Every finding on record at Rosewalk Village at Lafayette

Based on observation, interview and record review, the facility failed to ensure a resident was assessed to self-administer medications for 1 of 1 resident randomly reviewed for self-medication administration. (Resident 109) Findings include:During an observation, on 2/24/26 at 12:41 p.m., a clear plastic medicine cup, containing a white oblong pill, was observed on Resident 109's bedside table.During an observation and interview, on 2/24/26 at 12:55 p.m., the Director of Nursing (DON) entered Resident 109's room and removed the cup with the pill in it from the bedside table. The DON indicated the cup with the pill should not have been left at the bedside table.The clinical record for Resident 109 was reviewed on 2/26/26 at 10:35 a.m. The diagnoses included, but were not limited to, type 2 diabetes mellitus with diabetic neuropathy, chronic pain, pain in the left and right knee, abnormal posture, and muscle weakness.A physician's order, dated 9/16/25, indicated to administer hydrocodone-acetaminophen 7.5/325 milligrams every four hours.A care plan, dated 1/28/26, indicated the resident had chronic pain and bilateral knee pain. Interventions included, but were not limited to, administer medications as ordered.The clinical record did not contain a physician's order, a self-medication administration assessment, or a care plan for Resident 109 to self-administer medications.During an interview, on 3/3/26 at 10:09 a.m., the Assistant Director of Nursing (ADON) indicated Resident 109 did not have a physician's order to self-administer medications. The medication cup with the pill in it should not have been left in the room on the bedside table.During an interview, on 3/3/26 at 10:15 a.m., Registered Nurse (RN) 4 indicated the staff administering the medication must stay in the room and observe all medications were taken by the resident. If medications were left at bedside, the resident must have an order.During an interview, on 3/3/26 at 10:16 a.m., the DON indicated Resident 109 did not have an order to self-administer medications and the cup with the pill should not have been left in the room on the bedside table.During an interview, on 3/3/26 10:26 a.m., RN 3 indicated staff must observe a resident taking all medications before walking away from the resident. Medicine should not be left at bedside.During an interview, on 3/3/26 10:28 a.m., RN 5 indicated medications should not be left at bedside and staff should watch the residents take the medication.A current facility policy, titled General Dose Preparation and Medication Administration, dated as last revised November 2024 and received from the ED on 3/3/26 at 9:37 a.m., indicated .During medication administration, facility staff should take all measures required by facility policy and applicable law, including, but not limited to the following.Observe the resident's consumption of the medication(s).A current facility policy, titled Self-Administration of Medications, dated as last revised January 2015 and received from the ED on 3/3/26 at 10:19 a.m., indicated .A physician order will be obtained specifying the resident's ability to self-administer medications and, if necessary, listing which medications will be included in the self-administration plan. 410 IAC (Indiana Administrative Code) 16.2-3.1-11(a)

Based on interview and record review, the facility failed to ensure a physician's order to hold medications was followed according to the parameters for 1 of 3 residents reviewed for quality of care. (Resident 29)Findings include:The clinical record for Resident 29 was reviewed on 2/26/26 at 11:59 a.m. The diagnoses included, but were not limited to, Alzheimer's disease, vascular dementia with psychotic disturbance, psychotic disorder with delusions, adjustment disorder with anxiety, muscle weakness, and hypotension.A care plan, dated 8/7/25, indicated Resident 29 was at risk for fluid imbalance due to blood pressure issues. Interventions included, but were not limited to, administer medications as ordered.A physician's order, dated 9/13/25, indicated to administer 5 milligrams (mg) of midodrine (a medication used to treat low blood pressure) every morning and to hold the medication for a systolic blood pressure (SBP) greater than 130.The Medication Administration Record (MAR), dated 12/1/25 through 12/31/25, indicated midodrine was administered outside of the hold parameters on 12/13/25, with a systolic blood pressure of 155, and on 12/16/25 with a systolic blood pressure of 135.The MAR, dated 1/1/26 through 1/31/26, indicated midodrine was administered outside of the hold parameters on 1/8/26, with a systolic blood pressure of 138, and on 1/30/26 with a systolic blood pressure of 137.The MAR, dated 2/1/26 through 2/26/26, indicated midodrine was administered outside of the hold parameters on 2/22/26, with a systolic blood pressure of 153.During an interview, on 3/3/26 at 11:13 a.m., Licensed Practical Nurse (LPN) 2 indicated if a medication was due and the blood pressure was outside of the parameters, the medication would be held and the doctor notified if needed. If a medication was held, the nurse's initials would be in parenthesis on the MAR to indicate it was held.During an interview, on 3/3/26 at 11:21 a.m., the Director of Nursing (DON) indicated a medication should not be administered outside of the hold parameters.During an interview, on 3/3/26 at 11:54 p.m., the Assistant Director of Nursing (ADON) indicated the facility did not have a policy specifically about medication parameters.A current facility policy, titled General Dose Preparation and Medication Administration, dated 12/1/07 and received by the Executive Director on 3/3/26 at 9:37 a.m., indicated .Prior to administration of medication, facility staff should take all measures required by facility policy and applicable law, including, but not limited to the following.if necessary, obtain vital signs.410 IAC (Indiana Administrative Code) 16.2-3.1-37(a)

Based on observation, interview and record review, the facility failed to ensure employee food and drinks were not stored in the kitchen, cardboard boxes were off the floor, and expired food was discarded. This deficient practice had the potential to affect 110 of 110 residents who received food from the kitchen. Findings include: During the kitchen observation, on [DATE] at 10:20 a.m., with the Executive Director (ED), the following were observed: a. The reach-in refrigerator contained two brown plastic grocery sacks containing employee lunches. b. The walk-in freezer had one large cardboard box containing a bag of frozen blueberries and one large cardboard box with two boxes stacked on top. The cardboard boxes were stored on the floor. c. The food preparation station had two half empty clear plastic waters bottles stored on the shelf in the food area. d. The food preparation refrigerator had a large clear container of diced ham with a use-by date of [DATE]. e. The food preparation station had four empty cardboard boxes on the floor under the food preparation sink. During an interview, on [DATE] at 10:28 a.m., the ED indicated the employees were not supposed to store their lunches in the refrigerator. During an interview, on [DATE] at 10:48 a.m., the ED indicated food, or cardboard boxes should not have been stored on the floor. During an interview, on [DATE] at 11:15 p.m., [NAME] 7 indicated staff should not have had their drinks or food in the kitchen. During an interview, on [DATE] at 12:19 p.m., the Dietary Manager (DM) indicated the cardboard boxes should not have been on the floor and nothing should have been stored on the floor. A current facility policy, titled Food Storage, dated as revised ,d+[DATE] and received from the ED on [DATE] at 3:31 p.m., indicated .Sufficient storage facilities are provided to keep food safe, wholesome, and appetizing. Food is stored at an appropriate temperature and by methods designed to prevent contamination .Food is stored a minimum of 6 above the floor and 18 below the sprinkler heads on clean racks or other clean surfaces and protected from contamination .Leftover prepared foods and processed meats such as lunchmeat, are to be stored in covered containers or wrapped securely. The food must clearly be labeled with the name of the product, the date it was prepared, and marked to indicate the date by which the food shall be consumed or discarded 3XXX,d+[DATE](i)(3)

Based on interview and record review, the facility failed to ensure care plan meetings were held with the resident and the resident's representative in a timely manner for 4 of 4 residents reviewed for care plan meetings. (Resident 9, 2, 3 and 16). This deficient practice was corrected on 3/21/25, prior to the start of the survey, and therefore was past noncompliance. Findings include: 1. The clinical record for Resident 9 was reviewed on 4/1/25 at 1:23 p.m. The diagnoses included, but were not limited to, Parkinson's disease, chronic obstructive pulmonary disease, dementia, diabetes mellitus, depressive disorder, muscle weakness, difficulty in walking, vitamin deficiency, and esophageal obstruction. The clinical record indicated care plan meetings for Resident 9 were held on 2/15/24, 3/19/24, 9/10/24, 11/14/24 and 2/13/25. The record did not indicate a care plan meeting for the second quarter between the dates of 3/19/24 and 9/10/24 was held. During an interview, on 4/4/25 at 12:26 p.m., the Executive Director (ED) indicated no care plan meeting was conducted during the period of 3/19/24 through 9/10/24. It had been identified, and a plan of correction was in place. During an interview, on 4/4/25 at 12:28 p.m., the Social Worker indicated a care plan meeting should have been completed during the second quarter for the period of 3/19/24 through 9/10/24. 52091 2. The clinical record for Resident 2 was reviewed on 4/2/25 at 9:23 a.m. The diagnoses included, but were not limited to, chronic obstructive pulmonary disease, diabetes, end stage renal disease, hypertension, depression, anxiety, bipolar, schizoaffective disorder, psychotic disorder with delusions, epilepsy, cerebrovascular accident, and pain. The clinical record indicated care plan meetings for Resident 2 were held on 3/1/24, 5/14/24, 9/18/24, and 3/14/25. The record did not indicate a care plan meeting for the fourth quarter between the dates of 9/18/24 and 3/14/25 was held. During an interview, on 4/4/25 at 12:09 p.m., the Executive Director (ED) indicated the care plan for the last quarter of 2024 was not completed. 49891 3. The clinical record for Resident 3 was reviewed on 4/2/25 at 11:00 a.m. The diagnoses included, but were not limited to, Alzheimer's disease, dementia with psychotic disturbance, psychotic disorder with delusions, moderate intellectual disabilities, asthma, major depressive disorder, anxiety disorder, and psychotic disorder with hallucinations. The clinical record indicated care plan meetings for Resident 3 were held on 3/22/24, 9/23/24, 12/3/24, and 2/17/25. The facility conducted a Minimum Data Set (MDS) assessment on 6/18/24. The record did not indicate a care plan meeting for the second quarter of 2024 during the months of April, May, or June was held. During an interview, on 4/3/25 at 11:04 a.m., the Social Services Director (SSD) indicated care plan meetings and reviews should occur on admission and quarterly with the long-term care Minimum Data Set (MDS) assessments. All meeting summaries were recorded in the electronic medical record in the observations section labeled Care Plan Summary. During an interview, on 4/3/25 at 3:32 p.m., the Director of Nursing (DON) indicated the family had been invited to a care plan meeting in May, but the family did not come. The facility did not conduct a care planning meeting for that quarter. 4. The clinical record for Resident 16 was reviewed on 4/1/25 at 2:39 p.m. The diagnoses included, but were not limited to, respiratory failure with hypoxia, chronic obstructive pulmonary disease, dementia with behavioral disturbance, type 2 diabetes, chronic kidney disease, congestive heart failure, post-traumatic stress disorder, major depressive disorder with psychotic symptoms, psychosis, and anxiety disorder. The clinical record indicated care plan meetings for Resident 16 were held on 2/15/24, 5/3/24, 10/17/24, and 3/11/25. The facility conducted a Minimum Data Set (MDS) assessment on 7/29/24. The record did not indicate a care plan meeting for the third quarter during the months of July through September was held. During an interview, on 4/3/25 at 3:34 p.m., the DON indicated the facility did not conduct a care plan review meeting for Resident 16 during the July, August, and September quarter. A current facility policy, titled IDT Comprehensive Care Plan Policy, dated 8/2023 and received from the DON on 4/3/25 at 2:15 p.m., indicated .Care plan problems, goals, and interventions must be reviewed and revised by the interdisciplinary team periodically and following completion of each MDS assessment The deficient practice was corrected by 3/21/25, after the facility implemented a systemic plan which included audits and conducting or scheduling care plan meetings for all residents who were missing care plan meetings for over 90 days. 3.1-35(d)(2)(B)

Based on interview and record review, the facility failed to ensure a preadmission screening and resident review (PASARR) was completed when an antipsychotic medication and mental health diagnosis was added for 1 of 1 resident reviewed for PASARR. (Resident 97) Findings include: The clinical record for Resident 97 was reviewed on 3/31/25 at 11:48 a.m. The diagnoses included, but were not limited to, anxiety disorder and depressive disorder. A PASARR, dated 11/20/24, indicated Resident 97 did not have any mental health diagnoses or mental health medications. A physician's order, dated 12/17/24, indicated to administer sertraline (an antidepressant medication) 50 milligram (mg) once a day. A physician's order, dated 2/17/25, indicated to administer clonazepam (an antianxiety medication) 0.25 mg at bedtime. During an interview, on 4/3/25 at 3:34 p.m., the Executive Director (ED) indicated Resident 97 did not have a new PASARR level I completed when the new medications or diagnoses were added. During an interview, on 4/4/25 at 12:26 p.m., the Social Service Director indicated the resident did not have a new PASARR level I completed when the psychotropic medications and mental health diagnoses were added. A new PASARR should have been completed. A current facility policy, titled PASARR Policy, dated 11/17 and received from the Executive Director on 4/3/25 at 3:36 p.m., indicated .It is the policy of this facility to ensure that .PASARR assessments are updated with significant changes in mental or physical status A current facility policy, titled Psychotropic Management, dated 9/24 and received from the Executive Director on 4/4/25 at 11:12 a.m., indicated .It is the policy of this facility to ensure that a resident's psychotropic medication regimen helps promote the resident's highest practicable mental, physical and psychosocial well-being with person centered intervention and assessment .These drugs included, but are not limited to .Anti-psychotic; Anti-depressant; Anti-anxiety 3.1-16(d)(1)(A) 3.1-16(d)(1)(B)

Based on observation, interview and record review, the facility failed to ensure a dependent resident was provided incontinence care in a timely manner for 1 of 1 dependent resident reviewed for activities of daily living (ADL) care. (Resident 39) Findings include: During an observation, on 3/30/25 at 1:03 p.m., Resident 39 was in the dining room sitting in a wheelchair. The resident was leaning to his left side and was sliding down in his seat. A strong bowel movement and urine odor came from the resident. The resident's sweatpants on the right side were pulled down and the resident had his hand in his pants. There was bowel movement all over his right hand. Certified Nursing Assistant (CNA) 2 entered the dining room, unlocked the wheelchair brakes, and took the resident to his room. During an interview, on 3/30/25 at 1:05 p.m., CNA 2 indicated Resident 39 was last checked/changed at 10:00 a.m. and residents were to be checked and changed every 2 hours. The clinical record for Resident 39 was reviewed on 4/2/25 at 10:48 a.m. The diagnoses included, but were not limited to, vascular dementia with behavioral disturbance, bipolar disorder, anxiety disorder, schizophrenia, psychotic disorder with delusions, conduct disorder, and cognitive communication deficit. A care plan, dated 2/21/23, indicated the resident required assistance with morning and evening care, nutrition, hydration, and elimination. A care plan, dated 2/22/23, indicated the resident required assistance with toileting due to incontinence. Interventions included, but were not limited to, assist with incontinence care as needed, check every 2 hours for incontinence, and document any abnormal findings and notify the physician. A care plan, dated 2/22/23, indicated the resident required assistance with activities of daily living which included bed mobility, transfers, eating, and toileting. Interventions included, but were not limited to, assistance with one staff for toileting and incontinent care. An annual Minimum Data Set (MDS) assessment, dated 12/12/24, indicated the resident was severely cognitively impaired. A quarterly MDS assessment, dated 4/8/24, indicated Resident 39 was dependent on staff for toileting hygiene, showers and baths, and personal hygiene. During an interview, on 3/30/25 at 1:13 p.m., CNA 3 indicated residents should be checked every 2 hours and changed if needed. Resident 39's brief had a very strong odor of urine and bowel movement. During an interview, on 4/3/25 at 4:03 p.m., Resident 39's family member indicated when he would visit the resident at mealtimes, the resident would have dried bowel movement on his hands. The staff did not wipe off the resident's hands before meals and he would eat with the dried bowel movement on them. The resident had been observed multiple times with dried bowel movement on his hands during meals. During an interview, on 4/4/25 at 10:41 a.m., CNA 4 indicated when residents were in the dining room, she would check and change the residents every hour. If a resident could not communicate, CNA 4 would take the resident to their room to check and change them every 2 hours. A Certified Nursing Assistant job description, dated 10/2014, indicated the CNA should maintain a homelike environment for the residents, protect and promote resident rights, and assist the person to maintain independence and control to the greatest extent possible. Promptly assist residents to the bathroom according to their toileting schedule or promptly bring a clean bedpan or urinal. Open, remove clothing in preparation, clean the resident if the resident was unable to clean self, adjust clothing, clean resident's and own hands. Change position of bedfast residents at least every two hours. A current facility policy, titled Bowel and Bladder Program, dated 5/2019 and received by the Executive Director on 3/31/25 at 3:31 p.m., indicated .If a resident is totally incontinent and unable to be placed on a toilet or bedpan, resident should be checked and changed every two hours 3.1-38(a)(2)(c) 3.1-38(a)(3)

Based on interview and record review, the facility failed to ensure insulin doses were not administered when the blood sugar readings were below the physician's ordered hold parameter for 1 of 2 residents reviewed for quality of care. (Resident 12) The deficient practice was corrected on 3/28/25, prior to the start of the survey, and therefore was past noncompliance. Findings include: The clinical record for Resident 12 was reviewed on 4/1/25 at 11:50 a.m. The diagnoses included, but were not limited to, type 2 diabetes mellitus with hyperglycemia, diabetic nephropathy, and chronic kidney disease. A physician's order, dated 11/21/24, indicated to give 35 units of Fiasp FlexTouch U-100 Insulin (a fast-acting insulin) three times a day with special instructions to hold for a blood sugar below 130. The Medication Administration Record (MAR), dated 12/1/24 through 12/31/24, indicated 35 units of Fiasp FlexTouch U-100 Insulin were administered on the following dates with a blood sugar below 130: On 12/1/24, with a blood sugar of 97. On 12/2/24, with a blood sugar of 112, 112, and 109. On 12/3/24, with a blood sugar of 116. On 12/4/24, with a blood sugar of 111. On 12/8/24, with a blood sugar of 121. On 12/9/24, with a blood sugar of 87. On 12/14/24, with a blood sugar of 91. On 12/17/24, with a blood sugar of 111. On 12/20/24, with a blood sugar of 117. On 12/21/24, with a blood sugar of 126. On 12/27/24, with a blood sugar of 126. On 12/28/24, with a blood sugar of 83. On 12/29/24, with a blood sugar of 96. On 12/30/24, with a blood sugar of 107 and 116. The MAR, dated 1/1/25 through 1/31/25, indicated 35 units of Fiasp FlexTouch U-100 Insulin were administered on the following dates with a blood sugar below 130: On 1/6/25, with a blood sugar of 98. On 1/10/25, with a blood sugar of 124. On 1/12/25, with a blood sugar of 120. On 1/14/25, with a blood sugar of 116. On 1/15/25, with a blood sugar of 126. On 1/17/25, with a blood sugar of 110. On 1/19/25, with a blood sugar of 129. On 1/26/25, with a blood sugar of 122. The MAR, dated 2/1/25 through 2/28/25, indicated 35 units of Fiasp FlexTouch U-100 Insulin were administered on the following dates with a blood sugar below 130: On 2/5/25, with a blood sugar of 128. On 2/11/25, with a blood sugar of 126. On 2/12/25, with a blood sugar of 129. On 2/19/25, with a blood sugar of 124. On 2/21/25, with a blood sugar of 115. On 2/23/25, with a blood sugar of 128. During an interview, on 4/3/25 at 11:17 a.m., LPN 6 indicated when an insulin dose was held based on the physician's hold parameter, the nurse's initials on the MAR were in parenthesis or it would have been marked as zero (0) units given. During an interview, on 4/3/25 at 11:20 a.m., RN 7 indicated a residents' insulin dose should be held if the blood sugar was below the ordered hold parameter. During an interview, on 4/4/25 at 11:45 a.m., the Director of Nursing (DON) indicated the facility had noticed medications were administered against the ordered hold parameters. Staff education was completed, a quality improvement plan was formed, and monitored throughout March. Their quality improvement plan was completed 3/28/25. During an interview, on 4/3/25 at 2:15 p.m., the DON indicated the facility did not have a specific insulin administration policy or a policy related to following a physician's ordered hold parameter. A current facility policy, titled Medication Administration (Medication Pass Procedure), dated 7/2023 and received from the DON on 4/3/25 at 2:15 p.m., indicated .Vital signs were obtained, if necessary .Perform the 5 rights of medication .Right Dose The deficient practice was corrected by 3/28/25, after the facility implemented a systemic plan which included audits and conducting staff education on following the physician's ordered hold parameters with all nursing staff. 3.1-37(a)

Based on interview and record review, the facility failed to ensure insulin doses were held per physician's order, to notify the physician in a timely manner, and to follow the ordered hypoglycemic protocol for 1 of 2 residents reviewed for insulin. (Resident 5) Finding includes: The clinical record for Resident 5 was reviewed on 5/23/24 at 3:11 p.m. The diagnoses included, but were not limited to, type 2 diabetes mellitus with hyperglycemia (high blood sugar), hypoglycemia (low blood sugar), diabetic neuropathy, diabetic retinopathy without ocular edema (eye disease), hypotension, Alzheimer's disease, and syncope and collapse. 1. A physician's order, dated 4/3/24 and discontinued 5/16/24, indicated to give 10 units of lispro insulin with meals with special instructions to hold the dose if the blood sugar was less than 110. A vital signs record indicated the following: a. On 5/11/24 at 8:59 a.m., the blood sugar was 109 mg/dL. b. On 5/14/24 at 7:24 a.m., the blood sugar was 83 mg/dL. c. On 5/14/24 at 11:55 a.m., the blood sugar was 95 mg/dL. A diabetic medication administration record (MAR) indicated the following: a. On 5/11/24 at 7:00 a.m., 10 units of lispro insulin were given in the right arm with a recorded blood sugar of 109 by RN 2. b. On 5/14/24 at 9:50 a.m., 10 units of lispro insulin were given in the abdomen with a recorded blood sugar of 83 mg/dL by RN 3. c. On 5/14/24 at 1:46 p.m., 10 units of lispro insulin were given in the left arm with a recorded blood sugar of 95 mg/dL by RN 3. During an interview, on 5/28/24 at 2:41 p.m., the Assistant Director of Nursing (ADON) indicated the nurses would know when to hold a medication by looking at the hold order on the Medication Administration Record (MAR). 2. A physician's order, dated 4/3/24, indicated to check the blood sugar four times per day and to notify the physician if the blood sugar was below 60. A physician's order, dated 4/8/24, indicated a hypoglycemic protocol: if the blood glucose was 60 or below and the resident was able to consume intake then administer 4 ounces of juice and recheck the blood glucose in 15 minutes. A vital signs record indicated the following: a. On 5/15/24 at 7:41 p.m., the blood sugar was 56 mg/dL. b. On 5/17/24 at 10:00 p.m., the blood sugar was 58 mg/dL. The electronic medical record did not include a rechecked blood sugar for 5/17/24 at 10:00 p.m. A nursing progress note, dated 5/15/24 at 9:00 p.m., indicated the resident's bedtime blood sugar was 56. A message was left in the binder for the provider to review later. A nursing progress note, dated 5/19/24 at 11:06 p.m., indicated the previous shift nurse left another message in the binder due to hypoglycemia episodes over the weekend. During an interview, on 5/28/24 at 2:41 p.m., the ADON indicated the nurse should call the doctor for blood sugar readings below or above the parameters given in the orders, which were typically below 60 and above 450. The hypoglycemic protocol for low blood sugars under 60 was to give 4 ounces of juice if the resident was able to safely drink and then recheck the blood sugar in 15 minutes. During an interview, on 5/28/24 at 3:49 p.m., the Director of Nursing (DON) indicated the nurse should notify the Nurse Practitioner (NP) by writing the blood sugar on the non-urgent log for the provider to see the information while she rounded that day or on the next day. If the abnormal blood sugar happened on a weekend when the NP would not be coming in, then the nurse should call the on-call provider. The hypoglycemic protocol was to give 4 ounces of juice and to recheck the blood sugar in 15 minutes. Waiting over an hour for a recheck of the blood sugar was not following the protocol. A current policy, titled Resident Change of Condition Policy, dated as revised on 11/2018 and received from the DON on 5/29/24 at 10:00 a.m., indicated .All symptoms and unusual signs will be documented in the medical record and communicated to the attending physician promptly A current policy, titled Blood Glucose Monitoring, dated as revised on 2/2015 and received from the DON on 5/29/24 at 10:15 a.m., indicated .The physician will be notified when the resident's blood glucose is outside the physician stated parameters .Immediate treatment of hypoglycemia will be completed as follows .(resident) will receive 4 ounces of juice. Recheck blood glucose in 15 minutes and document .Blood glucose results will be documented on the Capillary Blood Glucose Monitoring Tool or on the medication administration record. 3.1-37(a)

Based on interview and record review, the facility failed to notify the physician about a significant weight loss in a timely manner for 1 of 5 residents reviewed for nutrition. (Resident 67) Finding includes: The clinical record for Resident 67 was reviewed on 5/23/24 at 11:53 a.m. The diagnoses included, but were not limited to, end stage renal disease, chronic diastolic (congestive) heart failure, acquired absence of left leg below the knee, hypertensive heart, chronic kidney disease with heart failure, and stage 5 chronic kidney disease. A current care plan, with a start date of 5/19/21, indicated to notify the medical doctor (MD)/family of significant weight changes. The weight log indicated the following weights: 7/5/23: 216 pounds 8/10/23: 197 pounds 8/16/23: 198 pounds 9/12/23: Not Taken (refused) 10/06/23: Not Taken (refused) 10/11/23: INVALID 10/13/23: 171 pounds 10/25/23: INVALID 10/27/23: 172 pounds An interdisciplinary team (IDT) progress note, dated 8/10/23, indicated the resident's weight was 197 lbs. The resident had a significant weight loss of 9% in 36 days. The root cause for the weight loss was because the resident had a left below the knee amputation (BKA). The physician was notified of the weight change. An IDT progress note, dated 10/23/23, indicated the resident's current weight was 171 lbs. The resident had a weight loss of 14% in 158 days. The resident had a 13% weight loss from 8/16/23 to 10/13/23. The provider was not notified of the significant weight loss until 10 days later. During an interview, on 5/29/24 at 3:48 p.m., the Director of Nursing (DON) indicated they did not see notification to the physician until 10/23/24. A current policy, titled Resident Weight Monitoring, dated as last reviewed on 7/2023 and received from the DON on 5/29/24 at 3:50 p.m., indicated .The physician/health care provider will be notified of unplanned significant weight loss/gains 3.1-46(a)(1)

Based on observation, interview and record review, the facility failed to ensure over the counter (OTC) medications were labeled with the directions for use and the physician's name for 1 of 3 medications carts reviewed for medication storage. (Cart 100) Finding includes: During an observation of medication storage, on 5/21/24 at 12:22 p.m., with LPN 2 the medication cart 100 on the dementia unit had the following: a. One bottle of OTC aspirin 81 milligram (mg) with the name of Resident 104 handwritten in black. There was no label, no instructions for use of the medication, and no physician's name on the bottle. The bottle was not opened. b. One opened bottle of OTC aspirin 81 mg with 365 tables with the name of Resident 104 handwritten in black. There was no label, no instructions for use of the medication, and no physician's name on the bottle. c. One bottle of OTC turmeric 500 mg capsules for Resident 104. There was no label, no instructions for use of the medication, and no physician's name on the bottle. d. One bottle of OTC chewable aspirin tablets 81 mg with the name of Resident 87 handwritten in black. There was no label, no instructions for use, and no physician's name on the bottle. e. One bottle of OTC allergy relief cetirizine 10 mg with the name of Resident 87 handwritten in black. There was no label, no instructions for use, and no physician's name on the bottle. The clinical record for Resident 104 was reviewed on 5/21/24 at 3:05 p.m. The diagnoses included, but were not limited to, dementia and insomnia. A physician's order for Resident 104, dated 3/26/24 and open ended, indicated to give aspirin 81 mg once a day. A physician's order for Resident 104, dated 4/27/24 and open ended, indicated to give turmeric root extract 500 mg capsule once a day. The clinical record for Resident 87 was reviewed on 5/21/24 at 3:20 p.m. The diagnoses included, but were not limited to, dementia, low back pain, and heart disease. A physician's order for Resident 87, dated 2/26/24, indicated to give a chewable aspirin 81 mg once a day. A physician's order for Resident 87, dated 5/10/24, indicated to give cetirizine 10 mg at bedtime. During an interview, on 5/21/24 at 3:00 p.m., the Director of Nursing (DON) indicated the policy for medication labeling indicated according to regulations. The DON was not able to say what the regulations were for labeling OTC medications. During an interview, on 5/22/24 at 3:55 p.m., the facility pharmacist indicated she would need to look up the professional standards for labeling OTC medications in a long-term care facility. An email dated 5/22/24 at 4:16 p.m., from the facility pharmacist indicated the OTC medications would need to be identified with the resident's name, the physician's name, the expiration date, the name of the drug and the strength. A current policy, titled Storage and Expiration of Medications, Biologicals, Syringes and Needles, dated as revised on 1/13/23 and received from the DON on 5/21/24 at 3:01 p.m., indicated .Facility should ensure that medications and biologicals .Have an Expiration Date on the label .Facility should request that Pharmacy perform a routine nursing unit inspection for each nursing station in Facility to assist Facility in complying with its obligations pursuant to Applicable Law relating to the proper storage, labeling, security and accountability of medications and biologicals 3.1-25(j) 3.1-25(k)(1) 3.1-25(k)(2) 3.1-25(k)(5)

Based on observation, interview, and record review, the facility failed to ensure pureed foods were at the regulated temperature for hot and cold foods and to ensure the food was at a pudding thick consistency which had the potential to affect 18 of 18 residents who were on a pureed diet. Findings include: 1. During an observation, on 3/23/23 at 1:17 p.m., the Executive Director(ED) and Registered Dietitian (RD) were asked to take temperatures of the puree food served on the dementia unit. The RD took the 12th tray and removed the plate cover. The plate contained two white scoops and a large orangish/yellow liquid item covering half the plate and touching the two white scoops. The RD indicated the plate contained cauliflower, bread, and chicken pot pie. The cauliflower had an area of about 1/2 inch of clear liquid surrounding the scoop and the chicken pot pie had a liquid consistency. The RD placed the thermometer into the cauliflower and the temperature was 126.1 Fahrenheit (F). The temperature of the bread was 111.3 F. The RD took the thermometer and put the tip into the liquid chicken pot pie. The RD stated the chicken pot pie was normally served in a bowl. The chicken pot pie had a temperature of 110.2 F degrees. The RD temped the bowl of pureed pears and the temperature was 68.6 F. During an interview, on 3/22/23 at 12:18 p.m., the RD indicated every food item served hot needs to be 135 F or above and cold foods need to be 41 F or below. During an interview, on 3/23/23 at 3:02 p.m., the Executive Director(ED) indicated the chicken pot pie was covering half the plate and was normally served in a bowl. The [name of company] recipe for pureed chicken pot pie for a serving size of 25 indicated add twenty-five 8 oz ladles of chicken pot pie, 1 tablespoon and 3/4 teaspoon of low-sodium chicken broth, 1 1/4 quart of hot water. Prepare the chicken pot pie as directed and add to the food processor. Process until fine in consistency. Gradually add hot broth to mixture while processing. All liquid may not be required. Hot food held for later service must maintain a minimum internal temperature of 140 F. Place cooked green beans in food processor, add melted margarine and a food thickener. Process briefly until mixed. 36454 2. During a kitchen test tray observation on 3/22/23 at 12:38 p.m., the pureed bun tasted gooey and had no flavor of bread, the pureed hamburger still had little chunks of meat and was not a smooth texture and was not the flavor of a typical hamburger. During an interview, on 3/22/23 at 12:43 p.m., the kitchen staff indicated the test tray did not include the bun only the pureed French fries and they would bring a test tray with the pureed bun and pureed French fries. During a kitchen test tray observation on 3/22/23 at 12:44 p.m., the new test tray with the pureed hamburger and the pureed bun mixed together, the pureed hamburger still had a bitter taste. The pureed French fries had a gooey texture and tasted like starch and water. The flavor was not the taste of French fries. 3. During an interview, on 3/23/23 at 11:21 a.m., Resident 82's family indicated the pureed food had to be stiffened up because it was too runny. He showed a picture of two different colored pureed foods which were runny and had spread across the plate blending the two foods. The foods were not in a scoop form and were very flat on the plate. The pureed food was also cold, and the family warmed the food in the microwave before serving it to the resident. The record for Resident 82 was reviewed on 3/28/23 at 4:00 p.m. Diagnoses included, but were not limited to, Alzheimer's disease and dysphagia (difficulty swallowing). A physician's order, dated 1/23/23, indicated pureed diet with nectar thick/mildly thick liquids. 4. During an interview, on 3/23/23 at 11:28 a.m. Resident 22's family member indicated the pureed foods should be the correct consistency for residents who have swallowing problems. The family brought in their own thickener because the pureed foods had water all over the plate and were not thick. The record for Resident 22 was reviewed on 3/23/23 at 4:12 p.m. Diagnoses included, but were not limited to, unspecified dementia, dysphagia and adult failure to thrive. A physician's order, dated 2/25/23, indicated pureed diet with nectar thick/mildly thick liquids and 2 times the dessert at dinner. During an interview on 3/23/23 at 11:46 a.m., the Social Services Director (SSD) indicated he had observed the pureed foods to be runny on the plate and he would file a grievance when the pureed food was runny. He did turn in a grievance on 3/22/23 for the pureed foods being a runny consistency. During an interview, on 3/23/23 at 3:02 p.m., the Executive Director indicated the pureed chicken pot pie should have been served in a bowl since it had expanded onto the other food on the plate. It was hard to puree chicken pot pie and he was not sure if the kitchen staff had added thickener to the pot pie. A current policy titled, Food Temperatures, revised 10/2022, received by the Executive Director on 3/23/23 at 3:46 p.m., indicated, .The facility proper temperature control to prevent food borne illness. 1. Hot foods that are potentially hazardous will be held for a serve at or above 135 F(Fahrenheit), and cold foods at or below 41 F. 2. All hot and cold food items will be served to the resident at a temperature that is considered palatable at the time the resident receives the food. 5. Temperatures should be taken with a sanitized and calibrated thermometer. Should this thermometer have a tube or sheath type cover, it must also be sanitized. 6. To take hot food temperatures, insert the thermometer into the thickest portion of the food item while avoiding bones, if present. 9. Hot food will be held at or above 135 F. If minimum temperature requirements are not maintained, food will need to be reheated to a minimum of 165 F for 15 seconds before serving. 10. Cold food will be held at or below 41 F. If cold food temperature is not maintained, food item will need to be chilled at < F before serving A current policy titled, Protocol for Altered Diet Consistency/Thickened Liquids, undated, received by the Executive Director on 3/23/23 at 4:29 p.m., indicated, .Speech Therapist determines an altered diet consistency and/or thickened liquids are necessary. Reasons for the altered diet consistency and/or thickened liquids order i.e. chewing/swallowing difficulties, risk for aspiration .An altered consistency diet is any diet consistency that is not a regular consistency. Mech Soft, Ground or Chopped Meat, Puree, etc 3.1-21(a)(1) 3.1-21(a)(2)

Based on observation, interview, and record review, the facility failed to ensure a resident was provided thorough washing of all areas for 1 of 1 residents being observed for catheter care (Resident 2). Findings include: During an observation, on 3/27/23 at 11:21 a.m., LPN 3 and the Assistance Director of Nursing(ADON) were providing catheter care for Resident 2. LPN 3 gathered water from the bathroom and had wash cloths on the bedside table. LPN 3 started cleaning the resident's tubing attached to the catheter bag. LPN 3 did not wash the resident's peri area or clean the catheter in a circular motion for about 4 inches and did not start cleansing where the catheter entered the meatus and down the drainage tub. Resident 2's peri area appeared very red. Resident 2's record was reviewed on 3/24/23 at 4:23 p.m. Diagnoses included, but where not limited to, pressure ulcer of left buttock, epilepsy, hypertension, depressive episode and traumatic brain injury and artificial knee joints. A facility form, titled, Procedure Steps for Catheter Care (urinary), dated 2/2023, indicated to use the non-dominant hand and grasp the catheter tubing where it entered the meatus; use the dominant hand to retrieve a wet soaped washcloth, cleanse catheter in a circular motion for about 4 inches; and start cleanse where the catheter entered the meatus and down the draining tube. A Care Plan, dated 8/12/22, indicated Resident 2 required an indwelling urinary catheter due to a wound to the buttock. Approaches included, but were not limited to, provide assistance for catheter care per shift, report signs of urinary tract infection, and keep catheter system closed as much as possible. A Physician's order, dated 11/10/22, indicated Resident 2's urinary catheter was to have catheter care every shift and to record the output every shift. A quarterly Minimal Data Set (MDS), dated [DATE], indicated Resident 2 had a catheter and was a two person extensive assist with toileting. It also indicated the resident's Brief Interview for Mental Status (BIMS) score was 15 which indicated the resident was cognitively intact. During an interview, on 3/27/23 at 11:04 a.m., the Assistant Director of Nursing (ADON) indicated the procedure steps should be followed during catheter care. During an interview, on 3/27/23 at 2:14 p.m., the Executive Director indicated they did not have a Catheter Care policy. The facility form titled, Procedure Steps for Catheter Care (urinary), dated 2/2023, was the policy catheter care. The facility did not have a Catheter Care policy. 3.1-41(a)(1)

Based on observation, interview, and record review, the facility failed to ensure lorazepam (an anti-anxiety medication) was not administered after the expiration date and to reconcile the controlled substance record for 1 out of 3 medication carts observed for medication storage (Resident 24). Findings include: 1. During a medication storage observation on [DATE] at 11:30 a.m., a bottle of lorazepam for Resident 24 was dated as opened on [DATE]. The lorazepam should have been discarded on [DATE]. The record for Resident 24 was reviewed on [DATE] at 11:30 a.m. Diagnoses included, but were limited to, unspecified dementia, unspecified severity, with other behavioral disturbance. A physician's order, dated [DATE], indicated lorazepam intensol 2 milligrams/milliliters give 0.5 milliliters every 4 hours as needed. A medication administration record, dated [DATE] to [DATE], lorazepam intensol 2 milligrams/milliliter give 0.5 milliliters was administered on [DATE] at 10:53 a.m. for a behavior issue. 2. During a medication storage observation on [DATE] at 11:30 a.m., a bottle of lorazepam intensol contained 14 milliliters of the medication. A controlled substance record indicated 7.5 milliliters of the medication remained in the bottle. A controlled substance record for lorazepam 2 milligrams/milliliter indicated 27 doses were administered from [DATE] to [DATE] resulting in 7.5 milliliters being left in the bottle. A medication administration record, dated [DATE] to [DATE], indicated one dose of lorazepam was administered. A medication administration record, dated [DATE] to [DATE], indicated 2 doses of lorazepam was administered. A medication administration record, dated [DATE] to [DATE], indicated 14 doses of lorazepam were administrated. This was a total of 17 doses of lorazepam doses administered. The dates of administration on the medication administration record did not coincide with the dates of administration on the controlled substance record. The shift change records for the memory care unit were reviewed on [DATE] at 12:30 p.m., the records indicated the medication amount was checked and verified by staff every shift. During an interview on [DATE] at 12:35 p.m., Nurse 4 indicated she was not aware of an expiration date for the lorazepam, and she did not notice when she verified narcotic medications in cart and refrigerator. There was an error in the amount listed on the controlled substance record and in the actual medication bottle. A current manufacturer's insert, Pharmaceutical Associates Inc., indicated to discard opened bottles of lorazepam after 90 days. A current policy, titled, Storage and Expiration of Medications, Biologicals, Syringes and Needles, indicated, dated [DATE], received from the executive director on [DATE] facility should ensure that medications and biologicals that .have an expired date on the label . have been retained longer than recommended by manufacturer or supplier guidelines A current policy, titled, Inventory Control of Controlled Substances, dated [DATE], received from the executive director, on [DATE] at 3:46 p.m., indicated .facility should maintain a separate individual controlled substance records .facility should ensure that facility staff count all schedule III and IV controlled substances in accordance with facility policy and applicable law . a facility representative should regularly check the inventory records to reconcile inventory 3XXX,d+[DATE](e)(2) 3XXX,d+[DATE](o)

Based on interview and record review, the facility failed to ensure a pharmacy recommendation was addressed by the prescriber within 30 days for 1 of 5 residents reviewed for unnecessary medications (Resident 85). Finding includes: The record for Resident 85 was reviewed on 3/24/23 at 3:49 p.m. Diagnoses included, but were not limited to, dementia with behavioral disturbance, anxiety disorder, major depressive disorder and a sleep disorder. A pharmacy consultation, dated 6/8/22, indicated the resident received an antidepressant, sertraline 100 milligrams (mg), at bedtime which may interfere with sleep. The resident was receiving melatonin (a hormone which affects sleep) 3 mg once a day at bedtime as a sleep aid. Recommended to change the administration time of the sertraline to the morning and reassess the continued need for the melatonin. The Nurse Practitioner (NP) responded to the recommendation on 7/25/22 and indicated to adjust the sertraline dosing to every morning. The NP response was 47 days after the pharmacy recommendation. During an interview, on 3/28/23 at 11:44 a.m., the Executive Director (ED) indicated there was no answer why the NP had the delayed response to the pharmacy recommendation on 6/8/22. A current Nursing Drug book, indicated the adverse reactions of sertraline included, but were not limited to, insomnia. A current policy, titled, Medication Regimen Reviews and Pharmacy Recommendation, revised on 10/2018 and received from the executive director on 3/28/23 at 12;27 p.m., indicated, .It is the policy of ASC that the facility maintains the resident's highest practicable level of physical, mental and psychosocial well-being and prevents or minimized adverse consequences related to medication therapy to the extent possible by providing oversight by a licensed pharmacist, Attending Physician, Medical Director, and Director of Nursing .The drug regimen of each resident must be reviewed at least once a month by a licensed pharmacist. The drug regimen review must include a review of the resident's medical chart .The Consultant Pharmacist recommendations will be reviewed by the Director of Nursing and the Attending Physician will be notified promptly of any recommendation needing immediate attention .Pharmacy recommendations should be reviewed with follow up by the physician within 30 days of the facility receiving 3.1-25(i)

Based on interview and record review, the facility failed to ensure the prescribed antianxiety medication had documentation to show the clinical rationale for being prescribed and to ensure the continued need for the use of the medication was assessed for 1 of 5 residents reviewed for unnecessary medications (Resident 4), and to provide a clinical rationale for not accepting a gradual dose reduction (GDR) recommendation for 1 of 5 residents reviewed for unnecessary medications (Resident 48). Findings include: 1. The Record for Resident 4 was reviewed on 3/23/23 at 12:25 p.m. Diagnoses included, but were not limited to, Alzheimer's disease with late onset, unspecified dementia with psychotic disturbance, psychotic disorder with hallucinations due to a known physiological condition, moderate intellectual disabilities, recurrent major depression and a lack of coordination. The diagnoses did not include anxiety. A physician's order, dated 9/6/23, indicated to give buspirone (an anxiolytic to treat anxiety) 7.5 milligrams (mg) twice a day for depression. A care plan, dated 9/7/22, indicated the resident was at a risk for signs/symptoms of depression. The resident had a diagnosis of major depressive disorder and utilized an antianxiety medication. The interventions included, but were not limited to, allow the resident to express feelings and frustration, encourage activities of interest and medications as ordered. A care plan, dated 9/7/22, indicated the resident was at a risk for adverse side effects related to the use of psychotropic medication, an antidepressant and antianxiety medication. The resident had a diagnosis of major depression, dementia with behavioral disturbance and a psychotic disorder with hallucinations due to a known physiological condition. The care plans did not include the resident was at a risk for anxiety. A psychiatric progress note, dated 2/6/23, indicated the diagnoses and plan included: a. Alzheimer's disease with late onset to continue the Aricept and Namenda (memory medications). b. Major depressive disorder to continue the sertraline (an antidepressant). c. Other sleep disorder to continue the melatonin (a hormone which helps with sleep). d. Psychotic disorder with hallucinations due to a known physiological condition to continue the olanzapine (an antipsychotic medication) e. Other sexual dysfunction not due to a substance of known physiological condition to continue the sertraline. The diagnoses and plan did not include anxiety or the medication buspirone. A psychiatric progress note, dated 2/22/23, indicated the diagnoses and plan included: a. Alzheimer's disease with late onset to continue the Aricept and Namenda. b. Major depressive disorder to continue the sertraline. c. Other sleep disorder to continue the melatonin. d. Psychotic disorder with hallucinations due to a know physiological condition to continue the olanzapine. e. Sexual dysfunction not due to a substance or known physiological condition to continue the sertraline. The diagnoses and plan did not include anxiety or the medication buspirone. A psychiatric progress note, dated 3/6/23, indicated the diagnoses and plan included: a. Dementia which was moderately stable. b. Major depressive disorder to continue the antidepressant sertraline 150 mg. c. Other sleep disorder to continue melatonin 5 mg each evening. d. Sexual dysfunction not due to a substance or known physiological condition to continue the sertraline. e. Psychotic disorder with delusions due to a known physiological condition to continue olanzapine. The diagnoses and plan did not include anxiety or the buspirone. An Pharmacy consultation report, dated 3/14/23, indicated the resident had received buspirone 7.5 mg twice daily for major depressive disorder since 9/2022. For the initial attempt at a GDR, please reduce the buspirone to 5 mg twice daily. Please provide patient specific rationale desscribing why a GDR attempt was likely to impair function or cuase psychiatric instability. The NP response included the GDR was declined due to being clinically contraindicated. The NP signed the form on 3/20/23 and did not provide a clinical rationale for declining the GDR as requested on the form. During an interview, on 3/27/23 at 12:34 p.m., The DON indicated the NP was prescribing the buspirone even though he did not document the medication in any of the psychiatric progress notes. The NP was changing the diagnosis to anxiety for the use of the buspirone. During an interview, on 3/28/23 at 12:26 p.m., the Executive Director (ED) indicated the NP changed the diagnosis for the use of the buspirone to generalized anxiety disorder. The medication was documented as being given for depression prior to 3/28/23. The ED indicated once the diagnosis was changed to generalized anxiety disorder then the depression diagnosis would not show in the history on the electronic health record in the physician's orders. The copy of the physician's order provided by the facility would not show the original order had the diagnosis of depression. 46961 2. The record for Resident 48 was reviewed on 03/23/23 at 09:29 a.m. Diagnoses included, but were not limited to, major depressive disorder, delusional disorders, generalized anxiety disorder, and psychotic disorder with delusions due to known physiological condition. A physician's order, dated 1/23/23, indicated Lexapro (an antidepressant) 10 mg daily. A pharmacy recommendation, dated 9/19/22, indicated the resident had received an antidepressant, lexapro 5 milligrams once daily for the management of major depressive disorder since 3/2022. The recommendation was to consider documenting that a gradual dose reduction was clinically contraindicated. A patient-specific rationale describing why a gradual dose reduction attempt is likely to impair function or cause psychiatric instability in the individual. The physicians response, dated 9/19/12, indicated the escitalopram was an ongoing need and the GDR was declined. The physician response did not include the clinical rationale for declining the gradual dose reduction. A current policy, titled, Psychotropic Management, last revised on 7/22 and received from the Executive Director on 3/28/23 at 12:14 p.m., indicated, .It is the policy of American Senior Communities to ensure that a resident's psychotropic medication regimen helps promote the resident's highest practicable mental, physical and psychosocial well-being with person centered intervention and assessment. These medications are managed in collaboration with professional services and facility staff to include no pharmacological interventions, assessment and reduction as applicable .A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. These drugs include, but are not limited to, drugs in the following categories .Anti-psychotic .Anti-depressant .Anti-anxiety .Residents are not given psychotropic drugs unless the medication is necessary to treat a specific condition as diagnoses, and this is documented in the medical record. Each resident receiving psychotropic medication will have an adequate indication for use and supporting diagnosis for use which is documented in the clinical record .Gradual dose reductions [GDR] and use of no pharmacological intervention will occur for residents receiving psychotropic medication unless contraindicated by the prescriber with specific rationale why reduction is not indicated .Periodic re-evaluation of the medication regimen is necessary to determine whether continued use of a mediation is indicated .Prescribers will evaluate the efficacy and risks for psychotropic medications and document their assessment in the medical record . The prescriber may reduce the medication or clinically contradict the GDR based on relevant clinical standards of practice. All rationale must be documented in the medical record 3.1-48(a)(3) 3.1-48(a)(4)

Based on observation, interview, and record review, the facility failed to ensure insulin pens were dated when opened and unopened insulin was in the refrigerator for 1 out of 3 medication carts observed for medication storage (Residents 52 and 156). Findings include: During an observation, on 03/24/23 at 10:07 a.m., insulin lispro (a short acting insulin) 100 units/milliliter pens were in the medication cart without open dates. Another insulin pen was not open and was stored in the medication cart. The insulin pens belonged to Residents 52 and 156. The record for Resident 52 was reviewed on 3/24/23 at 11:00 a.m. Diagnoses included but were not limited to type 2 diabetes mellitus. The record for Resident 156 was reviewed on 3/24/23 at 11:00 a.m. Diagnoses included but were not limited to type 2 diabetes mellitus. During an interview on 3/23/23 at 4:15 p.m. LPN 3 indicated the insulin pens should have been dated when they were opened, and the unopened insulin should have been stored in the refrigerator. A current policy, titled, Storage and Expiration of Medication, Biologicals, Syringes and Needles, indicated .once a medication or biological package is opened, the facility should follow manufacturer/supplier guidelines with respect to expiration dates, for opened medications .facility staff should record the date opened on the medication container when the medication container when the medication has a shortened expiration date .the facility should ensure the medications and biologicals are stored at their appropriate temperatures according to the United States Pharmacopeia guidelines for temperature ranges 3.1-25(m)

Based on observation, interview and record review, the facility failed to follow a physician's order to have the resident seen at the physician's clinic one week after admission to the facility for 1 of 3 residents reviewed for quality of care. (Resident B) Findings include: The record for Resident B was reviewed on 9/8/2022 at 3:35 p.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician hospital discharge order, dated 7/11/2022, indicated there was a follow-up order to visit the orthopedic physician on 7/18/2022 at 9:20 a.m. Post-op orders indicated surgical risks for the fx ankle included pain, infection, bleeding, blood clots in the leg and damage to blood vessels, tendons or nerves. During an interview, on 9/9/2022 at 12:34 p.m., the physician's office staff member 5 indicated the resident was a no-show for her physician's appointment on 7/11/2022. She indicated some patients did not show up for their follow-up appointments and went to other clinics to have surgical staples removed and x-rays taken of the bone fracture. She indicated the clinic did not call patients to reschedule appointments when the patient was a no-show. She indicated the visit was to assess the patient's surgical procedure, wound and remove the patient's staples. She indicated the staples could remain attached if the wound had not healed for an additional three weeks. She indicated the facility had called the clinic, on 8/18/2022, to arrange for an appointment for the patient to be seen after the facility had removed the staples and an infection was present on the patient's left lower leg area. During an interview, on 9/8/2022 at 2:40 p.m., the Director of Nursing (DON) indicated the physician's appointment was not attended by the resident on 7/18/2022. The resident had a [CONDITION(S)] appointment she attended instead. Nurse Practitioner (NP) 3 for the facility had been observing the resident and she did not reschedule the resident's appointment. The resident did not show signs and symptoms of an infection and the dressing area was dry, clean and intact. She indicated, on 8/18/2022, NP 3 wrote an order to remove the resident's bandage and remove the staples to the wound. She removed the staples and bandage on 8/18/2022. NP 3 wrote an order to call and schedule a physician visit for the resident. The wound had an infection. A NP 3 order was reviewed and indicated, on 8/18/2022, nursing should remove the cast and staples at bedside. To cleanse the area to the LLE (left lower extremity) with NS (normal saline). Apply Santyl to the wound bed and to cover with ABD and wrap with kerlix. Change the dressing daily. Refer to orthopedics. Schedule the next available appointment. Start [MEDICATION(S)] (an antibiotic) 100 mg (milligrams) by mouth twice daily for 10 days. Take vital signs every shift due to skin infection. During an interview, on 9/9/2022 at 11:38 a.m., NP 4 (supervisor of NP 3) indicated the resident had a cast which did not have to be removed for 6 weeks per physician's note (physician post-op note indicated a cast could remain on a patient for up to 6 weeks for a non-surgical procedure). He indicated it was the responsibility of the surgeon and his office to schedule and reschedule patient's appointments, not the NP. The resident was seen by NP 3. He indicated NP 3 documented there were no signs and symptoms of an infection. During an interview, on 9/9/2022 at 11:48 a.m., NP 3 indicated she examined the resident on 7/12/2022, 7/14/2022, 7/25/2022 and 8/16/2022. She indicated the resident had no signs and symptoms of an infection. The resident had a cast and an ace bandage in place. She was aware the resident had missed her appointment to see the orthopedic surgeon on 7/18/2022. She had conferred with NP 4. NP 4 indicated the cast could remain in place for 6 weeks without removal and it was up to the surgeon to call and reschedule the resident's appointment if necessary. She was observing the resident for an infection. She was aware of the possible complications of an infection following a surgical procedure and the resident had a surgical procedure with staples in place. During an interview, on 9/8/2022 at 4:45 p.m., Resident B indicated she came to the facility after a hospital stay with surgery performed on her ankle. She did not remember the orthopedic doctor's office calling her to make an appointment to see him after surgery. The staff at the facility did see her daily. The facility staff knew she had a cast. She was upset it was not removed for over a month. She was mad her doctor did not see her after surgery to remove her staples. NP 3 told her she had an infection when the staples were removed from her wound at the facility. An orthopedic clinic note indicated, on 8/23/2022, a visit was approximately 7.5 weeks post open reduction and internal fixation of a left lateral malleolus fracture performed on 7/1/2022. The patient missed her last scheduled appointment. There was no splint on the left leg and the staples had been removed by the nurse at the facility. The physical exam of the left ankle indicated the patient has [CONDITION(S)] along the incision line without drainage. X-rays of the left ankle indicated the fracture looked almost completely healed. Radiographically her leg was in good alignment. The physician indicated he reviewed the x-rays with the patient and referred her to the wound care center for further evaluation. The physician indicated the patient had an open wound and started her on [MEDICATION(S)] (an antibiotic) 150 mg four times a day. The patient was in agreement with the care and follow-up with the wound care clinic. The current policy, titled Matrix Care Physician Orders Policy, dated as revised on 8/2019 and received from the DON on 9/9/2022 at 12:45 p.m., indicated .After admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] .Review each resident's orders on a monthly basis prior to the first of each month. Check all orders for accuracy and continued need This Federal tag relates to Complaint IN 932 3.1-37(a)

Based on observation, interview and record review, the facility failed to ensure staff were wearing masks over their nose and mouth while working in the kitchen, failed to date left over food, to removed dented cans from the pantry supply, to label open containers, to remove a scoop from a food storage bin, to date food items when received, to seal opened food items and to remove gloves between tasks. These deficiencies had the potential to affect 98 of 98 residents which receive meals from the kitchen. Findings include: During an observation of the Kitchen, with the Dietary Manager (DM) in attendance, on February 14, 2022, beginning at 11:10 a.m., the following observations were made: 1. Dietary Staff 4 was observed to be working at the food preparation table with her mask under her chin. 2. Dietary Staff 5 was observed to be working with packaged meat, at the preparation table, his mask was under his nose. 3. Dietary Staff 6 was observed to have her head in a cooler to the right of the kitchen entry. Upon standing up, her mask was observed to be worn under her nose. 4. In the cooler, a container of apricot halves were found without a date or item label on the container. 5. In the cooler, a container of left over eggs was found without a date or item label on the container. 6. In the cooler, a container with a brown substance was found without a date or item label on the container. At that time, the DM indicated she could not identify the substance. 7. In the pantry, a scoop was found in a bin of oats. At that time, the DM indicated scoops should not have been left in the bin. 8. In the pantry, a 117 ounce can of jellied cranberry sauce was found dented. At that time, the DM indicated the dented can should have been pulled from the shelf. 9. In the pantry, a 117 ounce can of apple sauce and two 117 ounce cans of nacho cheese sauce were found without received dates. At that time, the DM indicated the cans should have been dated when received. 10. In the pantry, three 80 ounce boxes of pancake mix were found without a delivery/received date. 11. In the pantry, three 80 ounce boxes of all-purpose biscuits were found without a delivery/received date. One box was found open and without an open date. 12. In the pantry, ten 40 ounce boxes of corn muffin mix were found without a deliver/received date. 13. In the pantry, two-5 pound bags of yellow cake mix were found without a deliver/received date. 14. In the pantry, one bag of vanilla wafers was found without a deliver/received date. 15. In the pantry, one-5 pound bag of elbow macaroni was found open to air and without an open date. 16. During an observation, on February 14, 2022 at 11:32 a.m., Dietary Staff 5 was observed wearing gloves while working with carrot salad. Dietary Staff 5 did not remove the gloves when he stopped his task and walked over to a drawer containing utensils, opened the drawer, removed the item he needed and then returned to the preparation table and continued working with the carrot salad. Dietary staff 5 was not observed to remove his gloves at any time during the task change. While wearing the gloves, he dropped a plastic lid on the floor, picked it up from the floor and then returned to his task with the carrot salad. He was not observed to removed his gloves or perform hand hygiene. He then put the carrot salad into a metal container, carried it and placed it into the service table, where other food items were. During an interview, on February 14, 2022 at 11:00 a.m., the DM indicated to prevent contamination staff only work with one food item at a time and they were to change gloves between tasks and perform hand hygiene. A current facility policy, titled Food Storage, dated as revised on June 2021 and provided by the Executive Director on February 18, 2022 at 2:45 p.m., indicated .dented cans .should be disposed of promptly .Scoops are not to be stored in the food containers .Hands must be washed .prior to handling any food items .Leftover prepared foods are to be .clearly labeled with the name of the product, the date it was prepared, and marked to indicated the date by which the food shall be consumed or discarded .Refrigerated .food .shall be clearly masked with the date the original container is opened .When removing items from the box they were shipped in, label with the delivery date A current facility policy, titled Implementing Prevention Measures for COVID-19, dated as reviewed on September 28, 2021 and provided by the Executive Director on February 14, 2022 at 2:12 p.m., indicated .All facility staff are to wear a mask while in the facility, this includes .kitchen 3.1-21(i)(3)

Based on observation, interview and record review, the facility failed to apply and remove TED ([CONDITION(S)]-[CONDITION(S)] deterrent) hose as ordered by the physician for 1 of 1 residents reviewed for [CONDITION(S)] (Resident 31). Finding includes: During an observation, on 2/15/22 at 1:49 p.m., Resident 31 was lying in bed, in her room, both of her feet had slight [CONDITION(S)] and she did not have TED hose on her legs. During an observation, on 2/17/22 at 1:15 p.m., the resident was lying in bed, in her room, and did not have any TED hose on her lower legs. During an observation, on 2/18/22 at 2:50 p.m., the resident was lying in bed, in her room, and did not have TED on her lower legs. The record for Resident 31 was reviewed on 2/17/22 at 12:14 p.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . There were not notes on the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The progress notes, for 2/15/22 and 2/17/22, did not include information on the resident refusing the TED hose. During an observation, with the DON (Director of Nursing), on 2/18/22 at 4:34 p.m., the resident did not have the TED hose on. The DON looked and there were not any TED hose in the resident's room. A current facility policy, titled Matrix Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] .All new orders will be entered into MatrixCare Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] .The MatrixCare Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] A Monthly Orders Review Checklist, not dated and received from the ED on 2/14/22 at 4:10 p.m., indicated .Review each resident's orders on a monthly basis prior to the first of each month .Check all orders for accuracy and continued need. Look for duplicate and or unnecessary orders requiring signing off on in eMAR. Obtain any necessary order clarifications and ADD/Edit/DC orders in Matrixcare as needed 3.1-37(a)

Based on observation, interview and record review, the facility failed to ensure medications were administered under the supervision of the nursing staff for 1 of 10 residents reviewed for accidents during medication administration. (Resident 93) Finding includes: During a random observation of Resident 93, on February 14, 2022 at 1:14 p.m., a small clear medication cup containing two purple pills was found sitting on the bedside table. There was no staff member present in the room. The record for Resident 93 was reviewed on February 18, 2022 at 2:02 p.m. Diagnoses included, but were not limited to, [CONDITION(S)], dementia with Lewy bodies and hallucinations. A physician's order, dated December 28, 2020, indicated to administer [MEDICATION(S)]-[MEDICATION(S)] (a medication used for [CONDITION(S)]) 25-100 milligrams (mg) for a total dose of 50-100 mg (2 pills). There was not a physician's order, a care plan or an assessment for Resident 93 to self-administer medications. During an interview, on February 14, 2022 at 1:15 p.m., LPN 10 indicated Resident 93 did not self-administer medication. The medications should not have been left at the bedside. LPN 10 indicated she thought the medications left at the bedside were [MEDICATION(S)]-[MEDICATION(S)]. A current facility policy, titled Medication Pass Procedure, dated as reviewed in December 2016 and provided by the Executive Director on February 14, 2022 at 2:12 p.m., indicated .Observed taking medications-not left at the bedside A current facility policy, titled Self Administration of Medications, dated as reviewed in January 2015 and provided by the Executive Director on February 14, 2022 at 2:12 p.m., indicated .If a resident desires to participate in self-administration, the Interdisciplinary Team will assess .the resident .A physician order will be obtained specifying the resident's ability to self-administer medications .the resident's care plan will be updated to include self administration 3.1-45(a)(2)

Based on observation, interview and record review, the facility failed to ensure a resident with diabetes mellitus type 1 received her insulin and to notify the physician of elevated blood sugars for 1 of 6 residents reviewed for hospitalization (Resident 96). This deficient practice resulted in Resident 96 being hospitalized for [REDACTED]. Findings include: During an interview, on 09/04/19 at 10:37 a.m., Resident 96 indicated she was diagnosed with [REDACTED]. She did not like to take her insulin at night because she was afraid her blood sugar would go too low and she did not like the facility to mess with her insulin. The record for Resident 96 was reviewed on 09/06/19 at 10:39 a.m. [DIAGNOSES REDACTED]. A care plan, dated 06/08/2017 and last revised on 08/29/19, indicated the resident was a diabetic. The goal was to have blood sugars monitored and managed through nursing interventions. The approaches included, but were not limited to, document abnormal findings and notify the doctor, medications as ordered, monitor blood sugars as ordered, cover blood sugar as needed per physician's orders [REDACTED]. A Progress Note, dated 06/28/19 at 7:00 p.m. and recorded as a late entry, indicated the resident returned to the facility from a 10 day hospital stay. The hospital discharge medication instructions, dated 06/28/19, indicated the resident was to receive insulin [MEDICATION NAME] (fast-acting insulin) by sliding scale at bedtime and 12 units of insulin (long-acting) at bedtime. A physician's orders [REDACTED]. If the blood sugars were less than 60 mg/dL (milligrams per deciliter- a measurement used to determine the amount of sugar in the blood) or greater than 400 mg/dL, the physician was to be notified. A physician's orders [REDACTED]. A physician's orders [REDACTED]. A review of the Medication Administration Record (MAR) for 6/28/19 indicated the resident did not receive her insulin upon returning to the facility. She returned to the facility at 7:00 p.m. and her insulin orders were not entered into the MAR until 11:28 p.m and 11:31 p.m. At that time, her blood sugar was not assessed and her bedtime insulin was not given. A Progress Note, dated 06/29/19, indicated at 4:30 a.m. the resident was easily awakened and reported not feeling well that morning or the night before. A Progress Note, dated 06/29/19 at 5:45 a.m., indicated the resident refused her oral medications due to feeling ill. It did not indicate she refused her blood sugar assessment or if the nursing staff followed-up with the resident to reassess her condition. A review of the vital signs record, the MAR and the Progress Notes did not indicate the resident had any blood sugar checks after returning to the facility from 7:00 p.m. on 06/28/19 until 12:25 p.m. on 06/29/19, and her blood sugar at that time was 536 mg/dL. A review of the MAR for (MONTH) 2019 did not indicate why the resident's blood sugar was not assessed at 5:00 a.m. on 06/29/19. At 1:00 p.m., the resident's blood sugar was 536, the physician was notified and ordered 5 units of sliding scale insulin. However, the MAR did not indicate any insulin was given. A Progress Note, dated 06/29/19 at 5:24 p.m., indicated the (r)esident [MEDICAL CONDITION] at this time. Writer notified on call MD (medical doctor) and received one time insulin sliding scale coverage The Progress Note did not indicate the resident received the insulin. A review of the vital signs, MAR and Progress Notes, did not indicate the resident's blood sugar was reassessed until 9:14 p.m. According to the Vitals Report for 06/29/19, the resident's blood sugar was 399 mg/dL and the resident was given 3 units of insulin. A Progress Note, dated 06/29/19 at 10:44 p.m. did not indicate the resident refused to have her blood sugar assessed. The note was edited at 11:49 p.m., after the resident was sent to the hospital at 11:15 p.m., and indicated the resident complained of a stiff neck and abdominal pain. She refused to allow her blood sugars and bowel sounds to be assessed because she did not feel good. The nursing staff informed the resident the doctor would be contacted and the resident stated OK because she .(f)elt terrible and didn't (didn't) mind going back to the hospital The IP (inpatient)-Discharge Summary from the hospital, dated 07/07/19, indicated the resident was admitted to the hospital on [DATE] for diabetic ketoacidosis and was started on intravenous insulin. According to the Mayo Clinic website, diabetic ketoacidosis symptoms included, but were not limited to, abdominal pain, nausea and vomiting, which could develop very quickly, sometimes within 24 hours. During an interview, on 09/10/19 at 8:35 a.m., the Assistant Director of Nursing indicated the resident did not have any medications after being readmitted from the hospital the evening of 06/28/19 and because of the severity of her diagnoses, she needed her bedtime medications to be administered. The resident should have been assessed for blood sugars and insulin should have been given. The nurses should have notified the physician and done further assessments and she should have been reassessed after that one time insulin dose. There was no documentation that she was reassessed after the one time insulin dose. She ended up going back to the hospital later on 6/29 and was admitted for diabetic ketoacidosis. She was in the hospital from (MONTH) 29 until (MONTH) 7. During an interview, on 09/10/19 at 3:01 p.m., the Director of Nursing indicated the resident should have received her bedtime insulin and blood sugar checks on 06/28/19 and if she did not, there should be an explanation and documentation the physician was notified. 3.1-37(a)

Based on observation, interview and record review, the facility failed to ensure pressure injuries were assessed and staged according to standards, a physician notified of a change in a wound, treatments completed per orders, and prevention interventions in place for 4 of 5 residents reviewed for pressure injuries. (Resident J, H, K, and T) Resident J presented with sheering to her left hip in June 2017, the wound was not consistently monitored and was then found to be an unstageable ulcer (90% slough) in August 2017 and physician intervention was not sought timely when the wound began deteriorating. Findings include: 1. During the initial tour on 9/25/17 at 5:20 a.m., Resident J was observed in bed. RN 18 indicated the resident has a pressure ulcer on her left hip. The left hip was observed to have a large dressing in place dated 9/24/17. There was brownish drainage noted on the outside of the dressing. The record for Resident J was reviewed on 9/25/17 at 10:01 a.m. [DIAGNOSES REDACTED]. A new skin event, dated 6/15/17, indicated the resident had a 3.6 centimeter (cm) by (x) 2 cm shearing area on her left hip. New orders were received for [MEDICATION NAME] dressing daily. The June - August 2017 Treatment Administration Records (TARs) indicated the [MEDICATION NAME] treatment was utilized until 8/7/17. There were no weekly assessments of this area through 8/7/17. A plan of care, dated 8/7/17, indicated a stage 4 pressure ulcer to her left hip with a [DIAGNOSES REDACTED]. Approaches included, but were not limited to, treatment per orders, pressure reducing mattress, and turn and reposition every 2 hours. Wound Management sheets indicated: Initial wound evaluation: 8/8/17: left hip 2.5 cm x 3.8 cm x 0.1 cm, stage 2, 90 % slough. 8/17/17: 2.8 cm x 4 cm x 0.1, stage 2, 95 % slough, light drainage 8/23/17: 2.5 cm x 3.8 cm x 0.1 cm stage 2, 95 % slough moderate exudate, new treatment order obtained. 8/29/17: 2.8 cm x 3.8 cm x 0.1 cm, stage 2, 80 % slough, heavy [MEDICAL CONDITION] drainage (yellow or tan, cloudy and thick) with foul odor. Physician was notified and new orders obtained. 9/7/17: 6.8 cm x 4.8 cm x 2 cm stage 4, heavy purulent drainage (opaque milky, sometimes green) 80 % slough. Debrided at wound care clinic on 9/6/17. 9/20/17: 7 cm x 5.3 cm x 2.9 cm, stage 4, moderate serosanguineous drainage, undermining 2.2 at 9 o'clock, 100 % slough. Debrided by wound care center this day. Physician orders [REDACTED]. 8/8-8/23/2017 cleanse left hip with normal saline, apply therahoney to wound bed, skin prep to peri wound area, cover with a foam dressing twice daily and as needed. 8/23-9/4/2017 cleanse left ischium with skin integrity wound cleaner, apply silver alginate to wound bed and cover with [MEDICATION NAME] once daily. 9/1-9/11/2017 cleanse left hip with skin integrity wound cleanser apply zinc oxide to periwound apply tender wet active to wound bed then cover with gauze dressing and border gauze. 9/7-9/14/2017 cleanse wound to left hip with normal saline apply silver alginate to wound bed, apply skin prep to peri wound, cover with ABD (abdominal dressing) pad, secure with cover roll daily. The TAR for 9/1-9/14/2017, indicated 2 different treatments were being performed on the same area. Progress notes indicated: 8/10/2017 at 8:34 p.m., dressing changed done to left hip with moderate amounts of yellowish reddish drainage noted on old dressing. Wound bed noted to be brownish in color with a small area of pink observed. Bleeding noted during the procedure. 8/11/17 8:07 p.m., dressing change done twice this shift due to increase in drainage to left hip. Large amounts of yellowish reddish drainage noted on old dressing. Wound bed noted brownish in color with a small area of pink observed. 8/12/17 4:40 p.m. dressing changed to right (sic) hip. Moderate amount of yellowish/brown drainage noted. Wound was various colors white, brown and pink. Tender when touched. 8/14/17 7:54 p.m. dressing changed as ordered, tunneling noted at 9 o'clock, wound bed noted brown in color, moderate amount of brownish drainage. Some discomfort noted during procedure. Resident stated pain was a throbbing pain of an 8 on a scale 10 being worst. 8/17/17 IDT (Interdisciplinary team) wound review: Stage 2 ulcer to left ischium stable at this time. 8/23/17 IDT wound review: Stage 2 to left ischium stage at this time. 8/31/17 2:32 p.m. Nutrition as Risk review Stage 2 pressure ulcer R (right) ischium wound noted decline including foul odor, heavy amounts of [MEDICAL CONDITION] drainage and slight increase in wound size. Resident remains at risk for decline due to refuses to off load pressure ulcer by laying down between meals and had chronic contractures of bilateral hips. Physician was notified and new orders were obtained for treatment and wound culture. 9/1/17 wound culture obtained. 9/7/17 IDT wound review Stage 4 pressure ulcer to left ischium is noted to be declining. Has been seen out of facility at wound clinic. Root cause of wound is noted to be related to the breakdown of foam to the resident's customized wheelchair. Resident's position and contractures do not allow for pressure to off the left ischium at any time. Broda chair ordered with Roho cushion and to be up on 30 minutes for meals. (Name of Hospital) wound clinic visit note, dated 9/6/17, indicated an initial visit for Stage 4 left hip ulcer. The ulcer was large, deep and was present for some time. Measurements were 6.8 cm x 4.8 cm x 2 cm, with necrotic tissue and strong odor. The area was debrided. She needed alternating air bed and Roho cushion. .Suspect this wound is months old and she likely has osteo[DIAGNOSES REDACTED] Progress notes failed to indicate the physician was notified or treatment was changed when the wound started to show signs of deterioration on 8/11/17 until 8/31/17. During an interview with the DON (Director of Nursing) and the RN Consultant on 9/26/17 at 11 a.m., the DON indicated the area to the left hip started as sheering in June and then was incorrectly coded as a stage 2 on 8/8/17. A wound with slough should have been coded an unstageable wound. When she came to the facility as the DON, she recognized the wound had been incorrectly coded and she restaged the wound as a stage 4 on 9/7/17. The RN Consultant indicated there was no additional information to add related to the wound from June to August when it presented with slough. 2. During the initial tour at 5:51 a.m. with RN 18, Resident H was in bed. The RN indicated the resident had a pressure ulcer to her coccyx. At this time during observation, the RN rolled the resident onto her side. The was no dressing on the coccyx area. There was a wound observed on the coccyx which was open, dark in color and depth could be observed. The RN indicated she would have to check with the CNA who provided to care to know how long the dressing had been off. During an interview on 9/25/17 at 6 a.m. with RN 18 and CNA 19, CNA 19 indicated she did the last bed check around 4:30 a.m., and she was not clear if the dressing had come off during care or was not on at that time. She had not reported the dressing being off to the nurse. The record for Resident H was reviewed on 9/25/17 at 8:50 a.m. [DIAGNOSES REDACTED]. An 8/9/17 Annual Minimum Data Set (MDS) Assessment indicated the resident had a Stage 2 pressure ulcer (partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed without slough. May also present as an intact or open/ruptured.) A Significant change MDS was initiated on 9/26/17 for increase in Stage in pressure ulcer to a stage 3 (full thickness tissue loss. Subcutaneous fat may be visible but not bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling) A plan of care, dated 7/19/17 and updated on 9/22/17, indicated the resident had a stage 3 to her coccyx with approaches that included, but were not limited to, assess for pain and treat as ordered, notify physician of unrelieved pain or worsening pain, assess wound weekly documenting measurements and descriptions, notify physician of worsening, treatment as ordered, diet and supplements as ordered. Physician orders, dated 9/21/17, indicated an order for [REDACTED]. Wound measurements indicated: 7/20/17: initial wound evaluation coccyx 0.3 cm x 0.2 cm stage 2 7/27/17: 2.5 cm x 2 cm x 0.2 cm, stage 2 tissue type slough 8/3/17: area to coccyx was healed 9/6/17 12:22 p.m.: skin event indicated the resident had an open area to her coccyx/moisture associated [MEDICAL CONDITION] that originated on 8/23/17 and was a partial thickness wound measuring 1.5 cm x 0.8 cm x 0.1 cm with serous, yellow drainage. New order was obtained for silver collagen and [MEDICATION NAME]. 9/14/17: 1.3 cm x 0.8 cm x 0.2 cm, stage 3, slough 10 % 9/20/17: 1.4 cm x 0.4 cm x 0.3 cm, stage 3, slough 75 %, The record lacked any wound assessment from 8/23/17 when first noted until 9/6/17. Progress notes indicated: 7/19/17 Progress notes indicated found with two open areas to buttocks physician was notified and orders were received. 7/22/17 wound to coccyx was a stage 2, spreading over to right buttocks. 7/27/17 IDT notes, wound to coccyx was stable. 8/10/17 Dressing change to coccyx, moderate amount of drainage. 9/6/17 IDT coccyx wound healing slowly. 915/17 complaint of tenderness to coccyx area with cleaning and touching. Treatment complete with alginate and [MEDICATION NAME]. 9/20/17 IDT stage 3 wound to coccyx, improvement from last week. Dermafloat mattress ordered and new treatment implemented. During an interview with the DON on 9/26/17 at 1 p.m., she indicated she was unable to find an initial assessment of the wound for 8/23/17. 3. During the initial tour on 9/25/17 at 6:05 a.m., Resident K was observed in bed with an undated dressing to his right foot and bilateral heel boots were in place. On 9/25/17 at 6:56 a.m., CNA 20 was observed to provide a.m. care and transfer the resident to his wheelchair. He was transported to the dining room with bilateral boots in place and without foot pedals to the wheelchair. On 9/25/17 at 7:31 a.m., he was observed in his wheelchair in the dining room without foot pedals. On 9/26/17 at 9:30 a.m., the resident was observed being transported in his wheelchair in the hallway by the DON. He had bilateral boots on, resting on the floor, without foot pedals to his wheelchair. At that time during interview, the DON indicated she was taking him to find foot pedals for his wheelchair. The record for Resident K was reviewed on 9/25/17 at 12:30 p.m. [DIAGNOSES REDACTED]. A plan of care, dated 9/22/17, indicated impaired skin integrity to right heel for deep tissue injury related to tennis shoe rubbing. Approaches included, but were not limited to, no shoes, off loading boots on, weekly assessment, and notify physician of changes. Physician orders [REDACTED].>8/24/17 apply skin prep to the right heel 9/25/17 cleanse right heel with wound cleaner, apply skin prep to right heel, cover with heel foam and wrap with kerlix and secure with tape at bedtime. Progress notes indicated: 8/23/17 fluid filled blister to right heel intact. 8/24/17 IDT note off loading boots and skin prep for right heel. 8/31/17 wound healed. 9/22/17 right heel wound, small in size, the resident agrees to wear blue float boots. .Nurse to obtain wc (wheelchair) pedals to off load feet on 4. During the initial tour on 9/25/17 at 6:02 a.m., RN 18 indicated Resident T had multiple wounds, some were surgical, non-pressure and she did have a pressure wound to her coccyx. At this time during interview, the resident indicated her dressings did not routinely get changed as they should. This a.m., the Executive Director had come into her room and she told him, her dressings not been changed. She indicated he had them changed immediately. Her present dressing to the coccyx was dated 9/25/17. The record for Resident T was reviewed on 9/25/17 at 9:36 a.m. [DIAGNOSES REDACTED]. A plan of care, dated 8/17/17 and undated on 9/25/17 at 6:52 a.m., indicated the resident had a stage 3 pressure ulcer to the coccyx with approaches that included, but were not limited to, treatment as ordered. Current Physician orders [REDACTED]. A 9/7/17 wound note indicated, all wounds are noted to decline this week as evidenced by increase in exudate, blanchable redness to all periwound areas and larger and deeper measurements. Wound measurement notes indicated: 9/20/17 coccyx 2 cm x 1 cm x 0.2 cm, stage 3, 89 % slough 9/14/17 coccyx 1.8 cm x 2 cm x 0.1 cm, stage 2, granulation 75 % well defined edges. 9/6/17 coccyx 2 cm x 2 cm x 0.2 stage 2, 100 % granulation. 7/25/17 initial wound 3.5 cm x 2.8 cm x 0.3 cm, stage 2 Treatment Administration Records (TARs) for September 2017 indicated the dressing to her coccyx wound was not changed as ordered on [DATE] and 9/23/17 upon rising. A policy titled, Skin Management Program dated 9/2016, was provided by the DON on 9/26/17 at 1 p.m. and deemed as current. The policy indicated: .3. Offloading devices will be utilized .8. Any skin alterations noted by direct care givers during daily care .must be reported to the licensed nurse for further assessment .10 .b) Direct care givers will be notified of the resident's specific prevention interventions .Procedure for alterations in Skin Integrity .4. The wound nurse .will be notified of alterations in skin integrity .a) The facility must have an assigned wound nurse that assessed the wounds on a weekly basis .5. Direct care givers will be notified of skin alterations and specific care needs The National Pressure Ulcer Advisory Panel press release, dated 4/13/16, indicated the new definitions for pressure injuries. .Stage 2 Pressure Injury: .Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, and may also present as an intact or ruptured serum filled blister. Adipose (fat) tissue and deeper tissue is not viable. Granulation tissue, slough and eschar are not present .This stage should not be used to describe moisture associated skin damage (MASD) .Stage 3 Pressure Injury: . Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible .If slough or eschar obscures the extent of the tissue loss this is an Unstageable Pressure Injury .Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar This Federal tag relates to Complaints IN 199 and IN 930. 3.1-40(a)(2)

Based on record review and interview, the facility failed to notify the physician regarding a resident's vomiting and diarrhea for three consecutive days resulting in a hospitalization for 1 of 40 residents reviewed for physician notification. (Resident #97) Findings include: The clinical record of Resident #97 was reviewed on 5/16/13 at 10:00 A.M. [DIAGNOSES REDACTED]. A care plan, dated 12/10/12, titled "At risk for fluid imbalance related to:[MEDICAL CONDITION] or other infection, needs assistance with food and fluids, 9 or more meds." Goals included, but were not limited to: "Will remain free from dehydration or fluid overload, Notify MD (medical doctor) if dehydration or fluid overload noted, observe fluid intake, observe for symptoms of dehydration/fluid overload: dry pale mucous membranes, skin tenting, decreased urine output, SOB (shortness of breath), dyspnea, increased [MEDICAL CONDITION]." A nursing note, dated 12/26/12 at 4:11 P.M., indicated "...2 reported episodes of emesis noted this shift. Small amount of greenish emesis noted...." A nursing note, dated 12/26/12 at 9:50 P.M., indicated "...Reports emesis during the day and not feeling well." A nursing note, dated 12/27/12 at 1:02 A.M., indicated "Resident states that he cannot even keep water down and that he has had small amounts of emesis this evening...." A nursing note, dated 12/28/12 at 12:45 P.M., indicated "Resident sent to (name of hospital) via ambulance for diarrhea x 3 days...dark red blood noted in urine catheter bag...." A review of the Intake and Output report, dated 12/21/12 to 12/25/12, indicated the oral intake was monitored but the urine output was not. Input and output records were requested for 12/26/12 to 12/28/12 but were not received prior to the final exit. A hospital report, dated 12/28/12, indicated Resident #97 had dehydration with acute [MEDICAL CONDITION]. During an interview with the Director of Nursing (DON), on 5/16/13 at 2:30 P.M., she indicated the notification of the physician or nurse practitioner could not be found. 3.1-5(a)(2)

Based on record review and interview, the facility failed to maintain hydration to prevent dehydration, resulting in a hospitalization , for 1 of 1 resident for fluid imbalance in a sample of 40. (Resident #97) Findings include: The clinical record of Resident #97 was reviewed on 5/16/13 at 10:00 A.M. [DIAGNOSES REDACTED]. A care plan, dated 12/10/12, titled "At risk for fluid imbalance related to:[MEDICAL CONDITION] or other infection, needs assistance with food and fluids, 9 or more med's." Goals included, but were not limited to: "Will remain free from dehydration or fluid overload, Notify MD (medical doctor) if dehydration or fluid overload noted, observe fluid intake, observe for symptoms of dehydration/fluid overload: dry pale mucous membranes, skin tenting, decreased urine output, SOB (shortness of breath), dyspnea, increased [MEDICAL CONDITION]." A nursing note, dated 12/26/12 at 4:11 P.M., indicated "...2 reported episodes of emesis noted this shift. Small amount of greenish emesis noted...." A nursing note, dated 12/26/12 at 9:50 P.M., indicated "...Reports emesis during the day and not feeling well." A nursing note, dated 12/27/12 at 1:02 A.M., indicated "Resident states that he cannot even keep water down and that he has had small amounts of emesis this evening..." A nursing note, dated 12/28/12 at 12:45 P.M., indicated "Resident sent to (name of hospital) via ambulance for diarrhea x 3 days...dark red blood noted in urine catheter bag...." A review of the Intake and Output report, dated 12/21/12 to 12/25/12, indicated the oral intake was monitored but the urine output was not. Input and output records were requested for 12/26/12 to 12/28/12 but were not received prior to exit. During an interview with the Director of Nursing (DON), on 5/16/13 at 2:30 P.M., she indicated the notification of the physician or nurse practitioner could not be found. A hospital report, dated 12/28/12, indicated Resident #97 had dehydration with acute [MEDICAL CONDITION]. 3.1-46(b)

Based on observation, interview, and, record review, the facility failed to ensure residents were assessed for fall risk, effective interventions were implemented and revised, and care plans were updated to prevent falls, resulting in a resident sustaining a fractured nose, a fractured arm and a subarachnoid (brain) hemorrhage and resulting in repeated falls for 5 of 5 residents reviewed with falls in a sample of 6. (Residents #B, #C, #E, #G, #H). Findings include: 1. On 1/26/12 at 10:40 A.M., Resident #B was observed sitting in the hallway in a Broda chair. There was a Hoyer lift pad under the resident. He had a sling on his left arm. On 1/27/12 at 8:50 A.M., Resident #B was observed sitting in the Cafe Dining Room in a Broda chair. There was a Hoyer lift pad under the resident. There was dycem (a material to prevent sliding) between the Hoyer lift pad and the wheelchair seat. Resident #B's clinical record was reviewed on 1/26/12 at 11:30 A.M. The record indicated the resident was admitted with [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) Quarterly assessment dated [DATE], indicated the resident was severely impaired in cognitive decision-making skills, required extensive two-person physical assistance for transfer and toilet use, was non-ambulatory, was not steady during transitions and walking and was able to stabilize with human assistance, and had had a fall with no injury. A Fall Risk assessment dated [DATE], indicated the resident had had a history of [REDACTED]. Further review indicated "If any answer above is 'yes', the resident is at risk for experiencing a fall. Proceed to care plan with appropriate interventions based upon the risk factor(s)..." A Physical Therapy "Plan of Treatment" dated 9/12/11 indicated "...Reason for Referral: Recent pattern of falls indicating safety concerns with balance and mobility...Precautions: Fall risk...Current Level of Function...Standing Balance: General - The patient demonstrates standing balance of F (fair) dynamic (able to maintain balance without balance loss or UE (upper extremity) suport (sic) and min (minimal) weight shift ipsilaterally/front, difficulty crossing midline without balance loss) and maintains for 5 minutes requiring 15% stand by assistance (close enough to reach patient if assist needed)..." A resident care plan dated 9/27/11 indicated "Resident is at risk for falls r/t (related to) DX (diagnosis) dementia, arthritis, vitamin defeciency (sic), HX (history) falls, psychotropic use, antihypertensive use, narcotic use, incontinence, impaired mobility, impaired vision, impaired gait and balance, use of assistive device, HX noncompliance, poor safety awareness...Approach...Fall risk assessment...Observe for fall risk contributors such as medications, hypotension, pain, unsteady gait...Provide appropriated assistive devices such as Broda with dycem, hoyer for transfers, romove (sic) hoyer pad from chair after transfer bed low with mat on floor...Provide assistance for transfers, bed mobility...Refer to therapies for screening. A physician's orders [REDACTED]. Nurses' notes indicated: 9/17/11 at 2:00 P.M. "...needs frequent reminders to use walker - gait unsteady..." 9/28/11 at 10:15 A.M. "...often forgets to use walker, is reminded to use walker per staff..." 9/29/11 at 10:15 A.M. "...has to be reminded to use walker..." 10/19/11 at 12:30 P.M. "...has atempted (sic) to get up on own a few times, but decreased from yesterday..." 10/20/11 at 1:30 P.M. "...gait unsteady, but does not follow commands easily when trying to direct to walk..." 10/21/11 at 1:00 A.M. "...gets up frequently s (without) assistance, gait unsteady..." 11/4/11 at 11:00 A.M. "...extensive assist x ii (two) c (with) ADLs (activities of daily living) toileting et (and) transfers, not ambulatory as well, unable to follow directions..." 11/21/11 at 9:39 A.M. "Res (resident) was sittin (sic) in w/c (wheelchair) in dining room. Res had scouted (sic) forward to the edge of his sest (sic) and slipped onto the floor...Fall was witnessed...Res was repositioned in w/c and pulled up to the table where he could be monitored by staff. Res continued to be observed and repositioned in w/c when needed by staff." An IDT (interdisciplinary team) note dated 11/22/11 at 9:24 A.M. indicated "IDT safety review...res was sitting on hoyer pad in w/c...No injuries occurred (sic)...Staff will be instructed on not leaving hoyer pad under res in w/c and therapy will check for w/c positioning..." A "Fall Circumstance Report" dated 11/21/11 indicated "...What intervention(s) was put in to place to prevent another fall?...Res was repositioned in chair, pulled up to a table and placed where he could be monitored by staff..." A physician's orders [REDACTED]. Interview on 1/27/12 at 11:25 A.M. with the Executive Director indicated there were no therapy notes available for review related to the 11/21/11 fall or the use of the Broda chair. A nurses' note dated 12/7/11 at 5:27 P.M. indicated "called into room. Resident was found on floor on his side. No injuries noted...Resident placed in chair, et brought to dinner..." An IDT note dated 12/8/11 at 9:13 A.M. indicated "...Res. noted laying on right side next to bed facing bed room door...Res. unable to explain how they fell ...Nurse immediate intervention, replaced O2 per NC (nasal cannula), assisted back to bed...IDT agrees to put bed low with mat on floor. Bed against wall at this time...Care plan updated..." A resident care plan dated 9/27/11 and updated 12/8/11 indicated "...Bed in lowest position...hoyer lift for transfers...Mat on floor..." A nurses' note dated 12/26/11 at 8:32 P.M. indicated "Resident found on floor in room sitting on buttocks on foot rest of broda chair. Appears that resident slid self to edge of seat and 'slid' down to foot rest. No injury noted..." An IDT note dated 12/27/11 at 10:24 A.M. indicated "...IDT agrees that all interventions were effective at this time and staff awareness prevent fall (sic). Will continue all current interventions. Interventions include broda, bed low position with mat on floor..." An "Event Report" dated 12/26/11 indicated "...Sitting in broda chair in resident room...unable to provide statement due to dementia...What intervention(s) was put in place to prevent another fall...resident will not be left alone in room in broda chair..." A resident care plan dated 9/27/11 indicated documentation was lacking related to any additional interventions being implemented to prevent further falls after the 12/26/11 fall. A nurses' note dated 1/17/12 at 1:41 P.M. indicated "Resident admitted to (hospital name) with dx (diagnosis): nasal fx (fracture), left humerus fx and subarachnoid hemorrhage..." An IDT note dated 1/18/12 at 9:44 A.M. indicated "IDT fall review...Res. lying on bed fully clothed (sic) with hoyer pad underneath him. CNA left room to get assistance with hoyer transfer. Nurse called to room d/t (due to) res lying on floor next to mat on floor. Res. c/o (complained of) pain to left shoulder and to nose. Laceration noted to right and left side of bridge of nose...Current interventions in place: bed low with mat on floor and bed against wall...IDT agrees to review room for safety prior to return. Education on staff on hoyer transfers, do not leave res in room with hoyer pad underneath. Upon return from hospital will continue previous interventions of bed low with mat on floor and may have bed against wall, res not to be left in room when not in bed..." An "Event Report" dated 1/17/12 indicated "...What intervention(s) was put into place to prevent another fall...Resident already has low bed with mat on floor..." A hospital consultation report dated 1/17/12 indicated "...he had a fall today, falling forward, striking his nose and his left shoulder. He has a fracture of the left humerus. He is noted to have a nasal fracture and in addition on the CT (computed tomography) scan of his head, had a tiny dot of focal traumatic subarachnoid hemorrhage in a sulcus in the right frontoparietal convexity region (a bleeding in the brain)." A resident care plan dated 9/27/11 and updated 1/18/12 and 1/20/12 indicated "...Broda chair with dysem...Assess room for safety...resident not to be left alone in room unattended unless in bed...." A "CNA Alert Sheet" dated 1/26/12, provided by the Executive Director and identified as current, indicated "...not to be left alone when out of bed..." Documentation was lacking related to not leaving a hoyer lift pad under the resident. CNA #3's employee file was reviewed on 1/27/12 at 11:05 A.M. A job description signed by the employee on 10/20/11 indicated "...Transfer...Obtains assistance of another staff member if needed before starting to transfer a resident..." Interview on 1/27/12 at 9:40 A.M. with the Executive Director and the Director of Nursing indicated the criteria for discontinuing alarms were they "cause increased agitation and cause more harm." They indicated the alarms had been discontinued on 9/9/11 because it was "the standard then" to apply alarms on admission if at risk for falls and there was no order to apply alarms. The Executive Director indicated after the 1/17/12 fall, the room was checked for safety and the CNA had been disciplined. He indicated she had been trained on the procedure for the lift and transfers and should have known not to leave the resident on the hoyer pad. 2. On 1/26/12 at 1:15 P.M., Resident #C was observed sitting in the dining area of the memory care unit. The resident's rolling walker was next to her. There was no alarm in place on the chair. Staff was present in the dining area. Resident #C's clinical record was reviewed on 1/26/12 at 1:10 P.M. The record indicated the resident was admitted with [DIAGNOSES REDACTED]. The resident had been a previous resident in the facility and had been readmitted . An MDS Admission assessment dated [DATE], indicated the resident was severely impaired in cognitive decision-making skills, required limited one-person physical assistance for transfer and toilet use, required supervision for ambulation, was not steady but able to stabilize without human assistance for balance, and had had no falls. Interview on 1/27/12 at 11:25 A.M. with the Executive Director indicated a fall risk assessment for Resident #C could not be located for review. A resident care plan dated 11/30/11 indicated "...Fall risk related to: weakness, DX anemia, Alzheimer's, colon cancer...HX noncompliance with interventions, i.e. res had tendency to remove gripper socks...Approach...Encourage and remind resident to use call light...Fall risk assessment...Observe for fall risk contributors such as medications, hypotension, pain, unsteady gait...Provide assistance for transfers, bed mobility...Refer to therapies for screening..." Nurses' notes indicated: 12/30/11 at 1:40 P.M. "...ambulates with walker independently..." 1/3/12 at 1:24 A.M. "...Resident displays a very short-term memory, since she has no memory of the conversations, and incidents..." 1/15/12 at 8:15 P.M. "Res found in room lying on R (right) side in front of roommate's bed....Res stated that she stubbed her toe on 'that' (res referring to roommate's walker)...Res had removed gripper socks while in bed et (and) was not wearing them at the time of the fall. Res is often non-compliant et refused to wear gripper socks or shoes. Res often had to be reminded to use walker while ambulating...Will continue to observe..." An "Event Report" dated 1/15/12 indicated "...Res stated that she stubbed her toe on walker (walker belonged to another resident et resident was digging through other resident's belongings inside basket attached to walker)...No injuries...What intervention(s) was put into place to prevent another fall...Gripper socks reapplied, res currently sitting in main area on continuous monitoring..." A resident care plan dated 11/30/11 and updated 1/16/12 indicated "...Resident to wear hipsters except while bathing..." Documentation was lacking related to the resident wearing gripper socks. Nurses' notes indicated: 1/17/12 at 5:29 P.M. "...Res removed gripper socks et shoes..." 1/18/12 at 9:53 P.M. "Res found on floor sitting on buttocks @ 9:30p. Unwitnessed fall. Res was in other resident's room (uninvited)--had removed shoes et had them sitting beside her. Res had also removed gripper socks. Res has been non-compliant all shift...Res will not leave gripper socks or shoes on. Res will not amb (ambulate) with walker..." An "Event Report" dated 1/18/12 indicated "...Resident was in other resident's room, without permission...shoes et gripper socks off (res had removed)...What intervention(s) was put into place to prevent another fall...Gripper socks, shoes reapplied..." A resident care plan dated 11/30/11 indicated documentation was lacking related to any additional interventions being implemented after the 1/18/12 fall to prevent further falls. Nurses' notes indicated: 1/19/12 at 12:49 A.M. "...non-compliant with using walker and kept taking shoes and socks off prior to bed. Will continue to monitor..." 1/20/12 at 3:39 P.M. "...res requiring 1:1 attn (attention) and still getting up and down. Gait is unsteady and resident has nearly fallen several times in the last couple hours..." 1/20/12 at 10:55 P.M. "...CNA 1:1 at this time..." 1/20/12 at 11:25 P.M. "Resident found on floor in her room in front of the bathroom door lying flat on her stomach by CNA...last checked less than 5 min (minutes) prior to fall...resident sitting in chair in dining area for close monitoring due to poor safety from sedation and restlessness, gait unsteady..." An "Event Report" dated 1/20/12 indicated "...Resident was in bed resting but tossing and turning, hallucinating (sic) seeing bugs crawling and biting on blanket. Was sent to ER (emergency room ) earlier due to increased agitation. Resident sedated...What intervention(s) was put into place to prevent another fall...Resident was brought out to dining area and sat in chair to monitor one on one due to getting out of bed frequently, restlessness, sedation, and visual hallucinations..." A resident care plan dated 11/30/11 indicated documentation was lacking related to any additional interventions being implemented after the 1/20/12 fall to prevent further falls. Nurses' notes indicated: 1/21/12 at 12:00 A.M. "...attempted to get up q (every) 2-3 min...Continuing to monitor one on one at this time..." 1/21/12 at 4:08 A.M. "...2 assist as gait unsteady..." 1/21/12 at 2:00 P.M. "resident sitting on floor in room next to bed...will continue to observe..." An "Event Report" dated 1/21/12 indicated "...Resident was sitting on her buttock next to her bed...No injuries noted...What intervention(s) was put into place to prevent another fall...Re-educate the use of call light. Resident brought to dining room for observation and safety..." A resident care plan dated 11/30/11 indicated documentation was lacking related to any additional interventions being implemented after the 1/21/12 fall to prevent further falls. Nurses' notes indicated: 1/22/12 at 1:00 A.M. "Resident being checked on frequently due to unsteady gait, went to check on resident and was sitting up in bed, states going to the bathroom...will continue to monitor..." 1/22/12 at 11:30 P.M. "Resident was sitting in dining room looking at magazines, CNA was sitting with resident as was called away due to noise heard in another residents room. Resident got up and as writer looked over to check on resident she collapsed down on her right side to the floor, when got to resident her head was under a dining room chair and was lying on right side with her right arm underneath her...resident stated her head hurt and held right side of temporal area...send out to ER at (hospital name) to be evaluated...1 cm (centimeter) bump just above right temporal at scalp and resident complaining of right anlke (sic) pain..." 1/23/12 at 1:48 A.M. "Received report form (sic) (hospital name) ER, found no injuries..." 1/23/12 at 2:47 A.M. "Resident back from ER, arrived via ambulance on gurney, no new orders received, taken to bathroom...gait unsteady with 2 assist..." An IDT note dated 1/23/12 at 8:00 A.M. indicated "IDT review of falls on 1/21/12 (sic) at 11:25 P.M., 1/21/12 at 2:50 P.M., and 1/22/12 at 11:30 P.M....Interventions include bed and chair alarms, be sure of whereabouts, bed low, assist to transfer, hipsters...IDT agrees have MD review meds for risk vs. benefits, are waiting on a bed in psych unit for eval (evaluation)..." An IDT note dated 1/23/12 at 9:22 A.M. indicated "...IDT review of falls addendum. Resident had temporary 1:1 monitoring in place on 1/21/12 thru today...Will continue temporary 1:1 monitoring PRN..." An "Event Report" dated 1/23/12 indicated "...CNA had benn (sic) doing one on one w/ (with) resident, CNA heard noise which was another resident up out of bed walking w/o (without) assistance. Nurse saw resident begin to ambulate w/o walker and resident collapsed to floor. Hit floor hard, head under MDR (main dining room) chair...bump on rt (right) temporal area 1 cm...What intervention(s) was put into place to prevent another fall...bed and chair alarm. bed already in low position, hipster in place, observing one on one when needed..." Nurses' notes indicated: 1/24/12 at 2:11 A.M. "...She occasionally awakens and attempts to get up from chair..." 1/24/12 at 4:25 A.M. "Resident was sitting in her rocker with her clip alarm on. Heard alarm sound and responded in time to see resident sit on her bottom and then lie back...States she was hungry and got up to get something to eat..." An IDT note dated 1/24/12 at 9:38 A.M. indicated "...continue to wait for bed at (hospital name) for psych stay...Care plan up to date..." An "Event Report" dated 1/24/12 indicated "...Sitting on bottom on floor...Memory Care Dining room...No injuries...Resident stood from chair and before I could get to her sat on her bottom on the floor... intervention(s) was put into place to prevent another fall...Resident already had clip alarm, bed alarm, low bed and gripper socks..." A resident care plan dated 11/30/11 indicated documentation was lacking related to any additional interventions being implemented after the 1/24/12 fall to prevent further falls. A resident care plan dated 11/30/11 and updated 1/23/12 indicated "...attempt 1:1 supervision PRN (as needed)...Be aware of resident's whereabouts...bed and chair alarm...bed in lowest position except when providing care..." A "CNA Alert Sheet" dated 1/26/12, provided by the Executive Director and identified as current, indicated "...hipsters...bed and chair alarms...be sure of res whereabouts...bed low..." Documentation was lacking related to ensuring the resident had gripper socks/shoes in place. Interview on 1/27/12 at 9:40 A.M. with the Director of Nursing indicated "one on one doesn't mean having someone sit with her. It meant giving her more attention." She indicated the CNA should have stayed with the resident. 3. On 1/26/12 at 10:09 A.M., Resident #E was observed sitting on the edge of her bed in her room. The call light was next to her. There was a wheelchair with anti-roll brakes on the opposite wall from the bed. There were no alarms in place. On 1/27/12 at 8:50 A.M., Resident #E was observed sitting in her room in a chair eating breakfast. The call light was lying on the bed across the room. The wheelchair was next to the resident's chair with the back of the chair facing the resident. There was a sign above the bed indicating the "red button" should be pushed for help and a piece of red tape was on the call light. On 1/28/12 at 9:25 A.M., Resident #E was observed sitting in her room in a chair. The call light was lying on the bed across the room. There was a sign above the bed indicating the "red button" should be pushed for help and a piece of red tape was on the call light. Resident #E's clinical record was reviewed on 1/26/12 at 12:30 P.M. The record indicated the resident was admitted with [DIAGNOSES REDACTED]. An MDS Quarterly assessment dated [DATE] indicated was severely impaired in cognitive decision-making skills, required limited one-person physical assistance for transfer and ambulation, required extensive one-person physical assistance for toilet use, was not steady but able to stabilize with human assistance for balance, and had had no falls. Fall risk assessments dated 10/6/11, 10/12/11, 10/16/11 and 10/24/11 indicated the resident had had falls in the previous 3 months, demonstrated evidence of impaired gait/balance, had a history of [REDACTED]. Further review indicated "If any answer above is 'Yes', the resident is at risk for experiencing a fall. Proceed to care plan appropriate interventions based upon the risk factor (s)..." A resident care plan dated 7/21/11, indicated "...Resident is at risk for falls r/t...impaired gait and balance...HX falls...poor safety awareness, HX noncompliance, does not use call light...HX refusing proper fit shoe wear, refusal of helmet, refusal of hipsters...refusal of alarms, and refusal by family to transfer resident to smaller unit in room in common/dining area...Approach...All staff are to assist resident with feeding birds...Encourage and remind resident and staff that resident is NOT to go outside to feed birds unassisted...Fall risk assessment...Observe for fall risk contributors such as medications, hypotension, pain, unsteady gait...Provide assistance for transfers, bed mobility...Refer to therapies for screening...Proper lighting in non clutter environment...Therapy screen quarterly and PRN..." Further review indicated "9/16/11 may have bed against wall for room arrangement...9/25/11 antirollback brakes to promote safety...10/6/11 offer to toilet upon rising, before and after meals, at HS (hour of sleep), et q (every) 2 hours et PRN at NOC (night)..." A Medication Administration Record (MAR) dated November 2011 indicated "9/19/11 Bed pad alarm due to poor safety awareness to notify staff of unassisted transfers. Check placement every shift...9/19/11 Chair pad alarm due to poor safety awareness to notify staff of unassisted transfers. Check placement and function every shift..." A nurses' note dated 10/16/11 at 10:00 P.M. indicated "....Resident was found on the floor at 8:45 p. Resident sated that she was trying to pull up her brief when she fell ...alarm was placed on chair by doorway..." A "Fall Circumstance Report" dated 10/16/11 indicated "...Was trying to pull up brief. No alarm went off because resident was sitting in chair by door with no alarm...What intervention(s) was put in place to prevent another fall? Alarm was put onto the chair by the door. Resident teaching that she needs to have someone in the room if she is going to get up from her chair/bed. Old that if she wants to be out in the halls that she needs to be in her w/c and not walking..." Nurses' notes indicated: 10/18/11 at 9:00 P.M. "...non-compliant c (with) attempt to amb (ambulate) unassisted. Attempts to turn off alarms on her own when they sound..." 10/20/11 at 7:00 P.M. "... non-compliant c (with) call light..." 10/24/11 at 2:15 P.M. "Res in WC (wheelchair) in hallway. Res stood up et alarms sounded. Staff went in direction of res. Res gait was unsteady. Res went to knees..." A "Fall Circumstance Report" dated 10/24/11 indicated "...Res strolling through hallway...on knees in front of W/C...0 (no) injuries...What intervention(s) was put in place to prevent another fall? Taken to the bathroom/offered snack. Walked c (with) res..." Nurses' notes indicated: 10/25/11 at 7:25 P.M. "...Continues to be non-compliant c (with) call light et self transferring. Chair pad et bed pad alarms in place et functioning..." 10/26/11 at 2:00 A.M. "...Has made several attempts to transfer s (without) assist this shift...Alarms in place et functioning..." 10/28/11 at 12:10 A.M. "...Res has made multiple attempts to transfer s (without) assistance this shift...Alarms in place et functioning..." 10/28/11 at 6:00 P.M. "Res found on floor..." An IDT note dated 10/31/11 indicated "IDT review of fall that occurred on 10-28-11 @ 6pm...Team also agreed to D/C (discontinue) all alarms due to it causes resident to have increased (indicated by arrow) agitation and are not proventing (sic) residents falls. Agreed to toilet resident q20 (every two hours) while awake...resident does not use call light and continues to want to ambulate independently. Resident has unsteady gait and poor balance...careplan updated..." A "Fall Circumstance Report" dated 10/28/11 indicated "...Walking around room...What intervention(s) was put in to place to prevent another fall? (The form was blank)..." A nurses' note dated 11/6/11 at 8:00 P.M. indicated "Res fell in hallway. No injuries..." An IDT note dated 11/6/11 at 8:15 P.M. indicated "...Res was walking independently down hallway and fell , no injuries...IDT agreed to make sure resident has items in room that she comes to nurses station for such as iced tea, sugar. Will talk to family about installing birdfeeder outside her window..." A "Fall Circumstance Report" dated 11/6/11 indicated "...Walking to nurses station...What intervention(s) was put in to place to prevent another fall? (The form was blank)..." Nurses' notes indicated: 11/7/11 at 3:00 A.M. "...Ambulates independently; although encouraged to ask for assist as gait is very unsteady. Res noncompliant...Very forgetful..." 11/9/11 at 9:00 P.M. "...Ambulates independently but staff constantly reminds resident to use w/c et call light due to unsteady gait..." 11/13/11 at 3:45 P.M. "...Ambulates independently on occasion (sic) et needs constant reminder to use w/c et call light..." 11/22/11 at 5:10 P.M. "Called to res room per CNA. Res lying next to bed, head facing toward wardrobe closet with head resting on bed side table. Next to left eye res had a reddened area...Will continue to observe..." An IDT note dated 11/23/11 at 8:52 A.M. indicated "...IDT agrees to do neuro checks at this time. Alarms are not needed at this time d/t (due to) res non complience (sic) with alarms...care plan updated..." An "Event Report" dated 11/22/11 indicated "...Describe what the resident was doing prior to the fall...sitting in bed...What intervention(s) was put into place to prevent another fall...Neuro checks started and res returned to bed..." A resident care plan dated 7/21/11 indicated documentation was lacking related to any additional interventions being implemented after the 11/22/11 fall to prevent further falls. A nurses' note dated 11/25/11 at 11:53 P.M. indicated "Called to room by CNA. Resident sitting on floor by bed. Stated that she got up to get something and lost her balance and fell . No injuries seen..." An IDT note dated 11/28/11 at 9:58 A.M. indicated "...Resident had been sitting on edge of bed drinking juice and watching TV prior to fall...IDT team agrees to request orders from MD for labs...care plan updated..." An "Event Report" dated 11/25/11 indicated "...Describe what the resident was doing prior to the fall...sitting on side of bed watching TV and drinking juice...What intervention(s) was put into place to prevent another fall...Resident reminded to call for assist when getting up..." A resident care plan dated 7/21/11 and updated 11/28/11 indicated "MD to review labs..." Nurses' notes indicated: 11/26/11 at 8:30 P.M. "...Ambulating against advise. Encouraged to ask for assistance however resident continue to amb. per self..." 12/1/11 at 11:50 A.M. "...Resident came walking out of room by herself. Encouraged to call nurse or CNA to assist with walking or to use WC..." 12/12/11 at 10:05 P.M. "Res roommate alerted staff that res had fallen. Res was found lying on right side with head on bottom of TV stand, feet in middle of room....Res educated on use of wheelchair and using call light for assistance..." A nurses' note dated 12/12/11 at 11:30 P.M. indicated "Writer called to res' room by roommate. Res found lying on floor in left side facing bed. No injuries noted...Res assisted into w/c et is one on one supervision at this time..." An IDT note dated 12/13/11 at 9:28 P.M. indicated "...Met d/t falls on 12/12/11 at 1005pm and 1130pm...Will reattempt hipsters, and helmet. Nurse will assess for s/s (signs/symptoms) of UTI (urinary tract infection)/Resp (respiratory) issues d/t to hx of UTI and pneumonia...careplan updated..." A resident care plan dated 7/21/11 and updated 12/13/11 indicated "...encourage resident to remain out of room...therapy to screen..." Documentation was lacking related to reimplementation of hipsters and helmet or checking for UTI and respiratory problems. A "Transdisciplinary Therapy Screen" dated 12/13/11 indicated "...falls - res noncompliant with ed (education) to ask for assistance and recommended safety devices such as helmet, hipsters..." Documentation was lacking related to any additional interventions to prevent further falls. Nurses' notes indicated: 12/21/11 at 3:04 P.M. "...Res exhibits unsteady gait and is noncompliant with using WC..." 12/22/11 at 7:28 P.M. "Res. (resident) found sitting on buttocks in room on floor in front of chair. States she was moving from chair to w/c and slid to floor..." An "Event Report" dated 12/22/11 indicated documentation was lacking related to any additional interventions implemented to prevent further falls after the 12/22/11 fall. A resident care plan dated 7/21/11 and updated 12/23/11 indicated "...'push red button for help' signs to be in place in room with red tape applied to call light..." A nurses' note dated 1/9/12 at 1:27 P.M. indicated "Resident called writer into room. Resident was sitting on bottom with legs bend at the knees. She was sitting in between bedside table and her wheel chair. Resident stated that she dropped some beads on the floor and 'squated (sic) down to pick them up and could not get back up.'...No injuries noted..." Documentation was lacking related to an "Event Report" or IDT notes having been completed. Interview on 1/27/12 at 11:25 A.M. with the Executive Director indicated fall investigations had not been completed for the 12/12/11 at 10:05 P.M. and the 1/9/12 falls. Interview on 1/27/12 at 1:30 P.M. with the Director of Nursing indicated the 1/9/12 incident "wasn't a fall. She sat down deliberately." Interview on 1/27/12 at 9:40 A.M. with the Director of Nursing indicated the resident was "a challenge." She indicated several interventions had been attempted but "she refuses them." She indicated the toileting program had not been documented. 4. On 1/27/12 at 2:05 P.M., Resident #H was observed sitting at the far end of the hallway from the nurse

Based on record review and interview, the facility failed to assure there was supervision to prevent accidental injuries including fractures and a hematoma to the head, from side rail use and falls, for 3 of 8 residents (J, E,& G) reviewed for accidents in a sample of 8 and failed to assure root-cause analysis was completed to prevent further falls for 2 of 8 residents reviewed for fall prevention (E & G). Findings include: 1. The clinical record for Resident J was reviewed on 11/4/10 at 8:50 a.m. The resident had [DIAGNOSES REDACTED]. The Minimum Data Set assessment, dated 8/19/10, indicated the resident had both short and long term memory loss with impaired decision-making skills and was totally dependent on staff for bed mobility, transferring, toileting, and hygiene. The assessment also indicated the resident had full loss of her range of motion on one side for her arms and hands. It also demonstrated the resident had partial loss of range of motion on one side for her legs and feet. The resident assessment protocol for activities of daily living indicated the resident "makes not (sic) attempt to transfer self." The siderail assessment, dated 8/19/10, indicated Resident J needed the siderails on her bed for "...enables resident to reposition self in bed (demonstrated by resident)." The siderail assessment form was not completed for any other explanation of what siderails the resident was able to use or the safety of the use of the siderails. The care plan addressing "fall risk, impaired mobility and cognition" was dated as reviewed on 10/6/10. The goal was for the resident to be "free from injury daily." Interventions included: "broda chair for positioning; assist of 2 with gait belt; non-skid footwear; clutter free environment; tilt w/c (wheel chair) for positioning (resolved 10/6/10); modified wedge cushion for positioning (resolved 10/6/10); 1/2 siderails x 2 for positioning (resolved 10/6/10); hoyer lift with 2 staff assist (resolved 10/6/10)." The nursing notes, dated 10/18/10 as a late entry for 10/16/10 at 4 p.m., indicated the following: "Called to room by CNA - reported that legs were hanging off bed from knees down. Entered room, res was lying on left side, side rails in place - head to toe done - no abrasions, no open areas, no bruising or swelling. Res showed no s/s (signs/symptoms) of pain upon palpation. At 2:30 p.m. rounds res had been lying on right side with side rails in place and full body pillow in front of res. Will report to next shift to continue to observe for any changes." The facility reported investigation, presented by the Director of Nursing on 11/4/10 at 8:30 a.m., indicated the following had happened: "....Upon further investigation employee, (employee's name), entered the room of resident at approximately 4 p.m. on 10/16/10 and observed resident with right knee flush with side rails and pushing down on mattress. Left knee was between the two rails extending beyond. Resident's upper torso was at the edge of the bed with head and shoulder off the mattress. Nurse aide was fearful that resident would fall so aide attempted to reposition resident when he heard a popping sound. resident did not express pain at that time, later developing pain and swelling. Resident was assessed by licensed nurse with no signs and symptoms of injury...." The nursing notes, dated 10/17/10 at 4 a.m., indicated the resident's leg was painful, then the doctor was notified and the legs were x-rayed. Resident J then was sent to an area hospital and found to have bilateral fractures of the femurs. The Director of Nursing was interviewed on 11/4/10 at 1:00 p.m. She indicated the facility was not aware the resident was caught in the siderails until 4:00 p.m. on 10/16/10. She also indicated the resident had not been checked since around 2 p.m. when she was positioned in bed for a nap after lunch. The Director of Nursing presented inservices presented to all the staff since the first of 2010. She indicated these had included, but were not limited to: two inservices for abuse prevention, two inservices for fall preventions, two inservices for restraint use and two inservices for positioning to prevent pressure areas. No inservices were presented regarding siderails and safety specifically. 2. The "Resident Care Sheets" (nurse aide assignment sheets) were presented by Unit Manager # 2 during the Initial Tour on 11/3/10 at 10:30 a.m. The sheets indicated Resident # G was incontinent, used a wheelchair for mobility, and needed two assist for mobility. The clinical record of Resident # G was reviewed on 11/3/10 at 1:15 p.m. The record indicated the resident's [DIAGNOSES REDACTED]. The annual Minimum Data Set assessment (MDS), dated [DATE], indicated the resident had both long and short term memory loss, displayed difficulty making decisions and had fallen in the last one to 31 days. The MDS indicated Resident # G required staff assistance for transfer, ambulation, and toilet use. The care plan updated on the resident's return from the hospital, dated 10/27/10, indicated Resident # G was at risk for falls due to dizziness, unsteady, assist with transfers, frequent incontinence, and dementia. The care plan interventions included: "toilet every two hours and upon request, assist with transfers,and a bed alarm." The "Fall Risk Assessments," dated 9/28/10 and 10/25/10, indicated Resident # G was at risk for falls due to a history of falls, incontinence, and confusion. The "ADL (Activity of Daily Living) Case Mix Summary" indicated, from 10/19/10 through 10/25/10, Resident # G required limited to extensive assistance of one staff member for transfer and toilet use. A nursing note, dated 10/20/10 at 8:00 a.m., indicated Resident # G was observed getting up out of bed by a nurse aide. The resident stood and was incontinent of urine and slipped on the floor. The resident screamed out in pain and was sent to the hospital emergency room . She returned to the facility on [DATE] with a fractured hip. A "late entry" nursing note, dated 10/20/10 at 6:00 a.m., indicated the resident was in bed with the half side rails up and "calling out". The note did not indicate why the resident was calling out. It indicated only that Ativan was given to her for agitation. The "Fall Circumstance Report", dated 10/20/10, indicated there was a bed alarm on the bed. The report did not indicate if the alarm was sounding. The report did not include a root cause analysis for the fall. The Director of Nursing (DON) was interviewed on 11/4/10 at 12:50 p.m. The DON indicated there was no root cause analysis completed after Resident # G fell on [DATE] and fractured her hip. 3. The "Resident Care Sheets (nurse aide assignment sheets) were presented by Unit Manager # 2 during the Initial Tour on 11/3/10 at 10:30 a.m. The sheets indicated Resident # E needed the assistance of one staff member for all transfers and needed a wheelchair for mobility. During the tour, the Unit Manager # 2 indicated Resident # E had fallen out of bed. The clinical record of Resident # E was reviewed on 11/3/10 at 3:15 p.m. The record indicated the resident's [DIAGNOSES REDACTED]. The initial Minimum Data Set assessment (MDS), dated [DATE], indicated Resident # E needed the extensive assistance of one staff member to transfer and use the toilet. The MDS indicated the resident was continent of urine. A care plan, dated 10/17/10, indicated Resident # E was at risk for falls due to medications, a history of falls and fractures, poor safety awareness, and weakness. The Care Plan interventions included: "toilet every two hours and upon request." A care plan, dated 10/18/10, indicated Resident # E needed assistance with toileting. A care plan intervention indicated: "the resident should be assisted to the bathroom every two hours and upon request." The "Fall Risk Assessments," dated 8/10/10 and 9/26/10, indicated the resident was at risk for falls due to confusion, impaired gait/balance, medication use, and a history of falls. The October 2010 "ADL Record" (Activity of Daily Living) indicated Resident # E had needed the limited assistance of one staff member to transfer and use the toilet from October 1 through October 7, 2010. A nursing note, dated 9/7/10 at 10:00 a.m., indicated Resident # E required extensive assistance of one staff for transfers. A nursing note, dated 9/8/10 at 6:55 p.m., indicated Resident # E was found on the bathroom floor. The note indicated the resident had fallen asleep on the toilet, fell off the toilet, and hit her head on the sink. She was sent to the emergency room with a large hematoma on her forehead. The fall investigation was requested during the daily exit meeting on 11/3/10 at 4:00 p.m. with the Director of Nursing (DON). CNA # 1 was interviewed on 11/4/10 at 9:30 a.m. The CNA indicated when taking Resident # G to the toilet, she used a gait belt to transfer the resident from the bed to the wheelchair. She indicated if the resident complained she felt dizzy or weak, she would stay in the bathroom with the resident, if not, she would leave her alone on the toilet. The DON was interviewed on 11/4/10 at 9:00 a.m. The DON indicated a fall investigation and/or root cause analysis was not completed after Resident # E fell causing a hematoma on her forehead on 9/8/10. This federal tag relates to complaint number IN 712. 3.1-45(a)(2)