2/25 at 10:25 a.m., indicated lack of documentation on 5/1/25 from 3:00 p.m. to 5:00 p.m., 11:00 p.m. to 5/2/25 5:00 a.m., and 5/2/25 from 12:00 p.m. to 5:00 p.m. During an interview, on 6/2/25 at 10:06 a.m., CNA 4 indicated staff was to offer Resident C assistance with his personal care. The facility staff was to approach and supervise when the resident was observed attempting to perform tasks independently. She was unable to recall any fall interventions that were in place for Resident C, other than to prompt resident to ask for help. She was made aware of resident falls and interventions by shift reports. During an interview, on 6/2/25 at 10:28 a.m., QMA 8 indicated the nurses documented when a resident fell and the nurses put in a fall intervention in the nurse's notes. Resident C was not considered a high fall risk. He ambulated by himself with his walker and was a one assist for toileting needs. The fall interventions Resident C had in place was using a walker and wearing non-skid socks. She had not noticed a decline in his cognitive function. During an interview, on 6 /2/25 at 10:38 a.m., LPN 9 indicated that Resident C's fall interventions were using a walker or wheelchair, non-skid socks, and proper footwear. The nurse was to implement an immediate fall intervention with each facility fall. The immediate intervention was to be documented on a post-fall note and in the risk management assessment. LPN 9 indicated she did not update the care plans with immediate fall interventions. A paper form was passed between shifts and should inform staff of any new intervention put into place. IDT usually informed staff verbally of any care plan updates. During an interview, on 6/2/25 at 11:44 a.m., RN 3 indicated that the floor nurses were expected to do a post-fall assessment, obtain vital signs, assess for injuries, and implement an immediate fall intervention. A fall intervention was to prevent another fall from occurring. The nurses were to document interventions on a fall note template. She updated the care plan with new interventions after she reviewed the fall. RN 3 confirmed that Resident C's record lacked documentation of a nurses note on 1/6/25 for a fall. The immediate intervention for the 1/6/25 fall was re-education. She updated the care plan with that intervention after the 1/7/25 IDT meeting. No immediate intervention was put into place for Resident C's fall that occurred on 3/2/25 and she spoke with Resident C after the 3/3/25 IDT meeting about the natural decline of his body and his disease progression. The immediate intervention for Resident C's 3/21/25 fall was to assess for injuries and after the IDT meeting on 3/24/25 an intervention was added to place additional skid strips in front of Resident's C's recliner. The immediate fall intervention on 4/30/25 was to encourage Resident C to use his call light. RN 3 updated the care plan with a new intervention on 5/1/25. The new intervention was to increase fluids and have urinal within reach. There was no mention of Resident C and bathroom use in the post-fall note, but she felt she needed to come up with something and the resident was usually going to and from the bathroom. She considered Resident C's cognitive function when she implemented new fall interventions. Resident C's cognitive function had shown a 4-point decline since September 2024. He scored moderate cognitive impairment three months ago. New interventions were conveyed to staff by in-service papers that needed to be signed by the facility staff. RN 3 confirmed IDT usually met 24 to 72 hours after the initial fall and that an immediate intervention was to be placed prior to IDT meeting. RN 3 confirmed that the immediate interventions that were put into place at the time of Resident C's recent falls would not prevent another fall from occurring. During an interview, on 6/2/25 at 11:44 a.m., the DON indicated that the floor nurses were not using the fall template regularly and they could either use the template or enter a nurse's note. Fall packets were made to aid in the documentation processes. Floor nurses had been educated to update resident's care plan at the time of the fall. The nurses' notes regarding Resident C's falls were vague and needed to give more details. Re-education was to be done with each fall and was not considered a new intervention. A new intervention was not put into place for Resident C's 1/6/25 fall. The 4 P's form that was included in Resident C's fall packets had not completed accurately and contained missed documentation. The DON confirmed that the immediate interventions put into place at the time of Resident C's recent falls would not prevent another fall from occurring. During an interview, on 6/2/25 at 12:37 p.m., LPN 10 indicated Resident C was a high fall risk. Immediate fall interventions were documented by the nurses on the risk management form and IDT updated the care plans. During an interview, on 6/2/25 at 12:40 p.m., LPN 13 indicated the floor nurse completing the fall investigation and paperwork also determined the immediate fall intervention. The MDS Coordinator updated the care plans. New interventions were passed on during shift report. Alert paper charting was completed and stayed at the nurse's station. During an interview, on 6/2/25 at 1:10 p.m., LPN 11 indicated immediate fall interventions were relayed during shift report and documented on the risk management form. The risk management team reviewed the fall and updated the care plan accordingly. Staff inservices were provided with resident falls and their interventions. During an interview, on 6/2/25 at 1:35 p.m., LPN 12 indicated floor nurses were permitted to update the care plan, but usually did not and staff waited for the MDS Coordinator to update them. She relayed her immediate intervention for Resident C's 3/21/25 fall during her shift report. She was unaware of how notifications were conveyed when the risk management team or the MDS Coordinator updated the care plans. A current policy, titled Fall investigation and Risk Evaluation, provided by the DON on 6/2/25 at 11:10 a.m., indicated the following: . Policy: It is the policy of this facility to provide an environment that is free from accident hazards over which the facility has control and provides supervision and assisted devices to prevent avoidable accidents A current policy, titled Care Plan Revisions Upon Status Change, provided by the DON on 6/2/25 at 11:10 a.m., indicated the following: . The care plan will be updated with the new or modified interventions. Care plans will be modified as needed by the MDS Coordinator or other designated staff member This citation relates to Complaint IN00459934. 3.1-45(a)(2)

Based on record review and interview, the facility failed to ensure a Preadmission Screening and Resident Review (PASRR) was submitted for a resident with a newly diagnosed mental health condition requiring psychotropic medication for 2 of 3 residents reviewed for PASRR (Resident 76 and 90). Findings include: 1. Resident 76's clinical record was reviewed on 10/28/24 at 10:41 a.m. Diagnoses included unspecified dementia, severe, with anxiety (9/9/23), major depressive disorder (9/9/23), generalized anxiety disorder (9/9/23), and psychotic disorder with delusions due to known physiological condition (9/15/23). Current orders included olanzapine (antipsychotic) 2.5 milligrams (mg) daily (started 9/17/24), risperidone (antipsychotic) 1 mg twice a day (started 7/26/24), clonazepam (antianxiety)1 mg daily (started 8/14/24), and fluoxetine (antidepressant) 20 mg daily (started 7/27/24). An annual Minimum Data Set (MDS) assessment, completed 9/12/24, indicated the resident's diagnoses included depression, anxiety, and psychotic disorder. The resident's medications included an antipsychotic and antidepressant. The resident received the antipsychotic on a routine basis. A current care plan for behavioral symptoms such as throwing things, pacing, slapping, cursing, repetitive verbalization, spitting, rummaging, yelling/screaming, having delusions and hallucinations, and having an anxiety disorder and a cognitive deficit was initiated on 9/12/23 and last revised on 5/10/24. Interventions included the following: When the resident's behavior disrupts a social setting, remove her if she is not able to be redirected (initiated 9/12/23). The resident has delusions that cause her distress. She needs reassurance, validation, and understanding from the staff (initiated 8/9/24). Do not argue or confront the resident regarding her behavior (initiated 10/11/24). A progress note, dated 7/12/24 at 11:46 a.m., indicated the resident had increased confusion and new or worsened delusions or hallucinations. The resident became physically violent with staff and spit on staff when staff attempted to redirect her from other residents' rooms. The provider was notified. A new order was received to send the resident to the emergency room for evaluation and then to a behavioral facility from the emergency room if appropriate. A progress note, dated 7/26/24 at 3:40 p.m., indicated the resident returned from her stay at a psychiatric facility. Resident 76's current PASRR, dated 9/9/23, provided by the Assistant Director of Nursing (ADON) on 10/28/24 at 9:25 a.m., indicated the resident's current suspected or diagnosed mental health conditions included anxiety disorder and depression/depressive disorder. Psychotic disorder was not listed. The behavior and symptoms section of the PASRR indicated there were no known mental health behaviors which affected interpersonal interactions. There were no known recent or current mental health symptoms. Bupropion (antianxiety) 300 mg daily was listed under mental health medications and lacked listing other psychotropic medications. 2. Resident 90's clinical record was reviewed on 10/28/24 at 9:56 a.m. Diagnoses included unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (4/1/24), anxiety disorder (4/1/24), delusional disorders (4/1/24), and major depressive disorder, recurrent, moderate (4/1/24). Current orders included escitalopram (antidepressant) 20 mg daily (started 9/17/24), risperidone (antipsychotic) 0.25 mg daily (from 4/2/24 through 8/13/24), and risperidone 0.25 mg every other day (from 8/14/24 through 8/28/24). A quarterly MDS assessment, completed 8/2/24, indicated the resident's diagnoses included anxiety disorder, depression, and psychotic disorder. The resident's medications included an antipsychotic, antianxiety, and antidepressant. The antipsychotic was received on a routine basis. A care plan for behavioral symptoms such as false beliefs, seeing and hearing things that are not there, repetitive verbalization/questions, hitting/kicking, slapping, grabbing, throwing, yell/scream, cursing, rummaging, and having an anxiety disorder, a cognitive deficit, delusions, hallucinations, and major depression was initiated on 4/22/24 and revised on 8/9/24. Interventions included the following: The resident has hallucinations that cause her distress. She needs reassurance, validation, and understanding from the staff (initiated 4/22/24). The staff should participate in the resident's reality when indicated (initiated 4/22/24). If the resident is agitated, the staff is to not begin care, give her space, and return later initiated (10/11/24). Resident 90's current PASRR, dated 3/12/24, provided by the Assistant Director of Nursing (ADON) on 10/28/24 at 9:25 a.m., indicated the resident's current suspected or diagnosed mental health conditions included anxiety disorder, depression/depressive disorder, and major depressive disorder, recurrent, moderate. Psychotic disorder was not listed. The behavior and symptoms section of the PASRR indicated there were no known mental health behaviors which affected interpersonal interactions. There were no known recent or current mental health symptoms. Buspirone (antianxiety) 5 mg daily and escitalopram (antidepressant) 20 mg daily were listed under mental health medications and lacked listing of other psychotropic medications. During an interview, on 10/29/24 at 9:36 a.m., the Social Services Director indicated she would submit a new PASRR when a resident had a new psychotropic medication or psychiatric diagnoses or if dementia was added. She indicated she had submitted several new applications for PASRR when a new medication was added, and the application was rejected saying it was not necessary. She had not submitted a new PASRR application for Resident 76 nor 90 because both had significant dementia. According to Indiana PASRR FAQs for providers [frequently asked questions], revised 2022, accessed on 10/31/24 at 11:48 a.m. at maximusclincalservices.com, .If a significant change in mental health status has occurred since the last approval, a new Level I screening is required When is Status Change review required? Whenever there is a change in the mental status of an individual, since the prior Level 1 review According to the Indiana PASRR Level I & Level of Care Screening Procedures for Long Term Care Services Provider Manual, last revised 4/20/20, If a NF [nursing facility] resident's behavioral or mental status significantly changes, the NF must submit a new Level I to report the change through the PASRR process. This applies to people who have a known Level II condition and to people with a previous negative Level I . Examples of a mental status change event include: A new mental health diagnosis that is not listed on previous [NAME] or Level II. A new psychotropic medication for mental illness A current policy, dated 2024, provided by the Nurse Consultant, titled Resident Assessment-Coordination with PASARR Program, indicated Any resident who exhibits a newly evident or possible serious mental disorder, intellectual disability, or a related condition will be referred promptly to the state mental health or intellectual disability authority for a level II resident review. Examples include: . b. A resident whose intellectual disability or related condition was not previously identified and evaluated through PASARR. c. A resident transferred, admitted , or readmitted to the facility following an inpatient psychiatric stay or equally intensive treatment

Based on record review and interview, the facility failed to ensure procedures were in place to ensure pending physician's orders were followed up on and medications administered in a timely manner for 1 of 5 residents reviewed for unnecessary medications (Resident 70). Finding includes: Resident 70's clinical record was reviewed on 10/29/24 at 2:12 p.m. Diagnoses included atherosclerotic heart disease of native coronary artery without angina pectoris and type 2 diabetes mellitus without complications. Current physician's orders included insulin glargine (for diabetes), inject 15 units daily (started 10/25/24), dulaglutide (for diabetes), inject 1.5 milligrams (mg) every Saturday (started 10/26/24), metformin (for diabetes)1000 mg twice a day (started 2/11/24), and obtain blood sugars at meals and at bedtime. Notify physician for blood sugars less than 60 or greater than 400 mg/dl (deciliters) (started 9/18/24). The pharmacist recommended an increase in semaglutide to 1 mg from 0.5 mg every week and a decrease in insulin glargine from 24 units to 15 units daily to augment glucose insulin dependent secretion, slow gastric emptying, provide cardioprotective benefits, and aid in weight loss. The nurse practitioner (NP) signed the order on 10/24/24. The resident's medication administration record (MAR) lacked initials indicating administration of the dulaglutide on 10/26/24. The record lacked documentation of the medication being held or physician notification about the medication. During an interview, on 10/29/24 at 4:36 p.m., the Director of Nursing (DON) was uncertain if the dulaglutide had been given on 10/26/24 and she would check into it. During an interview, on 10/29/24 at 4:41 p.m., the Assistant Director of Nursing (ADON) indicated the physician had been notified on 10/28/24 about a pharmacy interchange. During an interview, on 10/30/24 at 9:35 a.m., the DON indicated the dulaglutide was ordered on 10/24/24 and delivered on 10/25/24. The pharmacy had made an interchange for the originally ordered semaglutide to dulaglutide. Because of the substitution, the order became pending and needed confirmation. The order would not have shown up on the MAR and was not have been given. Pending orders showed up on the resident's orders but not on the MAR. The dulaglutide order was changed and given on 10/29/24 and set up for every week on Tuesdays. During an interview, on 10/30/24 at 2:27 p.m., LPN 7 indicated the nurse practitioner (NP) had agreed to the pharmacy recommendation. Semaglutide was ordered. The pharmacy changed the order from the semaglutide to dulaglutide as a pharmacy interchange. The pharmacy was able to change the order on the electronic software and would have caused the order to be pending until the new order was confirmed by the provider. The order was placed on the provider's notification board for the NP to review. She reviewed it on 10/28/24. When the order was confirmed, the order date would have been the date the pharmacy had changed the order and sent the medication. The next date to give the medication would have been the next Saturday, 11/2/24. During an interview, on 10/30/24 at 2:49 p.m., the ADON indicated when the order was confirmed, the order date did not change from the original date on 10/25/24. Providers understood and signed an agreement that an interchange for certain medications will be done unless they specifically write dispense as written. The order for the semaglutide was not written dispense as ordered. A current facility policy, dated 11/1/2023, provided by the Nurse Consultant on 10/30/24 at 3:30 p.m., titled Medication Orders, indicated .Documentation of Medication Orders: .b. Clarify the order .ensure the new order is in the MAR 3.1-25(a)

Based on record review and interview, the facility failed to provide prompt physical assessment of a resident complaining of having sustained a fall and experiencing hip pain, resulting in a delay in treatment for a hip fracture for 1 of 3 residents reviewed for accidents (Resident C). The deficient practice was corrected on 4/18/24, prior to the start of the survey, and was therefore past noncompliance. Findings include: Review of a facility reported incident, dated 4/15/24, indicated Resident C's family member had reported the resident was reporting right hip pain. The assessing nurse determined external rotation and swelling of the right leg. Resident C was transferred to the emergency department and found to have sustained a right hip fracture. Resident B's clinical record was reviewed on 4/26/24 at 9:22 a.m. Diagnoses included non-displaced right intertrochanteric (hip) fracture, chronic atrial fibrillation, osteoporosis, hypertension, muscle weakness, and Alzheimer's disease. Current physicians orders included, but were not limited to, metoprolol succinate extended release (blood pressure medication) 25 mg daily at bedtime, Aricept 5 mg (dementia medication), and Norco 5-325 mg (opioid pain medication) every four hours as needed for pain. A 3/5/24 Admission Functional Abilities assessment indicated Resident C had no upper or lower extremity impairments and used a wheelchair for mobility. The resident required substantial/maximum assistance to move from sit to stand, sit to lying, for chair/bed to chair transfers, toileting, and to walk ten feet in distance. A 3/5/24 quarterly fall risk evaluation indicated Resident C was at high risk for falls. A 3/13/24 Admission Minimum Data Set assessment, dated 3/13/24, indicated Resident C was severely cognitively impaired. Resident C's medication administration record dated 4/14/24 indicated Tylenol was administered at 4:49 p.m. for a pain level of 4 out of 10. LPN 5 recorded the resident's pain level at a 2 out of 10 at 5:49 p.m. A 4/14/24 at 11:03 p.m. Nurse Note indicated at approximately 6:35 p.m. that day, Resident C's family member reported the resident was complaining of having experienced a fall and was having very bad hip pain. The responding nurse observed the resident's foot to be rotated outward and her hip swollen. The resident was not able to move her leg and rated her pain at 8 out of a scale of 10. The ambulance was called at 7:49 p.m., and arrived at the facility at 8:10 p.m. A 4/14/24 at 11:33 p.m. Nurse Note indicated the resident was admitted to the hospital with a right hip fracture. A 4/15/24 at 11:20 a.m. interdisciplinary team note indicated Resident C had reported a fall on 4/14/24 at 6:35 p.m. The resident's care plan would be reviewed upon return to the facility. A hospital emergency department note dated 4/14/24 indicated the resident was seen by the provider at 8:55 p.m. Resident C had decreased range of motion to her right leg and pain with movement. She had an obvious deformity of her right hip. A 4/20/24 at 4:34 a.m. Nurse Note indicated the resident reported some pain with movement and an achy feeling at other times. During an interview, on 4/26/24 at 9:43 a.m., the DON indicated a review of the facility cameras showed Resident C standing in her doorway at around 4:00 p.m. on 4/14/24. The resident turned around and the bathroom door was observed to [NAME] open. A facility nurse had gone to Resident C to check on her and found the resident to be fine. Later in the day, around supper time, Resident C was complaining of pain. The resident had not experienced any falls while at the facility. During an interview, on 4/26/24 at 1:00 p.m., QMA 3 indicated she had started her shift on 4/14/24 at 2:00 p.m. CNA 8 reported to QMA 3 that Resident C was complaining of a fall and she couldn't move her leg. QMA 3 went to check on the resident, who was lying in bed. QMA 3 did not notice any bruising to indicate Resident C had fallen or that something was wrong with her hip. QMA 3 left to ask the nurse who had been on duty the day before if Resident C had fallen. She also asked the day shift CNA if the resident had fallen earlier in the day. They both said no. QMA 3 then reported to LPN 5 that Resident C was saying she had fallen, and QMA 3 had not seen any bruising. LPN 5 gave authorization for the QMA to administer Tylenol to the resident. She later reported to the oncoming nurse at shift change that Resident C had complained of having fallen. During an interview, on 4/26/24 at 11:15 a.m., LPN 5 indicated, on 4/14/24, she had heard Resident C holler out, and then the nurse heard a loud knock sound. LPN 5 ran into the resident's room, because it had sounded bad. The resident was sitting in her wheelchair, which was backed against the bathroom door. LPN 5 propelled the resident in her wheelchair, asking if she needed to use the bathroom. The resident said no. LPN 5 assisted the resident over near her bed, in the wheelchair, and gave her the call light. Resident C did not complain of pain or injury. When QMA 3 had notified her of Resident C's complaint of having fallen and hip pain, QMA 3 had told the nurse there was no bruising noted. LPN 5 felt the pain must have been related to arthritis. LPN 5 did not assess Resident C. During an interview, on 4/29/24 at 9:14 a.m., LPN 5 indicated she should have assessed Resident C when she complained of having fallen and hip pain. She didn't normally work that hallway, or provide care for Resident C. When the resident's family member voiced concern about the resident's complaint, LPN 5 asked RN 13 if she would assess her, since it was the second time the resident had voiced the complaint. During an interview, on 4/29/24 at 11:21 a.m., RN 13 indicated, on 4/14/24 during shift report, she was told Resident C had told staff she had fallen, but no one witnessed a fall. No one had assisted her back to bed. QMA 3 reported to RN 13 that she had looked at Resident C, but hadn't seen any bruising, and LPN 5 had given authorization for Tylenol to be given for pain. When RN 13 went to assess Resident C, the resident's upper thigh was swollen and her foot was rotated outward. She called the doctor and had the resident sent to the emergency department. Resident C's family member came to the nurses station and reported to someone else the resident's complaints of pain and having fallen. RN 13 did not assess Resident C immediately, as the off-going staff wasn't too concerned about anything. She usually started her medication pass around 7:00 p.m., so she began with that. During an interview, on 4/29/24 at 10:10 a.m., the DON indicated QMAs are allowed to repeat what the resident reports, but the nurse should complete an assessment. Nursing staff had been educated about nurses completing the assessment themselves and not the QMA. It was very unusual for Resident C to be seen standing by herself, she required assistance with mobility. Review of a current, undated, facility job description titled Licensed Practical Nurse (LPN), provided by the DON on 4/29/24 at 11:21 a.m., indicated one of the primary purposes of the nurse's role included professional assessments and documentation of the resident's health. The LPN was also responsible for periodic resident visits to observe for symptoms, changes in condition, gauging unexpressed needs and ascertaining the need for additional or modified services. The deficient practice was corrected by 4/18/24 after the facility implemented a systemic plan that included the education of licensed and registered nurses regarding prompt assessment of residents complaining of injury, implemented a plan to review communication of reports of injury and pain, and ongoing monitoring in daily meetings and the facility Quality Assurance and Performance Improvement (QAPI) committee. This citation relates to Complaint IN00432566. 3.1-17(a) .

Based on observation and interview, the facility staff failed to sanitize a multi-use blood glucose meter according to manufacturer's instruction, and failed to ensure staff handled medications in a sanitary manner and performed hand hygiene during a medication administration observation. Findings include: 1. During a random observation on the 100 hall on 1/4/24 at 10:48 a.m., LPN 2 returned to her medication cart with a multi-use blood glucose meter. She used a sanitizing cloth to wipe the device and placed it in a basket on top of lancets (used to obtain blood sample). During an interview at the time of the observation, LPN 2 indicated the device would be ready to re-use after she completed her charting. She did not know what the wet time for sanitizing the device was. She indicated the device was wet when she wiped it down and would be ready to re-use after it dried. Following approximately 45 seconds, the nurse indicated the device was dry and ready for use. During an interview on 1/4/24 at 1:50 p.m., the DON indicated the blood glucose meter should be sanitized per the manufacturer's instructions with a wet time of two minutes. A current facility policy, revised 2/2022, titled, Glucose Meter Cleaning & Testing, provided by the Corporate Nurse Consultant on 1/4/24 at 10:55 a.m., indicated the following: .Procedure: .5. Wipe entire external surface of the blood glucose meter with germicidal wipe. Ensure meter stays wet for 2 minute time period. 6. Place cleaned meter on paper towel, in plastic cup or clean barrier 48384 2. During a medication administration observation on 1/5/24 at 2:46 p.m., when LPN 4 administered medications to Residents 44, 12, 2, and 61, hand hygiene was not completed before or after the administrations. She placed a pill directly into her bare hand before placing it into a medication cup, and administered the medication to Resident 44. She dropped a tablet into the narcotic box, retrieved it from the box with bare hands, placed it in a medication cup, and administered it to Resident 12. During an interview on 1/5/24 at 3:29 p.m., LPN 4 indicated she was unaware she shouldn't have retrieved the pill, since it had not fallen on the floor. Her practice was to put medications directly into a medication cup, never into her hand. She indicated she had washed her hands with soap and water at the beginning of the medication pass and it was not her practice to perform hand hygiene in between residents. During an interview on 1/5/24 at 3:45 p.m., the DON indicated LPN 4 should not have picked up the pill from the narcotic drawer and administered the medication. The medication should have been discarded. LPN 4 should have been performing hand hygiene before preparing medications to be administered and again following administration to a resident. A current facility policy, dated 2023, titled Medication Administration, and provided by the Corporate Nurse Consultant on 1/5/24 at 3:35 p.m., indicated the following: .4. Wash hands prior to administering medication per facility protocol and product .13. Remove medication from source, taking care not to touch medication with bare hand .16. Wash hands using facility protocol and product 3.1-18(a)(l)

Based on observation, record review and interview, the failed to provide adequate supervision to prevent falls, and failed to develop and implement immediate interventions to prevent further falls for 4 of 7 residents reviewed for accidents (Residents 50, 56, 55, and 51). Findings include: 1. During an observation, on 1/18/22 at 11:00 a.m., Resident 50 was sitting up in a chair in her room. Her clinical record was reviewed on 1/19/22 at 10:45 a.m. Diagnoses included, but were not limited to, Alzheimer's disease and history of falling. Current physician orders included, but were not limited to, Broda chair for comfort and repositioning, order date was 1/19/22. A 11/16/21 significant change MDS (Minimum Data Set) assessment indicated she had severe cognitive impairment. She required extensive assistance with bed mobility, transfers, locomotion on the unit, with dressing, toilet use, and personal hygiene, and limited assistance with locomotion off the unit and eating. She had a history of falls and had fallen twice since her last MDS assessment. A current healthcare plan, with a revised date of 6/29/21, indicated she was at risk for falls related to a history of falls. Interventions included, but were not limited to, staff would encourage her to wear gripper socks when in bed, initiated 08/12/21 and revised on 11/8/21, staff to offer resident assistance more frequently due to her weakness and inability to take her self to the bathroom, initiated on 11/6/21, medications to be reviewed for those that she may have been taking that increased the risk of falls, initiated on 11/8/21, an anti-roll back device was used to lock her wheelchair because she had sometimes forgotten to lock the brakes, initiated on 11/22/21. A progress note, dated 11/3/21 at 3:08 p.m., indicated she had been found in front of the bed, on her knees, with head resting on the bed. No injury had been noted. Staff assisted her to stand then helped her to the chair in her room to eat breakfast. A fall IDT (Interdisciplinary Team) note, dated 11/4/21 at 10:23 a.m., indicated her 11/3/21 fall had been reviewed. Root cause of the fall: severe cognitive impairment, alert and oriented to self, able to voice needs and wants most of the time, however, she would experience episodes of [CONDITION(S)]. She is able to use her call light, but would frequently forget to activate it for assistance. She was able to self ambulate and take herself to the bathroom. She had last been seen by the NP (Nurse Practitioner) on 10/12/21 for an acute visit and orders had been reviewed at that time. Pharmacist had reviewed medications on 10/15/21 with no irregularities found at that time. She was receiving physical and occupational therapy services for gait training and neuromuscular re-education. Intervention and care plan updated: requested pharmacy medication review. Therapy aware of fall. A progress note, dated 11/7/21 at 1:25 a.m., indicated the resident had been found by her bed, on her knees on the floor. She complained of knees hurting. Immediate intervention: checked for injury, assisted with two person back to bed. NP informed of fall, new order received for a one time dose of risiperidone (antipsychotic) 0.5 mg (milligram). A progress note, dated 11/7/21 at 1:00 p.m., indicated the resident had been sitting near nurses station and attempted to get up without assistance and started to fall back. A staff member caught her by her sweater, she had landed on her side. No injury had been noted. NP notified, new orders had been received for blood draws and an urinalysis. She was placed on 15 minute checks. A fall IDT note, dated 11/8/21 at 9:30 a.m., indicated her 11/6/21 fall had been reviewed. Root cause of the fall: severe cognitive impairment, alert and oriented to self, able to voice needs and wants most of the time, however, she would experience episodes of [CONDITION(S)]. She is able to use her call light, but would frequently forget to activate it for assistance. No PRN (as needed) medications had been administered prior to the fall and no recent medication changes. She was receiving physical and occupational therapy services for gait training and neuromuscular re-education. Previous falls reviewed: On 11/3/21 she had been found on her knees beside the bed, she was unable to state what had happened. On 10/25/21 she had been found sitting upright on the floor facing away from her chair and toward her walker, and was unable to state what happened. On 10/20/21 she had been observed ambulating with her walker and fell to the floor in the dining room, she was unable to give an explanation for what caused her to lose her balance and fall. On 10/19/21 she had been found sitting on her bottom beside her bed, her walker in front of her, she was unable to give an explanation of what her intent was. On 10/15/21 she had been found sitting on her bottom on the floor in her room, her back was leaning against her bed. She indicted she had been trying to get up and just sat down. On 10/11/21 she had been found on the floor next to her bed in front of her lounge chair, lying face down. She was unable to give an explanation her intent. On 10/1/21 she had been found with bare feet crawling on her hands and knees in the hallway, indicated she was looking for her children and lost her balance. Intervention and care plan updated: staff assisted her into her wheelchair and out to the nurses' station, staff would offer her assistance more frequently due to her recent weakness. Therapy aware of fall. A fall IDT note, dated 11/8/21 at 9:45 a.m., indicated her 11/7/21 fall had been reviewed. Intervention and care plan updated: 15 minute checks initiated. Staff would assist resident to transfer to stationary chair when visiting at nursing station. Therapy was aware of fall. A progress note, dated 11/8/21 at 5:02 p.m., indicated fall interventions had been discussed with the resident's daughter who had questioned a bed alarm but was concerned that the resident's roommate would not rest well. IDT had been discussing a silent alarm that would sound at the nurses station. The daughter was in agreement with current fall interventions. A progress note, dated 11/12/21 at 6:16 a.m., indicated she had been found on the floor beside the bed on a mat, sitting with back to the bed and legs straight out in front of her. No injury had been noted. Immediate intervention: gripper socks were placed back on her feet, assisted to the bathroom and then back to bed. A fall IDT note, dated 11/12/21 at 10:36 a.m., indicated her 11/12/21 fall had been reviewed. Root cause of the fall: severe cognitive impairment, alert and oriented to self. Her diagnoses included, but were not limited to, Alzheimer's, dementia, chronic kidney disease, major depressive disorder, anxiety, stress incontinence, obstructive sleep apnea, diabetes, and hypertension. Resident was last assessed by the NP on 10/12/21 for an acute visit, no new orders had been received at that time. Psych NP had decreased the [MEDICATION(S)] on 11/8/21, she had not had any behaviors prior to the fall. Intervention and care plan updated: therapy will screen for post fall, intervention of floor mat was effective in preventing injury. A progress note, dated 11/13/21 at 11:37 p.m., indicated the resident had been found crawling on her hands and knees through the doorway from her room into the hallway. She was barefooted. She had last been checked on at 11:30 p.m., bed was in lowest position and fall mat was next to the bed on the floor. No new injury had been noted, bruising from a previous incident was noted. Immediate intervention: bed alarm added to bed until discussion with family and roommate about possibility of a silent alarm. A fall IDT note, dated 11/15/21 at 10:45 a.m., indicated her 11/13/21 fall had been reviewed. Root cause of the fall: severe cognitive impairment, alert and oriented to self. Her diagnoses included, but were not limited to, Alzheimer's, dementia, chronic kidney disease, major depressive disorder, anxiety, stress incontinence, obstructive sleep apnea, diabetes, and hypertension. She had last been assessed by the NP on 10/12/21 for an acute visit, no new orders had been received at that time. Psych NP had decreased the [MEDICATION(S)] on 11/8/21, she had not had any behaviors prior to the fall. Intervention and care plan updated: therapy to screen for post fall. Silent bed alarm per family request. A progress note, dated 11/21/21 at 4:44 a.m., indicated the resident had tried to get up from the wheelchair, it rolled back and she fell to the floor on her bottom, then fell backward. No injury had been noted. Immediate intervention: 15 minute checks and re-direction when she attempted to stand alone. A fall IDT note, dated 11/22/21 at 11:03 a.m., indicated her 11/20/21 fall had been reviewed. Root cause of the fall: severe cognitive impairment, alert and oriented to self. Her diagnoses included, but were not limited to, Alzheimer's, dementia, chronic kidney disease, major depressive disorder, anxiety, stress incontinence, obstructive sleep apnea, diabetes, and hypertension. She had last been assessed by the NP on 10/12/21 for an acute visit, no new orders had been received at that time. On 11/17/21 the Psych NP had increased [MEDICATION(S)] to 0.5 mg three times a day due to an increase in behaviors. Intervention and care plan updated: immediate intervention of 15 minute check for 24 hours had been initiated. A maintenance request had been submitted for anti-rollbacks to be put on her wheelchair. A fall IDT note, dated 11/26/21 at 11:33 a.m., indicated her 11/24/21 fall had been reviewed. Staff had responded to the bed alarm and found the resident kneeling on the floor mat beside her bed. Root cause of the fall: severe cognitive impairment, alert and oriented to self. Her diagnoses included, but were not limited to, Alzheimer's, dementia, chronic kidney disease, major depressive disorder, anxiety, stress incontinence, obstructive sleep apnea, diabetes, and hypertension. She had last been assessed by the NP on 10/12/21 for an acute visit, no new orders had been received at that time. On 11/17/21 the Psych NP had increased [MEDICATION(S)] to 0.5 mg three times a day due to an increase in behaviors. Intervention and care plan updated: therapy notified of fall. Current interventions were effective in preventing injury. During an interview, on 1/25/22 at 10:31 a.m., LPN 21 indicated the resident used to have lots of behaviors and falls, had recently started hospice services. During an interview, on 1/25/22 at 10:22 a.m., the Assistant Director of Nursing indicated the resident had several falls related to wanting to get up. 2. On 1/19/22 at 1:28 p.m., Resident 51 was in bed, awake. On 1/20/22 at 11:21 a.m., she was in bed, yelling and kicking her legs up and getting caught in her quilt, which was partially on the floor. On 1/20/22 at 2:14 p.m., she was in bed, asleep. On 1/21/22 at 8:15 a.m., she was in her room, seated in her wheelchair with her breakfast tray in front of her. She was moving frequently in her chair. On 1/24/22 at 9:57 a.m., she was in bed, with both legs over the side, partially sitting up. Review of Resident 51's clinical record was completed on 1/19/22 at 2:00 p.m. Diagnoses included, but were not limited to, 11/5/21 fracture of clavicle, [CONDITION(S)] disease, dementia with behavioral disturbance, and cognitive communication deficit. A 12/14/21, quarterly, MDS assessment indicated she was moderately cognitively impaired and required extensive assistance with ADLs and mobility. She did not ambulate. She had a current, 1/17/20, care plan problem of risk for falls. Interventions included, but were not limited to, bed alarm, anti-roll back device for wheelchair, low bed, wheelchair alarm, and scoop mattress. Review of 11/4/21 progress notes indicated the resident had fallen at 3:45 p.m. in her room. She was found lying on her abdomen, facing to the right, on the floor between her bed and armoire. She complained of left shoulder pain and indicated she did not know how she had fallen. She was transported to the emergency department for evaluation; she was diagnosed with a fractured left clavicle and an abrasion to the back of her head. She returned to the facility on [DATE] at 2:15 a.m. No immediate interventions to prevent further falls was added to her plan of care. Review of an 11/5/21 at 11:04 a.m. Interdisciplinary Team (IDT) fall review note indicated the resident's care plan was to be reviewed upon her return to the facility. Staff was to be educated if the resident appeared restless while in bed, an offer was to be made to assist her up into her wheelchair and offer to bring her out of her room for socializing, watch the fish, or birds. She was to be moved to a room closer to the nurse's station. The interventions were not added to her care plan. An 11/21/21 at 5:56 p.m., progress note indicated the resident was found sitting on the floor in her room, beside her wheel chair, with no injuries noted. No immediate interventions to prevent further falls was added to her plan of care. Review of an 11/22/21 IDT fall review note indicated the immediate intervention following the fall was to provide bedtime cares and to assist her to bed. An intervention was added for a wheelchair alarm. Review of an 12/11/21 at 8:36 p.m. progress note indicated the resident was found sitting on the foot pedals of her wheel chair. The resident had apparently been attempting to get out of bed and landed on the pedals of her wheel chair. She was not injured. An intervention was to be implemented to not leave her wheelchair next to her bed. The intervention was not added to her care plan. 3. During random observations on 1/21/22 from 10:40 a.m. through 1:53 p.m., Resident 55 was observed sitting in a recliner in the lounge. On 1/21/22 at 2:55 p.m., she was sitting in her wheelchair in the lounge. On 1/24/22 at 8:16 a.m., she was seated alone at a table in the dining room for breakfast. Review of Resident 55's clinical record was completed on 1/19/22 at 12:01 p.m. Diagnoses included, but were not limited to, Alzheimer's disease, dementia with behavioral disturbance, age-related [CONDITION(S)], and cognitive communication deficit. A 12/17/21, quarterly, MDS assessment indicated she was severely cognitively impaired. She required extensive assistance with ADLs and mobility and she did not ambulate. She had no hallucinations or delusions, and had physical behaviors toward others 1-3 days of the assessment period. She had current physician orders for, but not limited to, [MEDICATION(S)] (anti-anxiety) 0.25 mg three times daily for anxiety, [MEDICATION(S)] (anti-depressant) 75 mg daily for anxiety, and [MEDICATION(S)] (anti-depressant) 7.5 mg daily for appetite stimulation. She had a current care plan problem of risk for falls. Interventions included, but were not limited to, bed alarm, staff member will sit at the same dining room table for meals, sit in a stationary chair for meals and activities, floor mat beside bed, hip protectors to be worn when up out of bed, and bed against wall. Review of an 11/3/21 at 1:36 p.m. progress note indicated the resident had been sitting in her wheelchair at a table in the dining room, participating with activities. She stood from her wheelchair and fell to the right side before staff could reach her. No immediate interventions to prevent further falls was added to her plan of care. Review of an 11/4/21 IDT fall review note indicated the resident was to be assisted to a stationary chair for eating and activities at the dining room tables. The intervention was not added to her care plan. Review of an 11/12/21 at 9:06 a.m. progress note indicated she stood from her wheelchair and fell on to her buttocks during breakfast. She was assessed for injury and then assisted back into wheelchair and redirected to her meal. Review of an 11/12/21 IDT fall review note indicated she was to be screened by the therapy department and was to be assisted to a stationary chair for meals and activities. Review of a 12/4/21 at 6:10 p.m. progress note indicated the resident stood up unassisted at the dining table, went to sit back down, and missed her wheelchair when she sat down. The immediate intervention placed was to assess the resident and assist her back into her wheelchair and then to a recliner within view of staff. Review of a 12/6/21 IDT fall review note indicated staff was educated to use the resident's wheelchair for transportation purposes only. Review of a 12/8/21 at 6:07 p.m. progress note indicated she had attempted to grab the med cart and stand up, when she lost her balance and fell . No immediate interventions to prevent further falls was added to her plan of care. Review of a 12/9/21 IDT fall review note indicated she had been sitting in her wheel chair, eating a snack, when she stood up from her wheel chair and lost her balance. She was to have a therapy screening and staff was educated her wheel chair was to be used for transportation only. Review of a 12/17/21 IDT fall review note, created on 12/19/21, indicated she had fallen from a dining room chair in the lounge on 12/16/21 at 6:33 p.m. An intervention was added for a staff member to sit at the table with her during meals. The clinical record lacked documentation from the time of the 12/16/21 fall, including whether an immediate intervention had been developed to prevent further falls. 4. On 1/19/22 at 1:32 p.m., Resident 56 was seated in a dining chair, asleep. The skin beneath his left eye was discolored. On 1/20/22 at 9:19 a.m. he was ambulating with his walker in the hallway. On 1/20/22 at 1:03 p.m., he was in bed. On 1/21/22 at 12:40 p.m., he was in bed. His shoes were on the floor next to the bed and his walker near his shoes. On 1/24/22 at 9:51 a.m., he was in bed asleep, with his shoes on the floor and his walker at end of bed. Resident 56's clinical record was reviewed on 1/19/22 at 2:25 p.m. Diagnoses included, but were not limited to, difficulty in walking, non-exudative age-related [CONDITION(S)], and vascular dementia with behavioral disturbance. He had current physician orders for, but not limited to, [MEDICATION(S)] (anti-psychotic) 0.5 mg twice daily, [MEDICATION(S)] insulin for sliding scale, insulin [MEDICATION(S)] 22 units daily, and [MEDICATION(S)] (anti-depressant) 150 mg daily. A 12/18/21, quarterly, MDS assessment indicated he was severely cognitively impaired and required supervision with ADLs and mobility and limited assistance with transfers. He had an 8/10/21 care plan problem for risk for falls. Interventions included, but were not limited to, proper footwear, half-rail to assist with transfers to and from bed Review of a 12/11/21 progress note indicated he had been found sitting on his buttocks between his bed and the wall at 2:15 a.m. He was not injured. No immediate interventions to prevent further falls was added to his plan of care. Review of a 12/15/21 late entry IDT fall review note for 12/13/21 at 10:46 a.m. indicated he had fallen on 12/11/21 at 2:00 a.m. in his room. He was found on the floor, between his bed and the wall. A new intervention to place his bed against the wall was added and his care plan updated. The intervention was not added to his care plan. Review of a 1/2/22 at 1:00 a.m. progress note indicated he was found on the floor beside his bed. An immediate intervention was completed of assisting him back to bed. He was not injured. Review of a 1/5/22 IDT fall review note indicated he had been found on the floor on 1/2/22 at 1:00 a.m. He was to be screened by the therapy department and half-rails were to be added to his bed. Review of a 1/9/22 at 4:23 a.m. progress note indicated he had been found on the floor near his bed at 3:00 a.m. He was transferred to the emergency department due to a laceration to the left side of his head. There was no intervention developed to prevent further falls upon his return from the emergency department. Review of a 1/10/22 IDT fall review note indicated he had fallen near his bed on 1/9/22. He was to be screened by the therapy department and staff was to offer to assist him to the bathroom if he was awake at night or appeared restless. During an interview, on 1/24/22 at 2:03 p.m., CNA 8 indicated fall prevention interventions were located in the resident's clinical record. During an interview, on 1/25/22 at 8:23 a.m., QMA 7 indicated fall interventions were located in the resident's clinical record. During an interview, on 1/25/22 at 8:43 a.m., LPN 5 indicated following a fall, the nurse was to ensure a new intervention was developed and placed in the clinical record. During an interview, on 1/25/22 at 8:47 a.m., QMA 9 indicated fall prevention interventions were located in the clinical record. Resident 55 was to have someone sit with her when she was at the dining table. During an interview, on 1/25/22 at 10:21 a.m., the DON indicated Resident 56's bed was not able to be right up against the wall due to his climate control system being in the window area, but they kept the bed as close to the wall as possible to encourage him to leave the bed on the other side. Following a fall, the nurses were expected to add immediate interventions, then the IDT would review and modify as needed afterwards. Review of a current facility policy, titled Fall Investigation and Risk Evaluation, dated 6/21 and provided by the Nurse Consultant on 1/25/22 at 9:21 a.m., indicated the following: .All residents will have a care plan developed that includes the resident's complications and risks, an attainable and measurable goal, and individualized interventions to decrease their risk of falls .Procedure .Update the care plan with new intervention 3.1-45(a)(2)

Based on observation, interview, and record review, the facility failed to ensure residents with dementia did not receive anti-psychotic medications without indication and had individualized interventions for targeted behaviors for 3 of 5 residents reviewed for unnecessary medications (Residents 55, 56, and 50). Findings include: 1. On 1/19/22 at 1:40 p.m., Resident 55 was sleeping in a recliner in the lounge. On 1/19/22 at 3:01 p.m., she remained in the recliner. On 1/20/22 at 9:23 a.m., she was seated in a recliner in the lounge, awake, and talking with another resident with a fidget popper in her hand. On 1/20/22 at 1:06 p.m., she was seated in a recliner in the lounge. During random observations on 1/21/22 from 10:40 a.m. through 1:53 p.m., Resident 55 was in a recliner in the lounge. On 1/21/22 at 2:55 p.m., she was sitting in her wheelchair in the lounge. On 1/24/22 at 8:16 a.m., she was seated alone at a table in the dining room for breakfast. Review of Resident 55's clinical record was completed on 1/19/22 at 12:01 p.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A 12/17/21, quarterly, MDS assessment indicated she was severely cognitively impaired. She required extensive assistance with ADLs and mobility and she did not ambulate. She had no hallucinations or delusions, and had physical behaviors toward others 1-3 days of the assessment period. She had current physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . She had a current, 4/7/21, care plan problem of cognitive deficit related to disease process (Alzheimer's). I am alert and oriented to person, confused to time and place. I present with short term memory loss. Interventions included, but were not limited to, offer me two choices, allow time to process what is being said, and reduce stimulus when talking to me. She had a current, 5/5/21, care plan problem of I have behavioral symptoms such as (biting, hitting, pinching, scratching, kicking, yelling/screaming, repetitive verbalization and questions, slapping, grabbing) choosing not to have care provided, cognitive deficit, and physical aggression. Interventions included, but were not limited to, do not begin care if agitated, alternate care giver, discuss old memories, coffee, and diversional activity. Review of a 9/10/21 Behavior Management Review indicated she had physical aggression, resistance, repetitive verbalization and questions, yelling/screaming seven times in the last 30 days. She received [MEDICATION(S)], with no changes since last review. Recommendations were to complete care and cease interaction, remove her from the stimuli, and walk with her. Review of a 9/13/21 psychiatric Nurse Practitioner note indicated on 8/23/21 staff had reported aggression when attempting to redirect when she was standing unassisted. [MEDICATION(S)] was of benefit, but was at a low dose due to multiple falls. Review of a 10/3/21 behavior sheet indicated at 6:33 p.m., she was exhibiting severe pinching, grabbing, and hitting others. Interventions were unsuccessful. Review of a 10/3/21 at 6:58 p.m. progress note indicated an order had been received for [MEDICATION(S)] (anti-psychotic) 5 mg injection now and may repeat 5 mg in one hour after initial administration if initial dose was ineffective at relieving behaviors. An additional order was received for a urinalysis via straight catheterization. Review of a 10/3/21 at 8:57 p.m. behavior sheet indicated mild wandering, severe delusions, moderate hitting, kicking, yelling, slapping, and grabbing others. She was pinching, hitting, slapping, biting and yelling at staff. Interventions were unsuccessful. Review of medication administration records indicated the [MEDICATION(S)] was administered on 10/3/21 at 6:59 p.m. and again at 8:00 p.m. She was catheterized at 8:59 p.m. and was resting in a recliner in the lounge at 9:34 p.m. She also received [MEDICATION(S)] (anti-anxiety) 0.5 mg on 10/3/21 at 11:09 p.m. Review of a 10/11/21 Behavior Management Review indicated she exhibited wandering, [CONDITION(S)], resistance, hitting, scratching, yelling/screaming, grabbing, repetitive verbalization, and delusions 20 times in the last 30 days. The delusions were not defined in the note. During an interview, on 1/25/22 at 11:02 a.m., the Social Service Director (SSD) indicated she had been notified by the nurse the resident had been being aggressive toward staff and the NP being notified and the order received on 10/3/21. 2. On 1/19/22 at 1:32 p.m., Resident 56 was seated in the dining room, asleep. At 1:35 p.m., he was up with his walker, asking how to get out of here. Staff redirected him by telling him to wait until his family was done with work. On 1/20/22 at 9:19 a.m., he was ambulating in the hallway in the direction of his room. On 1/20/22 at 1:03 p.m., he was in bed. On 1/21/22 at 10:02 a.m., he was in the main dining room, playing seated kickball with a group of residents. On 1/21/22 at 12:40 p.m., he was in bed. He remained in bed at 1:55 p.m. On 1/24/22 at 8:10 a.m., he was seated in the dining room. On 1/24/22 at 9:51 a.m., he was in bed asleep. On 1/24/22 at 2:00 p.m., he was seated at a dining table, eating ice cream. Resident 56's clinical record was reviewed on 1/19/22 at 2:25 p.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . He had current physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A 12/18/21, quarterly, MDS assessment indicated he was severely cognitively impaired and required supervision with ADLs and mobility and limited assistance with transfers. He had a current, 8/10/21 care plan problem of I have behavioral symptoms such as (repetitive verbalization and questions, cursing, yelling/screaming, grabbing) cognitive deficit, delusions (false beliefs), and physical aggression. The delusions mentioned in his care plan were not defined in the clinical record. Review of progress notes indicated he had been hospitalized at a geriatric psychiatric facility from 7/20/21 through 8/9/21. Review of an 8/9/21 psychiatric Nurse Practitioner note indicated he had readmitted to the facility with an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of 8/9/21 admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of an 8/23/21 psychiatric Nurse Practitioner note indicated [MEDICATION(S)] had been started due to the [MEDICATION(S)] not being covered by insurance. The resident continued with behaviors of cursing, screaming, and shouting. He believed someone stole his truck. The previous Nurse Practitioner had indicated this behavior was not unusual for him. [MEDICATION(S)] had been ordered again as the [MEDICATION(S)] was reported as not being beneficial. Review of a 9/1/21 psychiatric note indicated he had a physical decline and was more lethargic. Review of a 10/11/21 psychiatric note indicated he had recovered from COVID-19 and was still fixated on his truck, but was able to be redirected. Review of an 11/29/21 behavior sheet indicated he was looking for his truck and had set the door alarm off in an attempt to open the door. He was redirected. Review of a 12/7/21 psychiatry note indicated no concerns with delusions. A 1/10/22 Behavior Management Team review indicated no behaviors since last review. During an interview, on 1/24/22 at 2:03 p.m., CNA 8 indicated neither Resident 55 nor Resident 56 had been noted to have delusions or hallucinations. If they had been observed, she would report them to a nurse, who would document them in the clinical record. During an interview, on 1/25/22 at 8:47 a.m., QMA 9 indicated neither Resident 55 nor Resident 56 had hallucinations or delusions. During an interview, on 1/25/22 at 10:33 a.m., the SSD indicated the psychiatric Nurse Practitioner had started the antipsychotic based on the resident having been on it in the psychiatric facility. The SSD was not able to locate the order for the medication on the re-admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] During an interview, on 1/25/22 at 10:51 a.m., the SSD indicated she had located a nutritional assessment from the psychiatric facility with the antipsychotic medication listed as being a current medication. 3. During an observation, on 1/19/22 at 1:32 p.m., Resident 50 was sitting up in bed, two visitors were in her room. On 1/21/22 at 10:02 a.m., the resident was lying in bed. On 1/24/22 at 2:02 p.m., she was sitting up in bed, two visitors were in her room. On 1/25/22 at 10:30 a.m., she was lying in bed. Resident 50's clinical record was reviewed on 1/19/22 at 10:45 a.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Current physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] a. [MEDICATION(S)] (antidepressant) delayed release sprinkle 30 mg (milligram), one capsule at bedtime for depression, the order date was 5/30/21. b. [MEDICATION(S)] (antianxiety) 0.5 mg, one tablet two times a day for anxiety, the order date was 10/8/21. c. [MEDICATION(S)] (antipsychotic) 0.5 mg, one tablet two times a day for major depression, the order date was 1/12/22. A 11/16/21 significant change MDS assessment indicated she had severe cognitive impairment. She had not had any behaviors. Active diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . She had received an antipsychotic, antianxiety and antidepressant medication every day during the assessment period. A current healthcare plan, with a revised date of 9/28/21, indicated she was at risk for side effects related to the use of antidepressants, antianxiety and antipsychotic medications. Interventions included, but were not limited to, her use of [CONDITION(S)] medications would be reviewed quarterly by a pharmacist and the interdisciplinary team to ensure the need for continued use and the appropriateness for a gradual dose reduction. A current healthcare plan, with a revised date of 12/13/21, indicated she had behavioral symptoms such as (yell/scream, hitting, pinching, scratching, grabbing, repeats movement) cognitive deficit, verbal aggression, physical aggression and urinating in inappropriate places. Interventions included, but were not limited to, redirect her behavior when she had chosen not to have care, initiated on 11/10/21, diversional activity such as sorting buttons and folding towels, initiated on 11/12/21 and take her for a walk, initiated on 12/13/21, A progress note, dated 10/5/21 at 3:31 a.m., indicated the resident had been a little anxious that night and would not stay off of roommates side of the room, she was redirected several times and finally did go to bed and stay there. A behavior management team review, dated 10/11/21 at 11:07 a.m., summarized that her behaviors had included banging, wandering, [CONDITION(S)], delusions, resistance, inappropriate behavior and screaming. Medical considerations of behaviors included Alzheimer's late onset, dementia with behavioral disturbances, anxiety, sleep disorder, depressive disorder and cognitive communication deficit. Psychopharmacologic medications reviewed included [MEDICATION(S)], [MEDICATION(S)] and [MEDICATION(S)]. Reductions/increases, side effects, or failures of changes noted indicated [MEDICATION(S)] and [MEDICATION(S)] had been added on 9/27/2021. Team recommendations were to approach her from the front and make sure you had her attention, call her family for assistance, participate in her reality when indicated and reassure/comfort her when she needed it to calm her down. A progress note, dated 10/13/21 at 3:08 a.m., indicated she had not had any adverse side effects since starting [MEDICATION(S)] 1 mg, was resting in bed with eyes closed, no signs or symptoms of anxiety had been noted. A progress note, dated 10/19/21 at 3:54 a.m., indicated she had slept well that night, no increased agitation/anxiety related to decrease in [MEDICATION(S)], she had made no attempts to ambulate per self. No injuries noted related to fall on 10/15/2021. A progress note, dated 11/7/21 at 1:25 a.m., indicated she had been found on the floor by her bed on her knees. Call had been placed to the Psych NP and a new order for a one dose of [MEDICATION(S)] 0.5 mg had been received. A behavior management team review, dated 11/10/21 at 1:53 p.m., summarized that her behaviors had included resistance, wandering, hitting and biting. Medical considerations of behaviors included Alzheimer's late onset, dementia with behavioral disturbances, anxiety, sleep disorder, depressive disorder and cognitive communication deficit. Psychopharmacologic medications reviewed included [MEDICATION(S)], [MEDICATION(S)] and [MEDICATION(S)]. Reductions/increases, side effects, or failures of changes noted indicated [MEDICATION(S)] had been increased on 10/18/2021, then decreased on 11/8/2021. Team recommendations were to allow her time to calm and reapproach at a later time when agitated and redirect her behavior when she had chosen not to have care. A behavior sheet note, dated 11/17/21 at 9:53 a.m., indicated she had behaviors of repeatative verbalizations, repeatative questions, resistance to care hitting, kicking, scratching, slapping, grabbing others and yelling/screaming, all listed as severe intensity. The interventions attempted indicated behavior worsened. The note indicated she had became agitated and attempted to get out of chair, had begun to hit staff and stomp staff's feet. Redirection was unsuccessful. She had been offered activities, coffee, to be toileted and snacks. She yelled at staff to leave her alone. Staff called the resident's daughter who indicated she would come in and sit with her. A progress note, dated 11/17/21 at 11:54 a.m., indicated new orders had been received to increase rispridone to 0.5 mg three times a day and to give [MEDICATION(S)] 1 mg intramuscularly now, one time only. A behavior sheet note, dated 11/22/21 at 1:02 p.m., indicated she had behaviors of resistant to care of moderate intensity. Approaches attempted, with results of unchanged behavior, included, approached in a calm manner, established eye contact, called her by her name, used simple sentences, took her for a walk, toileted, offered fluids and a snack, and talked with her. The note indicated she kept attempting to stand from wheelchair, became very combative and does not comply with request to sit back into chair. She had been given PRN (as needed) acetaminophen for lower back pain with no change in behavior. She was yelling for mom and told any staff who assisted her, to get their mom. When resident sundown's redirection isn't successful. A behavior sheet note, dated 12/3/21 at 4:41 p.m., indicated she had repeated movements. Staff member talked with her and the behavior improved. The note indicated she had attempted to remove shirt several times, when staff attempted to assist her into her pajamas she wouldn't allow them. A behavior management team review, dated 12/13/21 at 2:40 p.m., summarized that her behaviors had included resistance and repeated movement. Medical considerations of behaviors included Alzheimer's late onset, dementia with behavioral disturbances, anxiety, sleep disorder, depressive disorder and cognitive communication deficit. Psychopharmacologic medications reviewed included [MEDICATION(S)], [MEDICATION(S)] and [MEDICATION(S)]. Reductions/increases, side effects, or failures of changes noted indicated [MEDICATION(S)] had been increased on 11/17/2021. Team recommendations were to talk with her, take her for a walk, diversional activity such as (sorting buttons, folding towels) and redirect my behavior when choosing not to have care. A behavior management team review, dated 1/10/22 at 12:37 p.m., summarized that she had not had any mood states or behaviors reported or documented since last review. Medical considerations of behaviors included Alzheimer's late onset, dementia with behavioral disturbances, anxiety, sleep disorder, depressive disorder and cognitive communication deficit. Psychopharmacologic medications reviewed included [MEDICATION(S)], [MEDICATION(S)] and [MEDICATION(S)]. Reductions/increases, side effects, or failures of changes noted indicated no changes since last review. Team recommendations indicated to continue to observe for 60 days and discontinue should mood state and behaviors remain stable. During an interview on 1/25/22 at 10:31 a.m., LPN 21 indicated the resident did have behaviors of being combative, had multiple falls and was difficult to give medications to. Behaviors were documented on the behavior note sheet and C.N.A.'s document behaviors under the Task tab or write it on a piece of paper and give that to the nurse. She did not know what behaviors supported the use of an antipsychotic medication. During an interview on 1/25/22 at 10:22 a.m., the Assistant Director of Nursing indicated the resident's behaviors included anxiousness, repeatative movement and verbalizations, wanting to get up and falling. She did not know what behaviors supported the use of an antipsychotic medication. During an interview on 1/25/22 at 10:27 a.m., C.N.A. 33 indicated she had worked at the facility for about six months, she didn't know of the resident having behaviors and she was cooperative with care. During an interview on 1/25/22 at 10:50 a.m., the Social Service Director indicated the resident's behaviors included, slamming her walker into the glass of the front door. She indicated she needed to look at her knows to verify what behaviors supported the use of an antipsychotic medication. Review of a current facility policy, titled PSYCHOACTIVE MEDICATIONS/GRADUAL DOSE REDUCTION POLICY, with a revised date of 1/21 and provided by the Nurse Consultant on 1/25/22 at 11:51 a.m., indicated .1. Residents receiving psychoactive medications will have their medical record reviewed for appropriate diagnosis. If a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Residents receiving psychoactive medications will have a care plan initiated that contains interventions regarding the target behaviors and possible adverse side effects of the medication(s) Review of a current facility policy, titled Behavior Management Policy, with a revised date of 10/19 and provided by the Nurse Consultant on 1/25/22 at 11:51 a.m., indicated Policy: To ensure the resident receives effective treatment and intervention for behavior and mood symptoms .1. The CNAs will document behaviors in the Electronic Medical Record when behaviors occur. The CNA will notify the nurse of the behavior. 2. The nurse or social service will complete the Behavior Sheet upon being notified of or witnessing a behavior No additional information was provided by the facility after exit conference. 3.1-37(a)

A. Based on observation, interview and record review, the facility failed to ensure staff had completed a health screening prior to walking through resident care areas to mitigate the spread of COVID-19 during a global pandemic for 1 of 1 staff observed for health screening (RN 28). B. Based on observation, record review and interview, the facility failed to ensure infection prevention and control strategies were followed to mitigate the spread of COVID-19 during a global pandemic when signage on a resident's door was not turned to communicate that additional PPE (Personal Protective Equipment) was required to enter the room during an AGP (Aerosol Generating Procedure) and for the one hour period after the AGP for 1 of 2 staff observed for effectively communicating an AGP was in process (LPN 5). Findings include: A. During a random observation, on 1/18/22 at 10:42 a.m., RN 28 opened the door at the end of the 300 hall and walked into the facility. During an interview, immediately following the observation, RN 28 indicated she had just started her shift, had ran out to her car to get something, had entered through that same door when she had first arrived for her shift, and had then walked through the 300 hall, through the dining room to the employee breakroom to complete her health screening. During an interview, on 1/21/22 at 8:48 a.m., the Administrator indicated employees were to enter through the breakroom door prior to the start of their shift to complete the health screen. Review of a current facility policy, titled COVID-19 RESIDENT, HEALTHCARE WORKER (HCW), VENDOR & VISITOR SCREENING, with a revised date of 10/21 and provided by the Administrator on 1/25/22 at 12:55 p.m., indicated .Screen all healthcare personnel (HCP) each shift, and screen all visitors and vendors entering the facility for known diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] B. During a medication administration observation, on 1/24/22 at 11:36 a.m., LPN 5 entered Resident 65's room, wearing a procedure mask and face shield, to administer his nebulizer treatment. She started the treatment, closed the resident's door, and remained in the room with the resident. She did not don any additional PPE prior to staying in the room. At 11:49 a.m., LPN 13 and CNA 10 entered the room, each with a meal tray. They did not don any additional PPE other than the procedure masks and eye protection they both already wore. Upon leaving the room, LPN 13 turned a sign on the door outward. The sign indicated an aerosol-generating procedure was in process and an N95 mask, gown, and eye protection were required to enter the room during the procedure and for one hour afterwards. During an interview, on 1/24/22 at 11:53 a.m., LPN 5 indicated she should have donned an N95 mask and gown when the nebulizer treatment was started. Review of a current facility policy, titled PANDEMIC RESPIRATORY TREATMENTS, dated 4/21 and provided by the DON on 1/24/22 at 2:07 p.m., indicated the following: .Due to the potential for airborne transmission of respiratory particles during these treatments, certain PPE and precautions need to be in place. CDC guidance for aerosol-generating procedures should be followed for infection control measures for the duration of the AGP [aerosol-generating procedure] and for one (1) hour after the procedure .This includes N95 mask, eye protection, gown and gloves 3.1-18(b) 3.1-18(l)

Based on observation, interview, and record review, the facility failed to follow care plan interventions for transfers for 1 of 1 random observations of transfers (Resident 44). Findings include: On 1/20/22 at 12:50 p.m., Resident 44 was assisted back to room by LPN 4, via her wheelchair. On 1/20/22 at 12:58 p.m., CNA 3 entered her room to assist her to lay down. No other employee entered her room during the observation. During an interview, on 01/20/22 at 1:13 p.m., CNA 3 indicated the resident required extensive to total assistance with ADL care and extensive assistance of one for transfers. Information for resident care was located in the resident's clinical record. Review of Resident 44's clinical record was completed on 1/18/22 at 2:23 p.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A 12/8/21, annual, Minimum Data Set (MDS) assessment indicated she was severely cognitively impaired and required extensive assistance of two for transfers. She had a current care plan problem of risk for falls. Interventions included, but were not limited to transfers with the assistance of two, dated 7/13/21. During an interview, on 1/25/22 at 8:23 a.m., QMA 7 indicated Resident 44 required extensive assistance of two staff for transfers. During an interview, on 1/25/22 at 10:08 a.m., the DON indicated the resident required the assistance of two for transfers. Review of a current facility policy, titled Fall Investigation and Risk Evaluation, dated 6/2021 and provided by the Nurse Consultant on 1/25/22 at 9:21 a.m., indicated the following: .It is the policy of this facility to provide an environment that is free from accident hazards over which the facility has control 3.1-35(a)

Based on interview and record review, the facility failed to report an allegation made by a resident of verbal abuse by a staff member to the State Survey Agency for 1 of 4 residents reviewed for abuse. (Resident C) Findings include: During an interview with Resident C on 10/21/21 at 10:57 a.m., she indicated when asked about male CNA's, one had called her a fat a-- b-t-ch. She told the male CNA she was waiting on CNA 2 and he said no I'm putting you to bed. The aide then called her that name and they fired him. The clinical record for Resident C was reviewed on 10/21/21 at 10:30 a.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A quarterly Minimum Data Set (MDS) assessment, dated 7/27/21, indicated the resident was moderately cognitively impaired. She required two-person assistance with bed mobility, transfer, dressing and hygiene. A health care plan, dated 4/23/21, indicated the resident had behavioral symptoms such as depression, delusional disorder and false allegations. Interventions included, but were not limited to, offer alternative care choices, redirect the behavior, allow time to calm down and reapproach. On 10/15/21, a new intervention included to have 2 staff members provide care. During an interview on 10/21/21 at 9:31 a.m., the Administrator indicated she did not have an Indiana Department of Health (IDOH) reportable related to Resident C, but had a grievance form from the resident. Review of a grievance report, provided by the Administrator on 10/21/21 at 10:01 a.m., dated 8/3/21, indicated Resident C was waiting for an female aide to put her to bed around 8:00 p.m. CNA 1 came in and said he was putting her to bed. The resident told CNA 1 that she wanted to wait for the female aide. CNA 1 then started yelling and screaming at her and called her a fat a-- b-t-ch. CNA 1 left the room and slammed the door repeatedly, but he came in again. The resident stated she did not want him in her room and she was terrified until 2:00 p.m. The nurse did not help, but made it worse. Review of CNA 1's written statement, dated 6/4/21, indicated he told the resident he was the aide and she started to tell him he was not her kind of woman related to his sexual orientation. The resident stated she did not want him to care for her and continued yelling. The charge nurse then told him to not go back into her room. A statement from CNA 2 indicated the resident had called CNA 1 a derogatory name. She was in the hallway during this time and did not heard him scream or call her a name. During an interview with the Administrator, Director of Nursing (DON) and nurse consultant on 10/21/21 at 10:10 a.m., the Administrator indicated the allegation was for 8/3/21, but CNA 1 wrote the wrong date; 6/4/21. The nurse on duty with CNA 1 wrote the statement provided by the resident. The incident was not reported to IDOH because another aide was in the hallway and did not hear anything. CNA 1 no longer worked at the facility. The DON spoke with the the resident who admitted to calling the aide a derogatory name and felt bad. The DON indicated she received a call at night from the nurse related to the incident. On 10/21/21 at 10:32 a.m., the DON indicated they spoke with the nurse on duty that night and she did not recall the incident and was not the person who took the statement from Resident C. The DON indicated she did not receive a call at home, but had the note waiting for her when she arrived to work. On 10/21/21 at 11:30 a.m., the nurse consultant indicated although CNA 1's statement indicated he had informed his charge nurse and was told to not go back into Resident C's room, the nurse on duty at the time did not recall the incident or provide a statement related to the investigation. A timeline of events was provided by the DON on 10/21/21 at 12:24 p.m., post-dated 8/4/21. The statement indicated the note was found in her door when she arrived to work. The Social Service Director (SSD) was also asked to speak to the resident and other's on the same hall. During a telephone interview on 10/21/21 at 12:41 p.m., CNA 1 indicated he went into the room to change her. The other CNA left to go get towels because it was a full bed change. The resident said he was not her kind of a woman. He stopped care and said he was offended and upset. The resident called him a derogatory name. He left the room and the other CNA was coming back with the towels. He told his charger nurse what happened and was told to not go back in her room. He indicated the nurse then went and talked to the resident. They had a great relationship prior to this and was not sure what happened on that day. During a telephone interview on 10/21 at 12:54 p.m., LPN 3 indicated she took the statement from Resident C and knew the DON would be in soon, so put the note on her door. On 10/21/21 at 12:59 p.m., the Administrator indicated the linen cart was close to the resident's room so the other aide would have heard any yelling or screaming. When they watched the video, it did not show the charge nurse go into the room or CNA 1 slamming the door. Review of CNA 1's time card for 8/3/21, he arrived to work at 2:00 p.m. and left at 9:56 p.m. CNA 1 worked the following days: 8/5/21, 8/7/21, 8/8/21, 8/11/21 and 8/12/21. CNA 2 arrived to the facility on [DATE] at 1:45 p.m. She indicated she was outside the room near the linen cart, but did not hear CNA 1 yell or scream at the resident. A New Hire Education Acknowledgment, dated 6/9/21, indicated CNA 1 received information on the following: a. Resident rights b. Abuse prohibition and prevention c. Job description. A current facility policy, dated 2/2012 and last revised 4/21, titled Abuse, Neglect and Misappropriation of Resident Property, provided by the nurse consultant on 10/21/21 at 1:01 p.m., indicated the following: Policy: This facility's policy is the resident has the right to be free from verbal, sexual, physical and mental abuse .Policy Interpretation and Implementation .7. The facility will ensure that all allegations of mistreatment, neglect or abuse, including injuries of unknown source, are reported immediately to the Administrator of the facility and to other officials in accordance with federal/state law (i) Report all alleged violations .immediately but not later than 2 hours 8. All residents will be evaluated immediately by the attending nurse This Federal Tag relates to complaint IN 507. 3.1-28(c)

Based on record review and interview, the facility failed to provide notification of transfer for 9 of 10 residents reviewed for hospitalization (Residents 48, 63, 49, 75, 81, 233, 57, 61, and 70). Findings include: 1. Resident 48's clinical record was reviewed, on 10/25/19 at 8:51 a.m. [DIAGNOSES REDACTED]. Progress notes indicated on 8/7/19, he was transferred to a behavioral center for evaluation and treatment due to becoming aggressive with staff and other residents. The clinical record lacked a Notice of Transfer, or indication one had been given, for the resident's transfer. 2. Resident 63's clinical record was reviewed, on 10/25/19 at 9:25 a.m. [DIAGNOSES REDACTED]. Progress notes indicated on 7/27/19, he was transferred to a local hospital. Review of a facility 7/27/19 Notice of Transfer or Discharge Form, provided by the BOM on 10/29/19 at 9:56 a.m., lacked indication the resident's representative had been notified in writing of the reason of the transfer. 3. Resident 49's clinical record was reviewed, on 10/25/19 9:32 a.m. [DIAGNOSES REDACTED]. Progress notes indicated on 7/15/19, he was transferred to a local hospital. A 7/16/19 progress note indicated he had been transferred to a hospital out of town with a [DIAGNOSES REDACTED]. The clinical record lacked a Notice of Transfer or indication one had been given, for the resident's transfer. 4. Resident 75's clinical record was reviewed, on 10/24/19 at 9:52 a.m. [DIAGNOSES REDACTED]. Progress notes indicated on 8/7/19, she was transferred to a local hospital. An 8/9/19 progress note indicated she had readmitted to the facility. An 8/12/19 progress note indicated she had been transferred to a local hospital. The clinical record lacked a Notice of Transfer or indication one had been given for the resident's transfer. 5. Resident 81's clinical record was reviewed, on 10/28/19 at 8:22 a.m. [DIAGNOSES REDACTED]. Progress notes indicated on 9/15/19, he was transferred to a local hospital and admitted for an urinary tract infection. The clinical record lacked a Notice of Transfer or indication one had been given for the resident's transfer. 6. Resident 233's clinical record was reviewed, on 10/29/19 at 8:56 a.m. [DIAGNOSES REDACTED]. Progress notes indicated on 10/21/19, he was transferred to a local hospital. A 10/22/19 progress note indicated he would be readmitted to the facility. The clinical record lacked a Notice of Transfer or indication one had been given for the resident's transfer. 7. Resident 57's clinical record was reviewed, on 10/25/19 at 10:11 a.m. [DIAGNOSES REDACTED]. Progress notes indicated on 9/21/19 he was transferred to a local hospital. A progress note, dated 9/28/19, indicated he had readmitted to the facility. A progress note, dated 10/15/19, indicated he had been transferred to a local hospital. A progress note, dated 10/18/19, indicated he had readmitted to the facility. The clinical record lacked a Notice of Transfer, or indication one had been given for the resident's transfer. 8. Resident 61's clinical record was reviewed, on 10/28/19 at 10:50 a.m. [DIAGNOSES REDACTED]. Review of progress notes indicated, on 10/14/19 , she had been transferred to a local hospital. The clinical record lacked a Notice of Transfer or indication one had been given for the resident's transfer. 9. Resident 70's clinical record was reviewed, on 10/24/19 at 3:33 p.m. [DIAGNOSES REDACTED]. Review of progress notes indicated, on 8/14/19 , he was transferred to a local hospital. A progress note, dated 8/17/19, indicated he had readmitted to the facility. The clinical record lacked a Notice of Transfer or indication one had been given for the resident's transfer. During an interview, on 10/29/19 at 9:52 a.m., the Business Office Manager (BOM) indicated the notice of transfer or discharge should be done by the nurse when a resident is sent out or transferred. She was aware there had a been a problem and these had not always been done. A current facility policy, titled DISCHARGE PR[NAME]EDURES, with a 10/19 revised date and provided by the Nurse Consultant on 10/29/19 at 9:59 a.m., indicated .7. If the transfer is not resident or resident representative initiated, the facility must send a transfer/discharge form from the State along with the bed hold form with the resident/resident representative and obtain signature of both the resident and resident representative on the form to prove notification was sent. 3.1-12(a)(6)(A)

Based on observation, interview, and record review, the facility failed to ensure immediate and individualized interventions were put into place to reduce the risk of falls for 1 of 3 residents reviewed for falls with injury (Resident 233). Findings include: On 10/23/19 at 11:49 a.m. Resident 233 was seated in a chair, with his eyes closed, in the[NAME]Lane family room. On 10/29/19 at 9:02 a.m., he was sitting in a chair, with his eyes closed, in the[NAME]Lane family room. He had a blanket covering from his lap to over his feet, with the excess blanket on the floor. On 10/29/19 at 9:48 a.m., he remained in the chair, with his eyes closed, and the blanket covering his lap and feet. On 10/29/19 at 11:06 a.m., he remained in the chair, with his eyes closed. A small purple linear area was visible to the back of his head. On 10/29/19 at 12:06 p.m., he was awake, seated in a wheelchair at a table, eating lunch. Resident 233's clinical record was reviewed on 10/23/19 at 10:09 a.m. [DIAGNOSES REDACTED]. His current orders included, but were not limited to, monitor the laceration to the back of his head and [MEDICATION NAME] (antidepressant) 75 mg at bedtime. He had a current, 10/14/19, care plan problem of risk for falls related to confusion, [MEDICAL CONDITION], and unsteadiness. Interventions and included, but were not limited to, the following: 10/14/19- proper or non-slip footwear on while up. 10/14/19- personal items in reach. 10/14/19- assistive devices kept in reach. 10/15/19-staff to ensure non-slip footwear was on, as he would sometimes take them off, initiated on 10/16/19. 10/21/19-medication review from pharmacist due to fall. 10/22/19-bed to be in lowest position with safety mat beside bed. 10/22/19- therapy services as indicated. 10/23/19-[MEDICATION NAME] decreased from 150 mg to 75 mg at bedtime, initiated on 10/21/19. He had a current, 10/15/19, care plan problem of difficulty sleeping related to difficulty falling asleep and history of sleeping problems. Interventions included, but were not limited to, medication as ordered, and encourage to refrain from napping through the day. He had a current, 10/21/19, care plan problem of impaired vision related to [MEDICAL CONDITION]. Review of a 10/14/19 admission assessment indicated he admitted at 11:15 a.m. He was oriented to person only, was cooperative, and with slow comprehension. He ambulated with an (undefined) device, and transferred independently. He had a history of [REDACTED]. Review of a 10/14/19 fall risk assessment indicated he was at moderate risk for falls due to a history of falls and inappropriate use of a device or footwear. A 10/14/19 progress note indicated he fell at 10:00 p.m. in his room, next to his bed. He was not injured, and non-slip socks were applied. A 10/14/19 progress note indicated at 10:35 p.m., he was pleasant, tried to get up on his own, and had an unsteady gait. He had been on one on one supervision all evening. He had urinary urgency, and would not stay in his bed or wheelchair. He was at the nurses station for supervision. A 10/15/19 Interdisciplinary Team (IDT) review of the 10/14/19 fall indicated he had removed his non-slip socks prior to the fall. The root cause was identified as him being confused and having an unsteady gait. His care plan was updated to ensure he had non-slip footwear on. A 10/15/19 physician's note indicated he had admitted to the facility for therapies. He had debility and gait disturbance due to generalized weakness and deconditioning. A 10/16/19 progress note indicated he was transferred to the secured unit. A 10/19/19 progress note indicated he was found on the floor at his bedside at approximately 3:45 a.m. The resident stated he was trying to get up. He was bleeding from his nose, a head wound, and his left wrist. He had a hematoma (bruise) to his left eyebrow, with a small laceration present, and a skin tear to his left wrist. Immediate interventions were to assess his range of motion, skin, and vital signs. The physician was notified, and advised to apply ice to his head wound, and to monitor his condition. His family was called and updated by phone, and in person. There was no immediate intervention put into place related to preventing additional falls or injuries. A 10/21/19 IDT review of the 10/19/19 fall, indicated his cognition did not allow for him to remember to call for assistance. The physician had been notified, with orders to treat his skin tear and laceration. The root cause of the fall were impaired mobility and cognition. An intervention was added for a medication review from the pharmacist. A 10/21/19 nurse practitioner note indicated he had fallen on 10/19, without injury. He used a wheelchair, and was able to follow directions. A 10/21/19 progress note indicated he was found on the floor in his room at 10:34 p.m. He was bleeding from his head. He had a two centimeter (cm) laceration, and a one inch laceration, to the back of his head. The 1 inch laceration was actively bleeding at the time of transfer to the emergency department. A 10/22/19 progress note indicated he was being discharged from the emergency department. His [MEDICAL CONDITION] had been closed with wound adhesive and a CAT scan of his head and neck were completed, with negative findings. There was no immediate intervention put into place related to preventing additional falls or injuries. A 10/22/19 IDT review of the 10/21/19 fall indicated the root cause of the fall was weakness, unsteady gait, and impaired cognition. He had been attempting to self-transfer, and was unable to tell staff what he was trying to do, due to dementia. A new intervention was added for his bed to be in the lowest position, with a safety mat at his bedside. A Falls investigation worksheet, dated 10/21/19 indicated he had gripper socks in place, as he was trying to get up. Interventions in place at time of fall were slipper socks and personal items in reach. New interventions added were the resident was in the lounge with staff and a medication review completed. The care plan was updated on 10/21/19. A 10/23/19 progress note indicated his [MEDICATION NAME] was reduced from 150 mg to 75 mg daily at bedtime. During an interview, on 10/29/19 at 11:04 a.m., CNA 31 indicated she hadn't seen the resident walk, and he transferred with the assistance of one person. He had a walker in his room, but didn't use it. His mobility had not changed, and was able to voice when he needed something. During an interview, on 10/29/19 at 11:09 a.m., LPN 33 indicated he did not ambulate independently, and used a wheelchair, which he could propel with his feet. He was usually more awake during the day, but did take a nap after breakfast, would use the bathroom, then would sleep more, before waking up more for the day. He would try to get up by himself, but she hadn't seen him ambulate by himself. Following a fall, the IDT would update the care plan; the nurse would not go into the care plan area of the clinical record and update anything. The resident tended to stay in the family room during the day, so staff could keep a good eye on him. He was able to voice when he needed to use the bathroom. During an interview, on 10/29/19 at 11:47 a.m., with both the DON and Nurse Consultant present, the DON indicated the resident had been really restless prior to his first fall, and would take his socks off, even his shirt. The intervention was added to ensure his socks were on at all times. After the 10/19/19, the facility did a medication review, due to a high dosage of [MEDICATION NAME]. He had been moved to[NAME]Lane, had gripper socks on, and was screened by physical therapy on 10/15/19. The intervention of therapy services as indicated was added to his care plan on 10/22/19. His bed was to be in the lowest position, after his third fall; after the third fall was when the [MEDICATION NAME] was decreased. The facility had attempted to get it decreased from 10/21/19, but the physician wanted to have him be monitored before changing his medication. The resident had been sleepy throughout the day since admission, then up all night. Since the medication had been reduced to 75 mg, he had been sleeping better during the night, and sleeping less during the day. The facility had just done an in-service due to immediate interventions not being put in after falls, and if the nurse was not sure what to put into place, they were to call the DON. The IDT would review the fall to see if the intervention was appropriate. During an interview, on 10/29/19 at 1:45 p.m., the DON indicated the physician had been notified of the falls, but didn't want to make any changes since the resident was new. Everything the resident was supposed to have was in place, so the facility felt it was all appropriate. There were no other interventions they could have put into place until the medication review was completed, as the facility felt the medication was the issue. The concern had resolved, since the medication had been reduced. During an interview, on 10/29/19 at 2:49 p.m., CNA 35 indicated the resident toileted himself with assistance. He spent his time in his room in his recliner, or the recliner in the family room. She had never heard him say he needed anything. He went to bed around 8 p.m., but would usually come out to sit in a chair in the family room if he didn't stay in bed. Review of a current facility policy, titled Fall Investigation and Risk Evaluation, revised 2/19 and provided by the Nurse Consultant on 10/29/19 at 1:41 p.m., indicated the following: .It is the policy of this facility to provide an environment that is free from accident hazards over which the facility has control and provides supervision and assisted devices to prevent avoidable accidents .All residents will have a care plan developed that includes the resident's complications and risks, an attainable and measurable goal, and individualized interventions to decrease their risk of falls .Procedure .8. Update the care plan with new intervention in the fall care (plan). 9. The Interdisciplinary Team will review the fall and determine the root cause to the extent possible. 10. Update the care plan with new intervention(s) as indicated 3.1-45(a)(2)

Based on observation, interview, and record review, the facility failed to ensure respiratory equipment was maintained for 1 of 2 residents reviewed, who were receiving respiratory services (Resident 49). Findings include: During an interview, on 10/23/19 at 2:15 p.m., Resident 49 was in bed, wearing a nasal cannula, connected to an oxygen concentrator. He indicated the facility staff changed his oxygen tubing regularly, but he didn't know about the oxygen machine itself. Observation of the filter on the back of the concentrator indicated it was covered with a dried, gray debris. On 10/25/19 at 9:26 a.m., the resident was in his room in bed, wearing a nasal cannula, connected to an oxygen concentrator. Observation of the filter on the back of the concentrator indicated it was covered with a dried, gray debris. On 10/28/19 at 1:38 p.m., he was in his room in bed, wearing a nasal cannula, connected to an oxygen concentrator. Observation of the filter on the back of the concentrator indicated it was covered with a dried, gray debris. Review of Resident 49's clinical record was completed on 10/25/19 at 9:32 a.m. [DIAGNOSES REDACTED]. His current orders included, but were not limited to, may wear oxygen at 2 liters per minute, per nasal cannula, to maintain saturation greater than 90%. He had a current, 7/21/16, care plan problem of potential for shortness of breath related to chronic [MEDICAL CONDITION]. During an interview, and observation of the oxygen concentrator filter, on 10/28/19 at 1:41 p.m., LPN 36 indicated the filter was covered with gray debris and it needed to be cleaned. During an interview, on 10/28/19 at 1:49 p.m., the DON indicated the company who serviced the concentrators was to clean the filters. 3.1-47(a)(6)

Based on observation, record review, and interview, the facility failed to ensure a residents anti-psychotic medication was not increased without adequate indication, for 1 of 5 residents reviewed for unnecessary medication use (Resident 54). Findings include: During an observation, on 10/23/18 at 9:33 a.m., Resident 54 participated in an activity of singing hymns. On 10/23/19 at 9:36 a.m., the resident indicated she wasn't going to sing anymore and handed the hymnal to the activity assistant. The activity assistant handed her a baby-doll to hold. On 10/29/19 at 9:00 a.m., she was sitting in a wheel-chair at a table in the activity/dining room area. She was holding onto a baby-doll with her eyes closed. The resident's clinical record was reviewed, on 10/25/19 at 10:21 a.m. [DIAGNOSES REDACTED]. Current physician orders [REDACTED]. a. [MEDICATION NAME] (antidepressant), 100 mg, one tablet once a day for depression, order date 9/28/18. b. Trazadone (antidepressant), 25 mg, daily at bedtime, for [MEDICAL CONDITION], order date 2/5/19. c. [MEDICATION NAME] (antianxiety), 0.5 mg, one tablet two times a day for anxiety, order date 7/25/19. d. [MEDICATION NAME] (antipsychotic), 1.0 milligram (mg), one tablet two times a day for other [MEDICAL CONDITION] not due to a substance or known physiological condition, order date 8/19/19. An 10/4/19, annual, Minimum Data Set assessment indicated the resident had moderate cognitive impairment. She had received an antipsychotic, anxiety, and antidepressant every day during the assessment period. Her current care plans, included, but were not limited to, the following: A 9/28/18 care plan for anxiety, as evidenced by repetitive verbalization and restlessness. Interventions included, but were not limited to, diversional activities such as caring for her doll, medications as ordered, and allow me to ventilate my anxiety when needed. A 9/28/18 care plan for depression, as evidenced by chronic pain, cognitive decline, long history of depression or other mental illness, and feeling tired. Interventions included, but were not limited to, encouraged to actively participate in activities of her choosing, medications as ordered, and participate in mental health services as ordered/needed. A 9/28/18 care plan for difficulty with sleeping, related to [MEDICAL CONDITION] (difficulty falling asleep and staying asleep). Interventions included, but were not limited to, encouraged to not consume caffeine and sugary products after evening meal, encouraged to refrain from napping during the day, offered mental health services as needed, medications as ordered, and offered non-pharmacological interventions such as a back rub, warm drinks, soft music or tones, re-positioning, decreased stimuli, and a comfortable environment. An 10/5/18 care plan for behavioral symptoms, such as cursing, yelling/screaming, resistance to care, and spitting out medication, cognitive deficit, repetitive yelling/screaming, verbal aggression, and physical aggression. Interventions included, but were not limited to, diversional activity, such as music, trivia, and reminiscing, explain to me that my behavior was not appropriate, if chosen not to have care, come back at a later time and re-approach me, medications as ordered, and mental health services as indicated. An 8/13/19 care plan for risk of side effects, related to the use of antianxiety medications, antidepressants, and antipsychotics. Interventions included, but were not limited to, medications as ordered, observed for adverse side effects related to my need for antianxiety medications including, nausea, nervousness or restlessness, dizziness, drowsiness, [MEDICAL CONDITION], weight gain or loss, headache, dry mouth. vomiting, and diarrhea, observed for adverse side effects related to the need for an antidepressant medication including, nausea, increased appetite and weight gain, fatigue and drowsiness, [MEDICAL CONDITION], dry mouth, blurred vision, constipation, dizziness, agitation, irritability, and anxiety, observed for adverse side effects related to the need for antipsychotic medication to treat the resident's mental health including, stiffness and shakiness, uncomfortable restlessness (akathisia), movements of the jaw, lips, and tongue (tardive dyskinesia), sleepiness and slowness, weight gain, constipation, dry mouth, and blurred vision, use of [MEDICAL CONDITION] medications would be reviewed quarterly by a pharmacist and the interdisciplinary team to ensure the need for continued use and the appropriateness for a gradual dose reduction (GDR). A review of Behavior Management Team Reviews, psychopharmacological medication changes, and behavior trackers included, but were not limited to, the following: On 7/10/19 the behavioral occurrences were summarized as cursing, yelling/screaming, repetitive verbalization and questions, and wandering. There had been two occurrences in the past 30 days. The psychopharmacological medications reviewed included, [MEDICATION NAME], and [MEDICATION NAME]. Reductions/increases, side effects, or failures of changes indicated no changes since last review. Recommendations included, approach her from the front and make sure you have her attention, use diversional activity such as music, trivia, and reminiscing, reassure/comfort when needed to calm her down, remove from stimuli when indicated, when behavior disrupted a social setting, remove if unable to be redirected. On 8/12/19 the behavioral occurrences were summarized as no mood state or behaviors since last review. The psychopharmacological medications reviewed included, [MEDICATION NAME], and [MEDICATION NAME]. Reductions/increases, side effects, or failures of changes indicated no changes since last review. Recommendations included, continue to observe for 90 days and discontinue should mood state and behaviors remain stable. An 8/19/19 nurse progress note indicated an order had been received to discontinue [MEDICATION NAME] 0.25 mg at 2:00 p.m. and 0.5 mg at bedtime, start [MEDICATION NAME] 1.0 mg twice a day. An 8/19/19 psychiatry progress note indicated the resident continued with psychotic symptoms and seemed to have escalated, [MEDICATION NAME] dose was increased with anticipation of stabilizing her mood and discontinuing benzodiazepine (antianxiety) at next visit. Review of a behavior tracker for (MONTH) 2019 indicated, an occurrence of grabbing on 8/5/19, an occurrence of abusive language on 8/14/19, an occurrence of yelling/screaming on 8/19 and 8/20/19, an occurrence of kicking/hitting on 8/21, 8/29, and 8/30/19. An Interdisciplinary Psychopharmacological Review, dated 10/28/19, indicated the reason for [MEDICATION NAME] was due to her yelling help repetitively. During an interview, on 10/29/19 at 11:46 a.m., the Social Services Director indicated the resident yelling out help me mother, help me, was the [MEDICAL CONDITION] behavior the resident exhibited, this behavior had increased in (MONTH) and the [MEDICATION NAME] dose had been increased. A current facility policy, titled PSYCHOACTIVE MEDICATIONS/GRADUAL DOSE REDUCTION POLICY, with a revised date of 5/18 and provided by the Nurse Consultant on 10/29/19 at 3:08 p.m., indicated .To ensure the resident is receiving the necessary medication at the lowest effective dose with an appropriate diagnosis . 3.1-48(a)(4)

Based on observation, interview and record review, the facility failed to ensure medications were properly labeled and dated, expired and discharged residents medications were disposed of for 1 of 3 medication storage rooms observed (100 hall medication room). Findings include: During an observation of the 100 hall medication room, on [DATE] at 11:04 a.m., accompanied by LPN 77, a cabinet contained, but was not limited to, the following: a. A clear storage bag contained an opened package of [MEDICATION NAME] and [MEDICATION NAME] (inhalant) and two closed packages with no date opened or resident identifiers on them. LPN 77 indicated they should have a name and an open date on them. b. A vial of [MEDICATION NAME] (antibiotic), belonging to a resident who had discharged from the facility, on [DATE]. LPN 77 indicated the resident had discharged and the medication should have been destroyed. c. Two pill packets, contained one [MEDICATION NAME] (muscle relaxant) pill, belonging to a resident who had been discharged from the facility, on [DATE]. LPN 77 indicated the resident had discharged and the medication should have been destroyed. d. A pill packet contained a tab-a-vite (multivitamin) pill, with no resident identifier on it. LPN 77 indicated it could have came from the Emergency Drug Kit (EDK). e. A pill packet contained an [MEDICATION NAME] (pain reliever) , with no resident identifier on it. LPN 77 indicated it could have came from the Emergency Drug Kit (EDK). f. A pill packet contained an losartan potassium (blood pressure), with no resident identifier on it. LPN 77 indicated it could have came from the Emergency Drug Kit (EDK). g. Opened bottles of vitamin C, cranberry, allergy relief and calcium and vitamin D, with no resident identifier on them. LPN 77 indicated she did not know who they belong to and would normally have a residents name on them h. A bottle of atrovastatin (cholesterol), [MEDICATION NAME] (blood pressure), eliquis (blood thinner), aspirin (pain reliever) and a box of artificial tears, belonging to a resident, who expired on [DATE]. LPN 77 indicated the resident expired and the family was supposed to come to the facility to pick up the medication, they should have been destroyed. i. A bottle of [MEDICATION NAME] (antifungal) powder, belonging to a resident who discharged from the facility on [DATE]. LPN 77 indicated the resident was not at the facility anymore and the medication should had been destroyed. j. A clear storage bag contained two unused [MEDICATION NAME] (pain reliever) vials. LPN 77 indicated they should have been sent back to the pharmacy. A drawer in the medication room, contained two open [MEDICATION NAME] (hcl) vials loosely in the drawer. LPN 77 indicated she did not know who they belonged to, they probably came from the EDK and would not normally keep them in the drawer. A current facility policy, titled GUIDELINES FOR MEDICATION STORAGE AND LABELING, revised ,[DATE] and provided by the Nurse Consultant, on [DATE] at 2:29 p.m., indicated the following: .General Guidelines: .7. Medications and biologicals are labeled in accordance with currently accepted professional principles, and include: .a. Although medication delivery and labeling systems may vary, the medication label at a minimum includes the medication name (generic and/or brand), prescribed dose, strength, the expiration date when applicable, the resident's name, and route of administration .9. Multi-dose vials that have been opened or accessed (e.g., needle-punctured) should be dated when the vial is first accessed and discarded within 28 days unless the manufacturer specifies a different (shorter or longer) date for that opened vial 3XXX,[DATE](j) 3XXX,[DATE](k)(1) 3XXX,[DATE](p) 3XXX,[DATE](q)

Based on observation and interview, the facility failed to ensure residents personal care items were stored correctly for 1 of 3 showers reviewed (Maple Lane). Findings include: During an observation of the shower room, on Maple Lane, accompanied by CNA 57, on 10/23/19 at 2:41 p.m., an unlocked cabinet contained, but was not limited to, the following: a. Three partially used barrier creams with no resident identifiers on them. b. One partially used silicone cream with no resident identifier on it. c. One partially used solid antiperspirant with no resident identifier on it. d. One partially used mouthwash with no resident identifier on it. e. One partially used spray antiperspirant with no resident identifier on it. f. One partially used bottle of moisturizer cream with no resident identifier on it. g. One partially used bottle of shampoo/body wash with no resident identifier on it. CNA 57 indicated they used the items for residents who did not have them and they used gloves when they shared the cream between the residents. They would normally bring the resident's baskets in the shower room when giving a resident a shower and the items would have their name on it. On 10/28/19 at 11:45 a.m., the Nurse Consultant indicated there was not a policy for co-horting. 3.1-18(a)

Based on observation, interview, and record review facility failed to transfer a resident with a mechanical lift and assistance of two staff members for 1 of 1 residents reviewed for accidents (Resident 45). This deficient practice resulted in Resident 45 sustaining a fractured humerus to her left arm. Findings include: During an observation on 10/30/18 1:56 p.m., the Resident 45 was sitting in her room in her Broda chair (high back wheelchair), a purple bruise was on resident's forehead near her hair line. During an observation and interview on 11/01/18 at 1:16 p.m., CNA 13 was alone in the resident's room, the resident was lying on her left side in bed and was uncovered, the hoyer lift was sitting away from the bed, CNA 13 indicated CNA 16 had just been in the room and assisted her with putting the resident in bed and had just stepped out. During an interview with CNA 16 on 11/01/18 at 1:20 p.m., she indicated she did not assist CNA 13 in putting Resident 45 to bed and she had been in another resident's room during that time. The clinical record was reviewed on 10/30/18 at 1:46 p.m. for Resident 45. [DIAGNOSES REDACTED]., unspecified. An annual MDS (minimum data set), dated 9/7/18, indicated the resident required assistance of two staff members and was totally dependent with transfers. A careplan, revised on 4/4/17, indicated she required a mechanical lift and assist of two staff for transfers. A nurses note, dated 9/14/2018 at 6:25 a.m., indicated an agency CNA was transferring the resident without a hoyer lift and was assisted to the floor in the resident's room, resident was guarding left arm and appeared to be twisted inward. A late entry, fall IDT (interdisplinary team) note, dated 9/14/18 at 9:40 a.m., indicated the resident was lowered to the ground by the CNA due to an inappropriate transfer technique. A nurses note, dated 9/14/2018 at 10:33 a.m., indicated a new order was received to send the resident to a local hospital for evaluation and treatment due to left shoulder. A nurses note, dated 9/14/2018 at 1:24 p.m., indicated the daughter was notified of staff having heard a 'pop' while transferring the resident. The resident had been seen by a nurse practitioner and a registered nurse from hospice and was sent to the hospital for an x-ray and she was found to have a fractured humerus. A nurses note, dated 9/14/2018 at 1:37 p.m., indicated the resident was returning to facility with a fractured humerus, a sling was placed to left arm for stability and hospice was to provide pain management. An x-ray report from the emergency room , dated 9/14/18, indicated the impression from x-ray to left shoulder was a minimally displaced proximal left humeral fracture and osteopenia (bone loss). A nurses note, dated 10/28/2018 at 9:50 a.m., indicated resident was injured in the resident's room at 7:41 a.m. with a bruise to top of forehead/scalp from staff removing resident from the hoyer lift. During an interview with the Nurse Consultant, ADON and DON, on 11/05/18 at 10:34 a.m., the Nurse Consultant was reviewing the investigation report and indicated the agency CNA lifted the resident with a hug and did not see a sling in her room and was not aware of how she was to be transferred, she had worked with the resident before but had never gotten her up. A policy titled Transfer/Positioning Total Mechanical Lift revised 10/18, provided by the DON on 11/5/18 at 11:22 a.m., indicated the mechanical lift was to be completed with two staff members. 3.1-45(a)

Based on observation, interview, and record review, the facility failed to ensure medications and biologicals were stored securely for 2 of 5 medication carts and 1 of 3 medication rooms during random observations of medication storage (Oak Lane and Birch Lane medication carts and Maple Lane medication room and treatment cart). Findings include: During a random observation, on 10/31/18 at 10:29 a.m., a medication cart was unlocked and unattended on Oak Lane. At 10:32 a.m., LPN 31 approached the Oak Lane nurses station. At 10:33 a.m., the Housekeeping Supervisor walked by the cart and down the hallway. During an interview, on 10/31/18 at 10:35 a.m., LPN 31 indicated the cart should have been locked and the cart stored medications for 16 residents. During a random observation, on 11/1/18 at 9:57 a.m., the door to the Maple Lane medication room was observed to be ajar and unattended. During an interview, on 11/1/18 at 9:58 a.m., the ADON indicated the hospital phlebotomist had just left the room with her cart. During an observation of the room, accompanied by the ADON at the time of the interview, the room contained, but was not limited to, various needles, phlebotomy and intravenous supplies, and syringes. An unlocked treatment cart, was observed in the room containing, but not limited to, various skin and wound medications. The ADON indicated the cart stored skin treatments for residents on the 100 Hall and should be kept locked. During a random observation, on 11/1/18 at 10:51 a.m., the Birch Lane medication cart was unlocked and unattended. During an interview at the time of the observation, RN 32 indicated the cart should be kept locked. During an observation of the medication cart, accompanied by the DON, three loose pills (two tabs and one capsule) were in the second drawer. During the same observation, QMA 33 indicated the pills must have fallen out of a package that had torn. Two medication cups were observed in a drawer; one cup contained one pill and the other contained nine pills. There were no resident identifiers on either cup. QMA 33 indicated they belonged to Resident 36, since and he hadn't wanted them during the previous medication pass and wanted to wait until later in the day to take them. She indicated she should have marked the cups with identifiers. Review of a current facility policy, titled Guidelines for the Storing of Medications, updated (MONTH) (YEAR) and provided by the Nurse Consultant and DON on 10/31/18 at 10:45 a.m., indicated compartments containing medications are locked when not in use and trays or carts used to transport such items are not left unattended. 3.1-25(m)

Based on interview and record review, the facility failed to develop and implement an initial careplan for the behavior and/or action of picking at the site of an arteriovenous fistula for 1 of 4 residents reviewed for care plans. (Resident B) Findings include: The closed clinical record for Resident B was reviewed on 10/12/18 at 8:55 a.m. [DIAGNOSES REDACTED]. The most recent 60-day Minimum Data Set (MDS) assessment, dated 9/27/18, indicated the resident was cognitively intact. A current health care plan, dated 8/1/18, indicated the resident was at risk for bleeding related to anticoagulant use. Interventions included, but were not limited to, obtain laboratory blood draws as ordered and administer medications as ordered. The clinical record lacked a care plan for scratching or itching her fistula site. A progress note, dated 9/11/18 at 8:00 a.m., indicated a staff person was called to the room and found active bleeding with a large amount of blood from the fistula site. Pressure was applied to the site and 911 was called to transport the resident to the emergency room . A physician visit, dated 9/11/18, indicated the resident was seen for an acute visit. Upon entering the room on 9/11/18, the resident was seated on the side of her bed and noted to have blood splattered on the front of her on her legs on both arms, blood noted on the floor and the furniture. The resident reported that she had an itch over her fistula site and scratched off the scab and the site began to bleed profusely. She was sent to the emergency room . A progress note, dated 9/22/18 at 9:49 a.m., indicated the resident was sent to the emergency room after scrubbing fistula site. She returned the same day with a dressing in place over the fistula. A physician visit, dated 9/24/18, indicated the resident was seen for an acute visit for a follow up from an emergency room visit over the weekend. The assessment and plan indicated the resident was seen at the emergency roiagnom on [DATE] after bleeding from the fistula site. The resident was educated on the importance of not picking the scabs. A progress note, dated 10/8/18 at 2:15 a.m., a nurse was called to the hallway because the resident was noted to have bleeding from the fistula site. She was sent to the emergency room and returned to the facility the same day. A late entry progress note, dated 10/9/18 at 9:46 p.m., indicated a staff member entered the resident's room and found her slumped over to the right and blood appearing to originate from left arm at fistula site. A gross amount of blood was noted on the clothing, wheelchair and floor. The resident had no respirations, no radial or apical pulse. She was unresponsive to verbal or tactile stimulation. A second nurse arrived to verify the findings. During an interview on 10/12/18 at 1:58 p.m., the nurse practitioner indicated she was in the facility the first time the resident picked her arm. She was sent to the local hospital then onto a larger hospital because she was on [MEDICAL TREATMENT]. She indicated the resident had said her arm had itched and she scratched it. She saw the resident the following day and the resident admitted to picking at the site. On 10/8/18, she again picked at the site and was sent to the emergency room . On 10/9/18, the resident returned from [MEDICAL TREATMENT] and again picked at the site. During a telephone interview on 10/12/18 at 2:07 p.m., the Social Service Director indicated the resident often scratched the fistula site because it itched. She had spoken to the [MEDICAL TREATMENT] center on 10/11/18 after the family had called her. Following [MEDICAL TREATMENT] on 10/9/18, they placed a clamp over the fistula site to apply pressure and the resident removed the clamp. She thought the nurse practitioner had talked to the resident about not picking the fistula, but she was unsure if she had a care plan for the fistula and/or picking at the site. During a telephone interview on 10/12/18 at 2:20 p.m., the attending physician indicated the resident had a long history of non-compliance. He indicated the cause of death was end stage [MEDICAL CONDITION]. No further information was provided prior to the time of exit. This Federal tag relates to Complaint IN 265. 3.1-30(a)

Based on interview and record review, the facility failed to act upon grievances voiced by residents during resident council meetings related to lack of staffing and poor food quality for 4 of 5 resident council metings reviewed (March, Aprl, May, June). Findings include: During an interview on 7/17/18 at 10:59 a.m., the Resident Council President gave permission to review the minutes. Review of the resident council Meeting minutes indicated the following: a. On 3/12/18, residents indicated staff was using their cell phones while working, as well as, not knocking on doors prior to entering. Another resident indicated the hamburger are cold. A nursing recommendation response, indicated an in-service would be done at the next all staff meeting. A dietary recommendation response, indicated the Dietary Manager (DM) spoke with the cooks regarding hamburgers be wrapped in foil prior to serving. b. On 4/9/18, indicated old business was discussed related to the facility serving cold hamburgers and staff not knocking on doors prior to entering. New business included, but was not limited to, water pitchers not being filled and Certified Nursing Assistants (CNA) were spending a lot of time outside on break and standing at the nurses' station. A nursing recommendation response, indicated it was discussed at the CNA meeting about passing water and taking long breaks. A dietary recommendation response, indicated the DM spoke with the cooks regarding hamburgers be wrapped in foil prior to serving. Review of a dietary in-service, dated 4/10/18, the following recommendation forms were attached from the Resident Council Meetings: March 12, (YEAR) April 9, (YEAR) May 7, (YEAR) The form was signed by six employees. c. On 5/9/18, residents indicated call lights were not being answered on third shift and new staff were not being trained to leave the call light on until the need was taken care of. The residents also companioned the hot ham and cheese sandwich were cold and the potatoes were hard and inedible. A nursing recommendation response, indicated an in-service would be provided on 6/5/18 for all staff. An all-staff inservice, dated 6/5/18, indicated the staff were educated on the facility smoking policy, knock prior to entering a resident's room, reporting abuse A dietary recommendation response, indicated the DM spoke with the night time cook regarding making a substitute if the food was overcooked. d. On 6/11/18, residents indicated they needed to have more CNA's on the front hall. The residents also complained the broccoli soup was mush and the tomato soup was cold. A nursing recommendation response, indicated the facility had posted an open position for 6:00 p.m. through 10:00 p.m. to help with night time care. No additional information was provided. A dietary recommendation response, indicated the DM spoke with the night time cook to check temperatures and to be consistent with the soup. On 7/17/18 at 2:31 p.m., the Administrator indicated he did not have any additional audits or in-services related to the complaints about food or staffing. On 7/17/18 at 4:50 p.m., the Administrator provided a complete list of employees that totaled 105. On 7/17/18 at 5:00 p.m., the Administrator indicated all staff had were not in-serviced on 6/5/18 and 7/3/18. An undated facility policy, titled Resident Rights, provided by Registered Nurse 1 on 7/17/18 at 3:45 p.m., indicated the following: .Voice complainants or grievances without fear of retaliation Be free from verbal, physical, sexual, and mental abuse; corporal punishment; neglect; and involuntary This Federal tag relates to Complaint IN 072. 3.1-3(k)

Based on observation, interview and record review the facility failed to prevent the development of a pressure ulcer for 1 of 1 residents reviewed for pressure ulcers (Resident #21). Findings include: On 9/28/2016 at 7:19 a.m., Resident #21 was in bed covered by a blanket. The clinical record was reviewed on 09/26/2016 03:26 PM. [DIAGNOSES REDACTED]. The most current Minimum Data Set (MDS), dated [DATE], indicated her cognitive status was unassessable. The MDS indicated the resident required the extensive assistance of two people for bed mobility, walking, toilet use and that she used a wheel chair. There was no pressure ulcer noted on the MDS. There was a current physician order [REDACTED]. The clinical record indicated a left heel pressure ulcer was first observed on 9/21/2016 and measured 2.0 cm (centimeters) x 0.6 cm x 0 cm with thin black eschar (a dry, darkened scab). During a wound care observation, on 9/28/2016 at 9:17 a.m., the Wound Nurse measured the wound to be 1.5 cm x .5 cm x 0 cm. She described the wound as having a black covering. During a wound care observation on 9/29/2016 at 2:40 p.m., the Wound Nurse completed the treatment for [REDACTED]. During an interview with LPN #43, on 09/27/2016 10:10 a.m., she indicated Resident #21 had an unstageable pressure ulcer on the back of her left heel. She indicated the pressure developed in the facility and was caused by wearing shoes. During an interview with Wound Nurse on 9/28/2016 at 9:37 a.m., she indicated PRN (as needed) RN #44 noticed the wound on 9/21/2016 and notified her right away. The Wound Nurse indicated she came into the facility and assessed it immediately. Wound Nurse indicated RN #44 worked PRN at the facility, but was also a wound nurse in a wound clinic. The Wound Nurse indicated Resident #21 was no longer wearing her shoes at this time due to the wound. During an interview with the Wound Nurse on 09/28/2016 at 10:05 a.m., she indicated Resident #21 walks and has all feeling in her lower extremities. She indicated she had inspected her shoes and found equal wearing, had vein stripping in 1975 causing poor perfusion, and her toes were warm and pink on inspection and her doctor was ordering an ABI (a circulation test) that day. The Wound Nurse indicated the pressure ulcer was caused by her [DIAGNOSES REDACTED]. She indicated the resident makes frequent movements, and physical therapy started seeing her due to unsteady gait. The physician ordered skin prep daily and blue boots when she was in bed. The Wound Nurse indicated she implemented the composure mattress for all heel pressure ulcers. During an interview with the Nurse Consultant on 9/28/2016 at 10:27 a.m., she indicated Promod (protein supplement) was ordered for Resident #21 on 9/23/2016, for wound care. There were no other dietary interventions. During an interview with the Wound Nurse on 9/28/2016 at 10:29 a.m., she indicated the resident always had a potential for development of pressure due to her [DIAGNOSES REDACTED]. She was referred to the dietician, received incontinence care, barrier cream, reminded to turn and reposition, and the staff observed skin weekly as preventative pressure ulcer interventions. The Wound Nurse indicated the CNAs were well educated on skin inspection. During an interview, with Physical Therapist (PT) #45 on 9/28/2016 at 1:20 p.m., she indicated the resident had been going to physical therapy three times per week for about three weeks. Her PT goal was to safely walk as desired in the facility. During an interview, with CNA # 46 on 9/29/2016 at 8:32 a.m., she indicated they began to off load her feet by putting them up with pillows in the recliner and placing her blue boots on then she was in bed. CNA #46 indicated the staff could have been doing a lot more to prevent the pressure ulcer on her heel and if they had the pressure would not have happened. CNA #46 indicated she felt the pressure developed from her heels laying on mattress while in bed. During an interview with CNA #47 on 9/29/2016 at 8:38 a.m., she indicated she felt the pressure ulcer on Resident #21's heel was caused by rubbing her heels on mattress when she moved around in bed. During an interview, with the Nurse Consultant on 9/30/2016 at 9:10 a.m., she indicated prior to the development of the pressure ulcer, there were no interventions implemented because she was ambulatory. The Nurse Consultant indicated she had had a decline in the past few weeks, but was still independently mobile. During an interview, with the Nurse Consultant on 9/30/2016 at 9:45 a.m., she indicated Therapy was notified and they started treatment when the staff noticed she was having difficulty with transfers. During an interview, with RN #44 on 9/30/2016 at 11:27 a.m., she indicated she worked at the facility PRN. RN #44 indicated she was getting her ready for bed when she noticed the pressure ulcer on Resident #21's left heel. RN #44 indicated it was a habit of hers to look at the heels of residents who were not as mobile as others, and she was not as mobile as usual. During an interview, with the Wound Nurse on 9/30/2016 at 11:33 a.m., she indicated the resident had a Braden Scale score of 15, which identified her as being at risk for pressure ulcers. She indicated she was on a check and change program and had a pressure reducing mattress. The Wound Nurse indicated the resident was still able to sit herself up on the side of the bed. A current care plan indicated, I have impaired circulation related to dependent [MEDICAL CONDITION], [DIAGNOSES REDACTED]. A current care plan indicated, I am at risk for developing Pressure ulcers related to one or more [DIAGNOSES REDACTED].e. [MEDICAL CONDITIONS] Arthritis and Dementia. Interventions included, but were not limited to, pressure reducing mattress, referred to dietary as needed, protein supplements as ordered, and weekly skin observations. A current care plan indicated, I have an unstageable pressure ulcer related to necrotic tissue covering wound. The care plan was initiated on 9/21/2016. Interventions included, but were not limited to, Blue Heel off boots when in bed, composure mattress, protein supplements as ordered, and slip socks on when up Lab work, completed on 8/10/2016, indicated her Hemoglobin was 10.7 G/dl (normal range 12-16). The TLC Weekly Skin Observation, dated 8/29/2016, indicated she had Bilateral Lower Extremity [MEDICAL CONDITION] (swelling). The TLC Weekly Skin Observation, dated 9/5/2016, indicated she had Bilateral Lower Extremity [MEDICAL CONDITION] (swelling). The TLC Weekly Skin Observation, dated 9/12/2016, indicated she had Bilateral Lower Extremity [MEDICAL CONDITION] (swelling). The TLC Weekly Skin Observation, dated 9/12/2016, indicated she had Bilateral Lower Extremity [MEDICAL CONDITION] (swelling). The Initial Pressure Report, dated 9/21/2016, indicated the pressure area on left heel was unstageable and measured 2.0 cm x 0.6 cm x 0 cm The EVALUATION OF PRESSURE ULCER AVOIDABILITY, dated 9/21/2016, was provided by the Wound Nurse on 9/30/2016 at 11:50 a.m., indicated 2 risk factors- severe [MEDICAL CONDITION] and Chronic or end stage [MEDICAL CONDITION], HGB (hemoglobin) below 12 mg, and was marked as unavoidable. The Physical Therapy Treatment Encounter Notes, dated 9/20/2016, were provided by the Nurse Consultant on 9/30/2016 at 9:45 a.m., and indicated Pt. (patient) requires constant verbal, tactile and visual cues to perform sit to stand. The Nurse Consultant indicated this was the date therapy started working with her. The Wound Prevention Protocol, provided by the Director of Nursing on 9/30/2016 at 10:30 a.m., indicated the following: Purpose: .2. Relieve or remove pressure. To prevent tissue trauma .Policy: .Resident specific interventions will be care planned 3.1-40 (a)(1)