Every finding on record at Signature Healthcare of Bremen

Based on observation, interview and record review, the facility failed to ensure a staff nurse performed CPR correctly for 1 of 3 residents reviewed for death. (Resident B) In addition, the facility failed to ensure nursing staff who received online Cardiopulmonary Resuscitation (CPR) training completed a hands on component led by an in- person or virtual instructor for 13 of 16 nursing staff members reviewed (Registered Nurses 2, 4, 5 & 6, Licensed Practical Nurses 7, 8, 9, 10, 11, 12 & 13, the Director of Nursing and the Assistant Director of Nursing). This deficient practice resulted in a resident death for 1 of 1 resident reviewed for CPR.This immediate jeopardy began on [DATE] when RN 6 incorrectly performed CPR on Resident B by failing to ensure there was a hard surface underneath the resident prior to initiating and during continued chest compressions. The Director of Nursing and the Administrator (via telephone) were notified of the immediate jeopardy at 2:45 P.M., on [DATE]. The immediate jeopardy was removed on [DATE], but the noncompliance remained at the lower scope and severity level of isolated, no actual harm with potential for more than minimal harm that is not Immediate Jeopardy Findings include: An observation, on [DATE] at 10:03 A.M., of body camera footage provided by the local police department, of CPR being performed on Resident B by RN 6 was reviewed The body camera video footage, from [DATE] at 7:15 P.M., confirmed RN 6 had failed to perform CPR correctly, ensuring there was a hard surface underneath the resident while she had provided CPR measures to Resident B, including chest compressions. In the video, Resident B was observed on a pressure redistribution mattress with her upper body on the mattress and her lower body off the side of the mattress and her feet on the floor. RN 6 had been observed providing CPR standing over Resident B.A record review for Resident B was completed on [DATE] at 11:17 A.M. Diagnoses included but were not limited to acute on chronic diastolic heart failure, diabetes mellitus type 2, chronic obstructive pulmonary disease (COPD) and conversion disorder with seizures/convulsions.A Quarterly Minimum Data Set (MDS) assessment, dated [DATE], indicated Resident B had severe cognitive impairment and was independent with bed mobility.A Care Plan, initiated on [DATE], indicated Resident B had completed an advanced directive indicating she desired to be a full code. A Nursing Progress Note, on [DATE] at 7:15 P.M., indicated Resident B had complained of not being able to get her breath. RN 6 had left the room to find another nurse to assist her. When RN 6 arrived back at Resident B's room, Resident B was unresponsive without blood pressure or an apical pulse. CPR was initiated by RN 6 and LPN 8 also arrived at Resident B's room to assist with CPR measures. Emergency Medical Services (EMS) were notified and once they arrived, they took over the CPR measures.A Nursing Progress Note, on [DATE] at 7:40 P.M., indicated EMS had called resident B's daughter with an update on the results of the CPR attempt and had informed the daughter of the resident's time of death.During an interview, on [DATE] at 8:17 A.M., RN 6 indicated Resident B should have been moved to a solid surface when she provided CPR.During an interview, on [DATE] at 9:20 A.M., LPN 8 indicated Resident B had not been on a solid surface when RN 6 had provided chest compressions and Resident B should have been moved to a solid surface.Review of a written statement, provided by the responding police officer, indicated he had entered the facility front doors as directed on the dispatch call. He indicated he had been informed there was an unresponsive female and CPR was being performed on the resident. When he entered the front door, he did not see any staff in the area near the front door, nor was there any staff member available to direct him to the resident's room. He indicated a female staff member, later identified as LPN 8, was slowly walking down the hallway and pointed him towards the resident's room. When he arrived at the resident's room, there was one female staff member performing chest compressions on a resident that was partially in her bed. The officer indicated another officer arrived a few seconds after he arrived and the two officers immediately placed the resident onto the floor and the officers took over chest compressions until the EMS staff arrived.On [DATE] at 8:15 A.M., nursing staff CPR certifications were provided. RN 6 had a CPR certification, dated [DATE] and LPN 8 had a CPR certification dated [DATE]. Both certificates were obtained from the online site (name of the online CPR certification website). The curriculum on the website specifically stated hands-on training for CPR was not provided and included a website link of nearby virtual and in person instructors for the hands on virtual skills competency component. Previous CPR certifications could not be provided by the facility for RN 6 or LPN 8. In addition, the following nursing staff members had also obtained their current CPR certifications, without any hands-on training, from the same online provider: Registered Nurses 2, 4, 5 and 6, Licensed Practical Nurses 7, 8, 9, 10, 11, 12 & 13, the Director of Nursing and the Assistant Director of Nursing. During an interview, on [DATE] at 11:47 A.M., the Executive Director indicated nursing staff were not required to have hands-on training as part of the facility's CPR certification process.A current policy was provided on [DATE] at 11:53 A.M., by the Executive Director. The policy titled, CPR Certification, indicated, .The facility's policy is to maintain Cardiopulmonary Resuscitation [CPR] certified personnel on a 24-hour basis.2. CPR training may include hands-on practices and in-person skills assessment or a virtual instructor-led setting, according to accepted national standards.The Immediate jeopardy that began on [DATE] was removed on [DATE] when the facility ensured all nursing staff were re-educated on CPR procedures and all nursing staff had completed a CPR class which included a return demonstration and skills check off component, as required, but the noncompliance remained at the lower scope and severity level of isolated with potential for harm, not immediate jeopardy because the facility needed to continue monitoring and ensure staff competency with CPR procedures. This citation relates to Intake 3000627410 IAC (Indiana Administrative Code) 16.2- 3.1-13 (a)

Based on observation, interview, and record review, the facility failed to update a care plan related to communication for 1 of 16 residents whose care plans were reviewed. (Resident 20)Finding includes: During an observation and interview on 5/8/2026 at 11:04 A.M. Resident 20 was in the common area talking to a staff member and indicated he was blind and kind of bored. The staff member offered several types of tactile activities for the resident to do but the resident declined. The resident was not able to make eye contact when spoken to and instead looked off into the distance. A Care Plan Problem, dated 2/11/2026 and revised on 4/8/2026, indicated Resident 20 had difficulty with communication. Interventions included, but were not limited to, the use of alternative communication tools such as, communication book/board, writing pad, signs and gestures. A record review was completed on 5/11/2026 at 3:20 P.M. and indicated Resident 20 had a diagnosis of unqualified visual loss in both eyes. A Quarterly Minimum Data Set (MDS) assessment, dated 4/2/2026, indicated Resident 20 had severe cognitive deficit and severe visual impairment. During an interview on 5/12/2026 at 10:56 A.M., the Clinical Reimbursement Specialist indicated she had completed the most recent MDS assessment and had updated the care plans. She indicated the resident had been able to answer her questions but had not been able to see her when she had completed the assessment. It was unclear why the care plan interventions regarding communication had not been updated to reflect the resident's severely impaired vision. During an interview on 5/12/2026 at 11:01 A.M., QMA 3 indicated she usually worked on the unit on which Resident 20 resided. She indicated Resident 20 was able to see shadows of objects and people near him, but was unable to see pictures or utilize a communication board. A current policy, dated 2/9/2024 and titled, Comprehensive Care Plans was provided on 5/12/2026 at 2:47 P.M. by the ED. The policy indicated, .Each resident's Comprehensive Care Plan is designed to be revised as necessary with changes 410 IAC (Indiana Administrative Code) 16.2- 3 1-35(d)(2)(B)

Based on observation, record review and interview, the facility failed to ensure the head of the bed was elevated at 30 degrees or above for a resident receiving artificial feeding via tube feeding for 1 of 1 resident reviewed for tube feeding. (Resident 7) Finding includes:During an observation, on 5/11/2026 at 1:18 P.M., Resident 7 was observed lying in bed with the head of the bed less than 30 degrees while his tube feeding was infusing. Resident 7's head was observed to be close to the body elevation.During an observation with LPN 12, on 5/11/2026 at 1:24 P.M., of Resident 7's bed, LPN 12 indicated the head of Resident 7's bed was a little low and not at a 30-degree angle. She indicated the certified nursing assistants (CNA) must have just gotten done changing Resident 7.During an observation and interview, on 5/11/2026 at 1:29 P.M. Occupational Therapist 14 measured the bed angle with a goniometer and the bed frame measured at 12 degrees.A record review for Resident 7 was completed, on 5/11/2026 at 1:40 P.M. Diagnoses included, but were not limited to: persistent vegetative state, tracheostomy and gastronomy status, moderate protein-calorie malnutrition, diffuse traumatic brain injury and quadriplegia.A Quarterly Minimum Data Set (MDS) assessment, dated 2/9/2026, indicated Resident 7 was rarely or never understood, received tube feeding and was dependent with bed mobility.A Physician's Order, dated 4/12/2021, indicated Resident 7's head of the bed should be elevated at 30 degrees every shift.A Care Plan, initiated on 4/9/2021, indicated Resident 7 had a need for a feeding tube. Interventions included, but were not limited to: keep head of bed elevated at least 30 degrees while tube feeding is infusing.A policy was requested, on 5/13/2026 at 11:14 A.M. The Regional Nurse Consultant indicated the facility did not have a policy regarding tube feeding specific to bed positioning.410 IAC (Indiana Administrative Code) 16.2-3.1-44(a)(2)

Based on interview and record review, the facility failed to ensure a care plan related to food allergies was followed for 1 of 3 residents reviewed for dietary needs. (Resident B)Finding includes:On 10/8/25 at 12:12 P.M., Resident B's clinical record was reviewed. Diagnoses included but were not limited to dementia, feeding difficulties, stroke, gastro-esophageal reflux, chronic obstructive pulmonary disease, anxiety, and atrial fibrillation.Resident B's most recent Face Sheet, dated 10/4/25, indicated the resident had an allergy to Tomatoes. Physician's orders included but were not limited to, a dietary order dated 2/28/25, that indicated the resident was allergic to tomatoes.Resident B's Care Plans included but were not limited to,1. Resident B had cognitive loss and dementia with impaired decision-making skills, dated 7/18/23. 2. Resident had an allergy to tomato, dated 2/20/24, and indicated the resident would not be served tomato at meals. 3. Resident B was at nutritional risk due to dementia, dated 7/26/23, and indicated the facility would provide his diet as ordered, and notify the physician as needed. A Nursing Progress Notes, dated 8/22/25 at 7:11 P.M., indicated Resident B was accidentally given tomato ketchup for his hotdog sandwich.On 8/24/25 a Grievance Report was filed by Resident B's family member that indicated the resident had received ketchup on his hotdog and that he was allergic to the ketchup. The grievance investigation by the facility indicated the resident was given ketchup, and that the ketchup came out of the kitchen on the resident's tray.Review of a written statement from CNA (Certified Nursing Assistant) 5, dated 8/24/25, indicated CNA 5 took Resident B his dinner tray and asked if he wanted ketchup and mustard n his hot dog and the resident indicated he did. CNA 5 gave him a few bites of the hotdog with ketchup and then noted his meal ticket indicated an allergy to tomatoes.On 10/10/25 at 1:07 P.M., the Administrator provided the policy titled, Comprehensive Care Plans, dated 4/6/15 and revised on 2/9/24, indicating it was the facilities current policy. The policy indicated, .The facility will. implement a comprehensive person-centered care plan for each resident This citation relates to Intake 2633300.3.1-35(a)

Based on interview and record review, the facility failed to ensure physician's orders related to treatment of a pressure ulcer were followed for 1 of 3 residents reviewed for wound care, (Resident B).Finding includes: On 10/8/25 at 12:12 P.M., Resident B's clinical record was reviewed. Diagnoses included but were not limited to chronic obstructive pulmonary disease, anemia, hypertensive heart disease, stroke, vascular dementia, myocardial infarction, atrial fibrillation, need for assistance with personal care, muscle wasting and atrophy. A facility Event Report, dated 8/19/25 at 3:00 P.M., indicated Resident B had developed a Stage 2 pressure wound to the right heel that measured 5 cm long, 7.5 cm wide and 0.2 cm in depth. A physician's order, dated 8/19/25 through 8/27/25, indicated to cleanse the wound to the right heel with wound wash, pat dry, apply calcium alginate to the wound bed and cover with ABD (specialized medical dressing designed for managing moderate to heavily seeping wounds) and rolled gauze, every morning. A new physician's order, dated 8/27/25 with no end date, indicated to cleanse the wound to the right heel with wound cleanser, pat dry, apply skin prep to the surrounding wound area, apply calcium alginate to the wound bed and cover with ABD and rolled gauze, every morning. A Grievance/Complaint Report, dated 9/29/25, indicated Resident B's family member was concerned that the resident's dressing to the right heel was not changed appropriately. The facility documentation on the investigation of the grievance indicated Resident B's heel had not been changed and a date - two days previous to the current date had been noted on the dressing. Review of a Coaching and Counseling Session form from the facility, dated 10/6/25, indicated LPN (Licensed Practical Nurse) 5, had not changed the dressing to Resident B's right heel on 9/27/25 and 9/28/25. LPN 5 indicated on the form that she had not realized she had not gotten the dressing changed because she had been the only nurse in the building all weekend. Resident B's Treatment Administration Record from 9/1/25 to 9/30/25, indicated on 9/27/25, QMA (Qualified Medication Aide) 6 had signed that the treatment had been complete and on 9/28/25, LPN 5 had signed that the treatment was completed. During an interview on 10/10/25 at 10:38 A.M. The Director of Nursing indicated that on 9/29/25, Resident B's family brought it to the attention of the nursing staff that the resident's right pressure area bandage was dated 9/26/25. The Director of Nursing indicated upon investigation that LPN 5 had documented that she had changed the resident's right heel dressing on 9/27/25 and 9/28/25 but did not actually treat the wound or change the dressing. An interview on 10/10/25 at 10:50 A.M., with LPN 7, indicated on 9/29/25, she was called to the resident's room because the family was concerned that the resident's heel dressing had not been changed. LPN 7 indicated she notified her supervisor that the dressing observed on the heel was still dated 9/26/25 and the resident's physician orders indicated the wound required daily changes. LPN 7 indicated she had changed the dressing at that time the issue was brought to her attention by Resident B's family. During an interview on 10/10/25 at 1:00 P.M., LPN 5 indicated she had not completed the dressing changes to Resident B's right heel wound on 9/27/25 or 9/28/25. She indicated she must have mistakenly signed the treatment off in the electronic charting system. A policy titled, Skin Integrity, dated 1/31/25, indicated, The facility will ensure that.A resident with impaired skin integrity receives necessary treatment and services, consistent with professional standards f practice, to promote healing. A policy titled Abuse, Neglect and Misappropriation of Property, dated 9/15/23 was provided by the Administrator on 10/10/25 at 8:45 A.M., and indicated, :.It is the organization's intention to prevent the occurrence of.neglect.neglect is defined as the failure of the facility, its employees.to provide.services to a resident that are necessary to avoid physical harm.Deprivation of Goods and Services by Stake holders.includes the deprivation by staff of goods or services that are necessary to attain or maintain physical.well-being.A policy regarding pressure wounds and pressure wound care was requested but not provided.This citation relates to Intake 2633300.3.1-40

Based on observation and interview, the facility failed to follow infection control procedures during a medication pass for 2 of 4 residents observed. (Resident 8 & 20) Finding includes: During an observation of a medication pass, on 2/12/2025 at 8:01 A.M., LPN 6 prepared Resident 8's medications. LPN 6, with her bare hands, broke 2 potassium chloride tablets in half. She indicated this was the only way she could break the tablets in half and she had sanitized her hands prior to starting the preparation of medication. During an observation, on 2/12/2025 at 8:08 A.M, LPN 6 was at the medication cart and coughed into her bare hand. During an observation, on 2/12/2025 at 8:10 A.M., LPN 6 prepared Resident 20's insulin injection. LPN 6 did not sanitize her hands prior to the preparation of the insulin. LPN 6 administered Resident 20's insulin injection without gloved hands. LPN 6 indicated she should have sanitized her hands between the resident's medication administration. During an interview, on 2/17/2025 at 11:52 A.M., the Director of Nursing (DON) indicated LPN 6 should have worn gloves to break medication tablets and when administering an injection. A policy was provided by the Executive Director, on 2/12/2025 at 12:01 P.M. The policy titled, Medication Administration, indicated .Medication Preparation .4 .If breaking tablets is necessary to administer the proper dose, hands will be washed with soap and water and gloves applied prior to handling tablets .Medication Administration .11. Hands are washed with soap and water and gloves applied before administration of topical, ophthalmic, otic, parenteral, enteral, rectal, and vaginal medications 3.1-18(a)

Based on observation, interview and record review, the facility failed to ensure food was stored, prepared and served under sanitary conditions in 1 of 1 kitchens and 2 of 2 resident nutrition pantries. This deficient practice had the potential to affect 59 of 61 residents who received meals out of the kitchen. (main kitchen, north unit nutrition pantry & south unit nutrition pantry). Findings include: 1. During the initial tour of the kitchen, on [DATE] at 10: 26 A.M., with the Dietary Manager the following was observed: In the walk in freezer: - there was an opened bag of chicken pieces not sealed. - the floor had pieces of food and other debris. 2. In the walk in cooler: - there was an opened container of Med Plus (supplement) with an expiration date of [DATE]. - there was 2 opened containers of Thickened liquid with no date when they had been opened. - there was an opened bag of hash browns with a use by date of [DATE]. - and a metal container of shredded pork with a use by date of [DATE]. 3. In the dry storage area: - there was an opened bag of graham crackers crumbs that were not sealed tightly. During an interview, on [DATE] at 10:49 A.M., the Dietary Manager indicated the expired foods should have been removed, the opened foods should have been sealed tightly and the liquids should have had a date when opened. 4. During a follow-up tour of the kitchen on [DATE] at 9:53 A.M., with the Corporate Dietician, the following was observed: - 3 skillets stored as clean and available for use with missing Teflon off the cooking surface along with rust-colored areas. - 2 small steam table pans stored as clean with dried food substances. - and opened unsealed box of cream wheat. - 2 serving scoops with dried food substances on them. - multiple soup bowls, stored as clean, had dried specs of food. - water pitchers with brown stained areas. - 3 large metal steam table pans stored as cleaned with visible water in them. - the plate covers, soup bowls and coffee cups being utilized to serve meals had a large buildup of lime causing the items to have a white substance on them. During an interview, on [DATE] at 10:20 A.M., the Corporate Dietician indicated the skillets should not be used, the scoops and other cooking utensils should have been clean, and the steam table pans should not have been put away wet. In addition, she indicated the cream of wheat should have been sealed appropriately. She indicated the plate covers, soup bowls and the coffee cups should not have the white color on them. She indicated the facility was not able to get the white lime buildup off due to the hard water. 4. During an observation, on [DATE] at 1:02 P.M., with the Director of Nursing of the south hall nutrition pantry the following was observed: - a microwave with a yellow substance on the glass turn table. - a microwaveable frozen food with a staff's name on it. - a broken seal along the bottom of the refrigerator door. - a dirty shelf with a brown substance in the refrigerator. - no thermometer was located in the refrigerator. During an interview, on [DATE] at 1:05 P.M., the Director of Nursing indicated the microwave should have been cleaned; there should have been a thermometer in the refrigerator; the seal to the refrigerator should have been fixed and there should be no staff items in the resident's refrigerators. 5. During an observation, on [DATE] at 1:07 P.M., with the Director of Nursing on the north hall nutrition pantry the following was observed: - in the refrigerator was a dirty shelf with a dried food substance. - the refrigerator had a dark substance stuck to the bottom of the drawer. - there was a cup of pudding with a date of ,d+[DATE] and a discard date of [DATE]. During an interview, on [DATE] at 1:10 P.M., the Director of Nursing indicated the refrigerator should have been cleaned and the pudding cup should not have been in the refrigerator. On [DATE] at 11:23 A.M., the Administrator provided the policy titled, Receiving, dated ,d+[DATE], and indicated the policy was the one currently used by the facility. The policy indicated . Safe food handling for time and temperature control will be practiced in the transportation, delivery, and subsequent storage of all food items . 5. All food items will be appropriately labeled and dated either through manufacture packaging or staff notation On [DATE] at 11:23 A.M., the Administrator provided the policy titled, Ware washing, dated ,d+[DATE], and indicated the policy was the one currently used by the facility. The policy indicated . All dishware, service ware, and utensils will be cleaned and sanitized after each use . 4. All dishware will be air dried and properly stored On [DATE] at 1:37 P.M., the Administrator provided the policy titled, Snacks, dated ,d+[DATE], and indicated the policy was the one currently used by the facility. The policy indicated . 7. All snacks will be properly stored for the time and temperature control, as appropriate 3XXX,d+[DATE](i)(3)

Based on record review and interview, the facility failed to ensure an advance directive was completed upon admission for 1 of 24 residents reviewed for advance directives (Resident 63). Finding includes: A record review was completed on 2/13/2025 at 10:21 A.M. for Resident 63 and indicated the resident was admitted to the facility on [DATE]. An Admission Minimum Data Set (MDS) assessment, dated 1/28/2025 indicated the resident's cognition was significantly impaired. A Physician's Order, dated 1/22/2025 indicated the following: Do Not Resuscitate (DNR). The record lacked documentation of a completed DNR form signed by Resident 63 and/or the resident's representative. During an interview on 2/13/2025 at 3:00 P.M., the Administrator indicated the resident should have had a signed DNR form upon admission. On 2/13/2025 at 2:35 P.M., the Administrator provided a policy titled, Advance Directives, dated 5/13/2024 and indicated it was the policy currently being used by the facility. The policy indicated, .During the admission process the facility will attempt to determine whether the resident has an advance directive and, if not, determine whether the resident wishes to formulate an advance directive 3.1-4(f)(5)

Based on record review and interview, the facility failed to notify the ombudsman of hospital transfers for 1 of 4 residents reviewed for hospitalizations. (Resident 52) Finding includes: A record review for Resident 52 was completed on 2/13/2025 at 10:13 A.M. Diagnoses included, but were not limited to: Alzheimer's disease, delusional disorder, neuromuscular disfunction of the bladder and obstructive and reflux uropathy. A Quarterly Minimum Data Set (MDS) assessment, dated 1/14/2025, indicated Resident 52 had severe cognitive impairment and had an indwelling urinary catheter. A Nursing Progress Note, dated 9/7/2024 at 2:20 P.M., indicated Resident 52 was transferred to a neuropsychological hospital. A Nursing Progress Note, dated 9/23/2024 at 11:42 A.M., indicated Resident 52 returned to the facility. A Nursing Progress Note, dated 9/27/2024 at 9:09 P.M., indicated Resident 52 had removed her urinary catheter. A Nursing Progress Note, dated 10/2/2025 at 11:24 P.M., indicated Resident 52 returned to the facility from the hospital. A report was provided from the hospital that the urinary catheter had been replaced. A review of the provided September and October transfer and discharge list sent to the Ombudsman did not have Resident 52 listed as a transfer from the facility. During an interview, on 2/17/2025 at 11:48 A.M., the Director of Nursing (DON) indicated the Ombudsman should have been notified of the transfers from the facility. A current policy was provided by the executive Director on 2/17/2025 at 1:02 P.M. The policy titled, Transfer/Discharge Notice, indicated, .7. Before a facility transfers or discharges a resident: a .Additionally, the facility must send a copy of the notice of transfer or discharge to the representative of the Office of the State Long-Term Care Ombudsman 3.1-12(a)(6)(A)((iv)

Based on interview and record review, the facility failed to accurately complete the Minimum Data Set (MDS) assessment for 1 of 4 residents reviewed for accidents. (Resident 54) Finding includes: During an interview on 2/11/2025 at 11:16 A.M., Resident 54 indicated she had fallen about 5 times with no major injuries within the last few months. A record review was completed on 2/14/2025 at 1:15 P.M. for Resident 54. Diagnoses included, but were not limited to, chronic obstructive pulmonary disease, type 2 diabetes mellitus, chronic bronchitis and generalized anxiety disorder. A Quarterly Minimum Data Set (MDS) assessment, dated 2/10/2025, indicated Resident 54's cognition was intact, she had no behavior issues, no functional impairments, ambulated without assistive device, was independent with toileting and transfers, and had no falls since the previous MDS assessment. The Events section of the clinical record for Resident 54 indicated the resident had two falls in January 2025, on 1/2/2025 and on 1/3/2025. There were no major injuries. During an interview on 2/14/2025 at 2:21 P.M., the MDS Nurse indicated she participated in the follow up Interdisciplinary Team Meetings after falls and used information found in the clinical record under the Events section to determine if there had been falls since the last MDS assessment. She indicated the two falls in January 2025 should have been documented on the Quarterly MDS assessment completed on 2/10/2025. 0214/25 03:05 PM The ED indicated there was no facility policy for completing MDS assessments as they followed the Resident Assessment Instrument (RAI) Manual.

Based on record review, interview and observation, the facility failed to develop and implement a comprehensive person-centered care plan for skin issues and abusive behaviors for 3 of 19 residents whose care plans were reviewed. (Residents 5, 38 and 52) Findings include: 1. During an interview, on 2/11/2025 at 11:53 A.M., Resident 5 indicated she picked at the areas on her face. Two scabbed areas with redness were bserved on the residents' face. The record for Resident 5 was reviewed on 2/14/2025 at 9:44 A.M. Diagnoses included but were not limited to: arthritis, osteoporosis and dysphagia. A Nursing Progress Note, dated 6/24/2024, indicated the following: 3.2 x 2.0 x 0 circle redness to the left cheek. The resident denies pain to the area, itchy at times. Current Physician Orders included: Triamcinolone acetonide cream 0.025 % apply topical to irritation to left cheek twice a day, ordered on 6/26/2024. A Nursing Progress Note, dated 6/26/2024, indicated triamcinolone 0.025 twice daily ordered for irritated spot-on left cheek. The resident states she has had it for years and it's skin cancer she scratches open at times. The residents' record lacked a care plan related to the cancerous areas on her cheek or her behaviors of picking at her face. During an interview, on 2/17/2025 at 1:36 P.M., the Administrator indicated there should have been a care plan for the cancerous areas on her face. 2. During an interview, on 2/12/2025 at 9:09 A.M., Resident 38 was observed with numerous purple areas on both of his arms and hands. The record for Resident 38 was reviewed on 2/13/2025 at 2:00 P.M. Diagnoses included, but were not limited to congestive heart failure, diabetes, renal disease and hypertension. Current Physician Orders included: Aspirin 81 mg (milligrams) every day. An Admission Assessment, dated 2/3/2025 at 4:32 P.M., indicated the resident had Skin Impairments upon admission. The assessment directed staff to complete an event form if there were noted skin impairments. A Nursing Progress Note, dated 2/3/2025, indicated the resident returned to the facility on [DATE] from a hospital stay with numerous bruises on his upper extremities, bilaterally, related to IV's and blood draws. The clinical record lacked a care plan related to the use of aspirin and the purple/discolored areas on the resident's arms that were present upon readmission. During an interview, on 2/14/2025 at 3:55 P.M., the Administrator indicated there was no skin event assessment completed and no progress were completed related to the numerous bruises noted upon admission. 45120 3. During an observation, on 2/12/2025 at 9:25 A.M., Resident 52 was noted to be crying at an activity. A record review for Resident 52 was completed on 2/13/2025 at 10:13 A.M. Diagnoses included, but were not limited to: Alzheimer's disease, dementia with agitation, major depressive disorder, post-traumatic stress disorder and delusional disorder. A Quarterly Minimum Data Set (MDS) assessment, completed on 1/14/2025, indicated Resident 52 had severe cognitive impairment, no mood or behavior issues and was taking an antipsychotic, antianxiety and antidepressant medication. A Physician's Order, dated 11/7/2024, indicated the facility was to monitor the resident's behaviors related to pointing her finger at other residents and taking her clothing off. A Physician's Order, dated 11/24/2024, indicated the facility was to monitor the resident's exit seeking behaviors. A Nursing Progress Note, dated 9/5/2024 at 8:15 P.M., indicated Resident 52 poked Resident 27 in the chest. Resident 27 responded by striking resident 52 in the right eye. A Nursing Progress Note, dated 9/7/2024 at 6:45 A.M., indicated Resident 52 was unkind to Resident 27. While staff walked away with Resident 52 arm in arm, Resident 52 struck Resident 27 in the face with Resident 27 instantly striking back. A new physician order was received to send Resident 52 to a psychiatric hospital for an evaluation and treatment and one-on-one observations were implemented. A Nursing Progress Note, dated 12/9/2024 at 4:30 P.M., indicated Resident 52 became upset about a Crayon box and made physical contact with the tips of her fingers to Resident 55's face. 15-minute checks were initiated by the facility. A Nursing Progress Note, dated 12/18/2024 at 7:25 P.M., indicated Resident 52 swatted at Resident 27 on the resident's forearms. A Nursing Progress Note, dated 2/1/2025 at 4:00 P.M., indicated Resident 52 was holding Resident 34's wrists. During the separation of Resident 52 and 34, Resident 52 pushed Resident 34's head. 15-minute checks were initiated by the facility. Resident 52 did not have a behavioral care plan in place to address physical altercations with other residents and preventative interventions other than a plan to address her behavior of pointing her finger at other residents. A policy was provided by the Executive Director, on 2/17/2025 at 1:02 P.M. The policy, titled, Comprehensive Care Plans, indicated, .The facility will develop and implement a comprehensive person-centered care pan for each resident, that includes measurable objectives and time frames to meet a resident's medical, nursing, mental, and psychological needs that are identified in the comprehensive assessment 6. The Comprehensive Care Plan will be person-centered for each resident 3.1-35(a)

Based on observation, record review and interview, the facility failed to ensure residents received scheduled showers for 2 of 4 residents reviewed for activity of daily living (ADL) care. (Residents 57 & 48) Findings include: 1.During an observation, on 2/11/2025 at 12:05 P.M, Resident 57 was observed in the dining room and had greasy and disheveled hair. During an observation, on 2/12/2025 at 10:39 A.M., Resident 57 was observed in the dining room and had greasy and disheveled hair. During an observation, on 2/14/2025 at 11:58 A.M., Resident 57 was observed in his room with his hair disheveled, greasy and with white specks in his hair. Resident 52 indicated he had not refused his showers and received a shower the other night. A record review for Resident 57 was completed on 2/13/2025 at 9:23 A.M. Diagnoses included, but were not limited to: dementia and diabetes mellitus type 2. An Admission Minimum Data Set (MDS) assessment, dated 12/16/2024, indicated Resident 57 had moderate cognitive impairment and required supervision for bathing. A Physician's Order, dated 12/20/2024, indicated Resident 57 was to have showers on Tuesdays and Fridays on second shift and refused showers were to be documented in the nurse's notes. The Medication Administration Record, for December 2024, January 2025 and February 2025, indicated no refusals for showers were documented. The Point of Care documentation for showers received from December 2024 through February 2025 indicated Resident 57 was only provided showers on the following dates: - 12/9/2024 - 12/24/2024 - 1/1/2025 - 1/22/2025 - 1/15/2025. There was no documentation indicating why the resident had not received showers on 12/12/2024, 12/17/2024, 12/20/2024, 12/27/2024, 1/3/2025, 1/7/2025, 1/10/2025 or 1/17/2025. A Care Plan, initiated on 11/19/2024 and updated on 2/12/2024, indicated Resident 57 had a self-care deficiency related to impaired physical functioning and medical conditions as evidenced by the need for staff assistance for adequate completion of ADL care. The goal was for Resident 57 to not experience any adverse outcomes related to requiring assistance with ADL care. Interventions included, but were not limited to: provide frequent encouragement, along with prompting and assistance as needed, encourage resident to participate if they are able and provide the amount of assistance resident needs for completion of ADL cares. During an interview, on 2/14/2025 at 11:46 A.M., QMA 3 indicated handwritten shower sheets were not used for documentation and all shower documentation was completed in the Point of Care module in the electronic medical record. During an interview on 2/14/2025 at 1:45 P.M., RN 5 indicated resident 57 sometimes refused showers and the CNA should have informed the nurse if a shower was refused. She indicated the refusal would be documented in the Medication Administration Record. During an interview, on 2/14/2025 at 3:29 P.M., Resident 57 indicted he was independent and requested when he wanted a shower. 38845 2. During an observation, on 2/11/2025 at 10:56 A.M., Resident 48 was observed with long fingernails. The record for Resident 48 was reviewed on 2/14/2025 at 3:25 P.M. Diagnoses included but were not limited to hypertension, hip fracture, aphasia, hemiplegia and anxiety. A Quarterly MDS (Minimum Data Set) assessment, dated 11/19/2024, indicated the resident required partial to moderate assist for transfers and substantial to maximum assist for showers. A Care Plan, initiated on 4/22/2024, indicated Resident 48 required assistance with ADL's (activities of daily living) including late loss ADLs of bed mobility, transfers, eating, toileting related to hemiplegia. Interventions included but were not limited to: Observe for decline in ADL function. Provide verbal, tactile cues to assist with ADL completion as needed. Stand pivot transfers with mod assist. Supportive devices as ordered (walker, splint, brace, wheelchair). A Physician's Order, dated 11/9/2024, indicated the resident preferred to receive showers on Wednesdays and Saturdays Day shift. The order instructed the facility to document in the progress notes if the resident refused showers. In addition the order indicated the nurse was to complete a skin assessment on Saturdays. The shower documentation, dated 1/18 to 2/14/2025, indicated the resident had not received any showers from 1/18 to 1/29/2025 (11 days) and no showers from 2/2 to 2/12/2025 (11 days). There was no documentation of any shower refusals in the Nursing Progress Notes from 1/8/2025-2/14/2025 for Resident 48. During an interview, on 2/13/2025 at 1:18 P.M., CNA 8 indicated the showers were only documented on the computer. On 2/17/2025 at 1:23 P.M., the Director of Nursing provided the policy titled, Activities of Daily Living (ADLs), dated 1/31/2025, and indicated the policy was the one currently used by the facility. The policy indicated . 1. For those residents who are unable to perform their own activities of daily living, the facility will provide the needed assistance for completion of care 3.1-38(a)(3)

Based on record review and interview, the facility failed to ensure a resident who returned from a hospital stay was assessed for new and or existing skin issues for 1 of 2 residents reviewed for skin issues. (Resident 38) Finding includes: During an interview, on 2/12/2025 at 9:09 A.M., Resident 38 was observed with numerous purple areas to both arms and hands. The record for Resident 38 was reviewed on 2/13/2025 at 2:00 P.M. Diagnoses included, but were not limited to congestive heart failure, diabetes, renal disease and hypertension. Current Physician Orders included: - Aspirin 81 mg (milligrams) every day. - Weekly Skin Assessment . A Nursing Progress Note, dated 2/3/2025, indicated the resident returned to the facility and numerous bruises on his upper extremities bilaterally were observed, related to IV's and blood draws. An Admission Assessment, dated 2/3/2025, indicated the resident had a Skin Impairment upon admission and staff were directed to complete a Skin Event assessment. The clinical record lacked a skin event and documentation/assessment of the numerous bruised areas to the residents' bilateral arms and hands. A Weekly Skin Assessment completed, on 2/8/2025, documented the resident as having existing impaired skin. There was no indication of where the skin impairment was located and/or a description of the skin issue. During an interview, on 2/14/25 at 2:09 P.M., the Director of Nursing indicated skin assessments should be done weekly. She indicated the wound nurse and the ADON (Assistant Director of Nursing) completed skin rounds every week. During an interview, on 2/14/2025 at 4:02 P.M., the Administrator indicated no skin event form was completed when Resident 38 returned from the hospital. During an observation and interview, on 2/17/2025 at 9:15 A.M., the resident indicated he was to receive his showers on Tuesdays and Fridays. He indicated a nurse did not complete any skin assessments on his shower days. Resident 38 was observed with numerous dark, purple areas to the his left arm and hand. Resident 38 indicated the areas on his left hand was where he had gotten the skin taken off by a wheelchair. There were other areas to the left upper arm and right arm that he indicated he received while in the hospital. On 2/17/2025 at 1:23 P.M., the Director of Nursing provided the policy titled, Skin Integrity, dated 1/31/2025, and indicated the policy was the one currently used by the facility. The policy indicated . 1. Upon admission, the licensed nurse shall complete the initial skin check . 3. Recommend ongoing observation of skin integrity by licensed nursing staff. 4. The licensed nurse shall initiate applicable Skin Integrity documentation if a new area of impairment is identified No further wound/skin assessments for Resident 38 were provided prior to the survey exit on 2/17/2025. 3.1-37

Based on observation, record review and interview, the facility failed to implement effective behavior monitoring to prevent resident to resident altercations from recurring. (Resident 52) Findings include: 1. During an observation, on 2/12/2025 at 9:25 A.M., Resident 52 was crying at an activity. A record review for Resident 52 was completed on 2/13/2025 at 10:13 A.M. Diagnoses included, but were not limited to: Alzheimer's disease, dementia with agitation, major depressive disorder, post-traumatic stress disorder and delusional disorder. A Quarterly Minimum Data Set (MDS) assessment, on 1/14/2025, indicated Resident 52 had severe cognitive impairment, no mood or behavior issues and was taking an antipsychotic, antianxiety and antidepressant medication. A Physician's Order, dated 11/7/2024, indicated behavior monitoring for pointing fingers at other residents and taking her clothing off. A Psychiatry Initial Consult note, dated 11/8/2024, indicated Resident 52 was observed pacing, restless, crying, confused and mildly agitated. Resident 52 was difficult for staff to redirect and was unable to sit still during the visit. Staff had attempted to redirect, but redirection was not accepted. A Physician's Order, dated 11/24/2024, indicated an order for behavior monitoring for exit seeking behavior. A Nursing Progress Note, dated 9/5/2024 at 8:15 P.M., indicated Resident 52 poked Resident 27 in the chest. Resident 27 responded by striking resident 52 in the right eye. A Nursing Progress Note, dated 9/7/2024 at 6:45 A.M., indicated Resident 52 was unkind to Resident 27. While staff walked away with Resident 52 arm in arm, Resident 52 stuck Resident 27 in the face with Resident 27 instantly striking back. A new physician order was received to send Resident 52 to a psychiatric hospital for evaluation and treatment and one-on-one observations were placed. A Nursing Progress Note, dated 12/9/2024 at 4:30 P.M., indicated Resident 52 became upset about a Crayon box and made physical contact with the tips of her fingers to Resident 55's face. 15-minute checks were initiated by the facility. A Nursing Progress Note, dated 12/18/2024 at 7:25 P.M., indicated Resident 52 swatted at Resident 27 on the forearms. A Nursing Progress Note, dated 2/1/2025 at 4:00 P.M., indicated Resident 52 was holding Resident 34's wrists. During the separation of Resident 52 and 34, Resident 52 pushed Resident 34's head. 15-minute checks were initiated. Resident 52 did not have a behavioral care plan in place with preventative interventions to address physical altercations. During an interview, on 2/17/2025 at 10:52 A.M., the Executive Director indicated behaviors were discussed every morning and monthly with the Nurse Practitioner, Social Service Director, Director of Nursing and Pharmacy Consultant. She indicated a psychologist came to the facility monthly, collaborated with staff to determine the root cause of the behavior and placed interventions, which were care planned. She indicated interventions should be placed in the care plan to detour further altercations/behaviors. A policy for behavior management was requested on 2/17/2025 at 11:28 A.M. A policy was not provided. The Director of Nursing indicated on 2/17/2025 at 1:02 P.M., a policy was not available. 3.1-27(a)(1)

Based on observation, interview and record review, the facility failed to ensure showers were provided for 8 of 17 residents reviewed for ADL's (Activities of Daily Living). (Residents H, J, L, C, N, P, M & Q) Findings include: 1. The record review for Resident H was completed on 10/31/2024 at 10:34 A.M. Diagnosis included, but were not limited to dementia, anxiety, need for assistance with personal care and dysphagia. A Quarterly Minimum Data Set (MDS) assessment, dated 8/21/2024, indicated Resident H resident was dependent on staff for showers. Shower documentation for Resident H, dated 10/1/2024 thru 10/31/2024, indicted the resident had only received a shower on 10/13/2024 and 10/19/2024. A current Care Plan, dated 9/13/2024, indicated the resident needed staff assistance with bed mobility, transfers and toileting. During an interview, on 11/1/2024 at 8:45 A.M., the Director of Nursing indicated the resident should have received two showers a week. 2. During an interview, on 10/30/2024 at 11:41 A.M., Resident J indicated he did not always receive a shower two times a week. A record review for Resident J was completed on 10/31/2024 at 10:16 A.M. Diagnoses included: Parkinson's disease, dementia, anxiety and neurogenic bladder. A Quarterly MDS assessment, dated 8/2/2024, indicated the resident had impairment to his upper and lower extremity on one side and was dependent on staff for toileting, showering and transfer needs. The shower documentation, dated 10/1/2024 thru 10/31/2024, indicated Resident J had only received a shower on 10/5/2024. During an interview, on 11/1/2024 at 8:45 A.M., the Director of Nursing indicated the resident should have received two showers a week. 3. The record for Resident L was completed on 10/31/2024 at 11:26 A.M. Diagnoses included, but were not limited to Alzheimer's disease, hypertension, depression dementia and need for assistance with personal care. An Admission Minimum Data Set (MDS) assessment, dated 8/4/2024, indicated the resident required substantial/maximum assists for showering. The shower documentation, dated 9/1/2024 thru 10/31/2024, indicated Resident L only received showers on the following dates: - 9/92024 - 9/19/2024 - 9/29/2024 - 10/5/2024 - 10/24/2024 During an interview, on 11/1/24 at 8:16 A.M., the Director of Nursing indicated the resident should have received had two showers a week. 45120 4. During an observation, on 10/30/2024 at 2:16 P.M., Resident C was observed with greasy hair with the comb tracts visible. During an observation, on 10/31/2024 at 8:52 A.M., Resident C was observed to be in the hallway with her hair combed back with comb tracts visible. Her hair was dirty and greasy. During an observation, on 11/1/2024 at 11:11 A.M., Resident C was observed in the dining room. Her hair was greasy. A record review for Resident C was completed on 10/30/2024 at 11:14 A.M. Diagnoses included, but were not limited to: Hemiplegia affecting the right dominant side, cerebral infarction, schizophrenia, bipolar disorder, and major depressive disorder. A Quarterly Minimum Data Set (MDS) assessment, dated 10/8/2024, indicated Resident C required substantial/maximal assistance with showering and had impairment of an upper and lower extremity. A Care Plan, dated 4/15/2024 and revised on 10/20/2024, indicated Resident C required assistance with her with activities of daily living (ADL) including bed mobility, eating and toileting related to her hemiplegia and multiple sclerosis diagnosis. Bathing documentation indicated Resident C only received showers on the following days: 10/3/2024 shower 10/5/2024 complete bed bath 10/7/2024 shower 10/11/2024 shower 10/14/2024 shower 10/21/2024 shower 10/24/2024 shower 49229 5. The record for Resident N was reviewed on 10/30/2024 at 11:45 A.M. Diagnoses included, but were not limited to: unspecified dementia, anxiety, depression, hypertension, diabetes mellitus, atrial fibrillation and chronic venous hypertension. A current Care Plan, reviewed on 8/21/24, indicated Resident N had a history of refusal of care such as refusing showers multiple times in a row. Interventions included but were not limited to: explain care process prior to delivery of care as needed, approach resident in a calm and unhurried manner to deliver provide services and provide education as needed on the benefits and risks of receiving recommended care. The medical record for Resident N lacked documentation for showers or shower refusal for the dates of 10/3/2024 through 10/30/2024. During an interview, on 10/30/24 at 12:30 P.M., Resident N indicated she did not get help with showers but indicated she normally cleaned herself up in the bathroom at the sink. During an interview, on 10/30/2024 at 12:18 P.M., CNA 1 indicated the residents received a shower twice a week. During an interview, on 10/31/2024 at 2:20 P.M., the Administrator indicated there were no printed shower sheets and all showers were documented in the electronic medical record (EMR). During an interview, on 10/31/2024 at 10:45 A.M., CNA 2 indicated residents received showers every day or when they asked. If a resident refused a shower, the aide notified the DON and documented the refusal in the EMR. During an interview, on 11/1/2024 at 11:30 A.M., the Administrator indicated she was unaware of the meaning of other bath in the EMR. During an interview, on 11/1/2024 at 11:30 A.M., the Corporate Nurse indicated she was unaware of the meaning of other bath in the EMR. 6. During an interview, on 10/30/2024 at 10:25 A.M., Resident P's representative indicated Resident P had not received a shower since his admission to the facility. During an observation and interview, on 10/30/2024 at 10:35 A.M., Resident P had disheveled hair and beard scruff 1/4 inch long. Resident P indicated he liked a clean-shaven face except for his mustache. During an observation, on 10/31/2024, Resident P was seated on his bed, with the same clothes as worn on 10/30/24 and the resident's face still had beard stubble. The medical record for Resident P was reviewed on 10/30/2024 at 12:20 P.M. The diagnoses included but were not limited to: encephalopathy, alcohol use, urinary tract infection, acute renal failure, hypertension, acute vision loss bilateral eyes and diabetes mellitus. An Admission Minimum Date Set (MDS) assessment, dated 10/10/2024, indicated the resident required partial assistance with showering and bathing. A current Care Plan, initiated on 10/3/2024, indicated Resident P had a self-care deficit related to impaired physical functioning and medical conditions. Interventions included but were not limited to: provide frequent encouragement, along with prompting and assistance as needed and to provide the amount of assistance resident needs for completion of Activity of Daily Living (ADL) cares. The medical record for Resident P indicated the resident refused a shower on 10/12/2024. The record lacked documentation of any other refusal of showers and lacked documentation Resident P received any showers from 10/5/2024 through 10/30/2024. 7. The medical record for Resident M was reviewed on 10/30/2024 at 2:19 P.M. The diagnoses included but not limited to: Alzheimer's disease, acute kidney failure, ventral hernia, urinary tract infection, frequent falls, depression, other artificial opening of the urinary tract, post-traumatic stress disorder, sepsis, neuromuscular dysfunction of the bladder, neurogenic bladder and obstructive uropathy. A Discharge MDS assessment, dated 9/27/2024, indicated Resident M had memory problems and was severely cognitively impaired. The MDS indicated the resident required partial assistance with showering and bathing. A current Care Plan, reviewed on 10/14/2024, indicated Resident M had a self-care deficit related to impaired physical functioning and medical conditions as evidenced by the need for staff assistance for adequate completion of ADL cares. Interventions included but were not limited to: provide frequent encouragement, along with prompting and assistance as needed and provide the amount of assistance resident needs for completion of ADL cares. The shower documentation for Resident M indicated he had only received two showers, one on 10/20/2024 and 10/24/2024 from October 2 - 30, 2024. 8. During an observation and interview, on 10/30/2024 at 11:00 A.M., Resident Q had very greasy hair and the resident was unsure when he last showered. During an observation, on 10/31/2024 at 3:00 P.M., Resident Q still had very greasy hair. During an interview, on 10/30/2024 at 12:18 P.M., CNA 1 indicated residents received a shower twice a week. During an interview, on 10/31/2024 at 10:45 A.M., CNA 2 indicated the residents received showers every day or when they asked. If a resident refused a shower, the aide notified the DON and documented the refusal in the EMR. The medical record for Resident Q was reviewed on 10/31/2024 at 10:13 A.M. Diagnoses included but were not limited to: encephalopathy, alcohol abuse, delirium, dementia, inguinal hernia, difficulty in walking, depression and anxiety. The Admission MDS assessment, dated 10/10/2024, indicated the resident was severely cognitively impaired. The MDS assessment indicated Resident Q required substantial assistance with showering and bathing. A current Care Plan, dated 10/3/2024, indicated Resident Q has a self-care deficit related to impaired physical functioning and medical conditions as evidenced by the need for staff assistance for adequate completion of ADL cares. Interventions included but were not limited to: provide frequent encouragement, along with prompting and assistance as needed, encourage resident to participate if they are able and provide the amount of assistance resident needs for completion of ADL cares. There was only one shower documented, on October 6 for Resident Q from 10/3/2024 through 10/30/2024 and no refusals of showers were documented. During an interview, on 11/1/2024 at12:35 P.M., the Executive Director indicated the showers were documented in the electronic health record chart. There were no paper shower sheets utilized for documentation. She indicated residents' frequency was their preference and the standard was a minimum of two showers per week. She indicated the residents' frequency of showers preference should be recorded in the activities of daily living (ADL) care plan. A policy was provided, on 11/1/2024 at 10:29 A.M., by the Executive Director. The policy, titled, Activities of Daily Living [ADL's], indicated, .Direct healthcare staff will assist, support and encourage the resident to maintain adequate ADL while attempting to allow the resident to ne able to maintain as much independence as possible with their ADL such as the following: Bathing .For those residents who are unable to perform their own activities of daily living, the facility will provide the needed assistance for completion of cares This citation relates to Complaint IN00445742. 3.1-38(a)(2)(A)

Based on observation, interview and record review, the facility failed to provide a continent resident timely assistance for toileting that resulted in an incontinence episode for 1 of 1 residents reviewed for toileting. (Resident C) Finding includes: During an observation, on 10/30/2024 at 12:20 P.M., Resident C was in a small dining room sitting in a reclining chair. The resident asked CNA 10, who walked by her, to take her to the bathroom. CNA 10 responded I'll see what your aides are doing now. At 12:21 P.M., the resident started to moan and stated Please help!, while trying to reposition herself in the reclining chair. Resident C was observed to bang her right hand down numerous times on the armrest of the chair while still moaning. CNA 10 observed to entered the dining room and asked Resident C,What's going on?, Resident C replied,I need to go to the bathroom. CNA 10 indicated Well, we are about to eat. Resident C indicated, I know but I have asked for 1/2 hour to go to the bathroom and they say I can't go by myself. CNA 10 left the dining room without assisting Resident C to the bathroom. Resident C was observed trying to position herself in the reclining chair and moaning. CNA 10 returned to the dining room with Resident C's lunch tray and sat down beside Resident C and was observed to start feeding the resident. The resident was still moaning. After she had assisted Resident C with her meal, CNA 10 then pushed Resident C out of the dining room and sat her by the nurse's desk. Resident C was heard saying, Please help me. Another staff member walked by and asked her what she needed. Resident C indicated she needed to go to the bathroom. The staff member said she would find her nurse when the resident indicated,I want to go to the ladies room-they just walk past me. During an observation, on 10/30/2024 at 12:53 P.M., Resident C was in her room in the reclining chair, moaning and saying she wanted to go home and wanted to got to the bathroom. Resident C indicted her pants were wet. CNA 10 indicated, We have to check with the nurse first. During an observation, on 10/30/2024 at 12:57 P.M., Resident C was in her reclining chair moaning and still had not been assisted to the bathroom. During an observation, on 10/30/2024 at 12:59 P.M., Resident C was placed in a hoyer (mechanical device for transfers) lift and transferred to her bed. Her brief was checked and noted to be wet with wetness observed extending up towards the back of the brief. During an interview, on 10/30/2024 at 1:10 P.M., QMA 8 indicated if a resident was saying they needed to go to the bathroom, she would take them. During this interview, LPN 9 interupted and indicated Resident C's family had requested she be kept up in the chair until after lunch. LPN 9 was informed Resident C had been in the dining room moaning and had requested to go to the bathroom several times and LPN 9 just reiterated Resident C was to be left in her chair until after the lunch meal. During an interview, on 10/30/2024 at 1:11 P.M., LPN 9 indicated, She (Resident C) usually is wet, she is incontinent. During the interview with LPN 9, the Administrator approached the nurse's desk and asked if Resident C had been toileted. She was informed the resident had been laid down in bed to check her for incontinence. The Administrator asked LPN 9 if the resident had been offered a bed pan. LPN 9 indicated she did not know. The nurse and Administrator were informed the resident was not offered a bed pan when she was laid down in bed. LPN 9 then indicated, Why would we offer the bed pan when she was wet. The Administrator instructed the staff to put the resident on the bed pan at this time. She indicated they should have taken the resident to her room and offered a bed pan when she had requested to go to the bathroom During an interview, on 10/30/2024 at 1:12 P.M., C.N.A 11 indicated she did not know anything about keeping the resident up in her chair until after lunch. A Bowel and Bladder Retraining Record, dated 10/23/2024 to 10/27/2024, indicated Resident C had a total of 5 incontinent episodes during the assessment time frame but was not always incontinent of her bladder. A current Care Plan, dated 10/172024 and revised on 10/24/2024, indicated the resident was at risk for complications associated with urinary incontinence. Interventions included, but were not limited to: obtain labs; provide assistance with peri care after incontinence as needed; report any changes in bladder status to nurse- low urine; output, foul smelling urine; discolored urine; Pain; Bladder distention; Frequency; Urgency; and Fever. On 11/1/2024 at 3:40 P.M., the Administrator provided the policy titled,Resident Rights, dated 6/1/2025 and revised on 9/15/2023, and indicated the policy was the one currently used by the facility. The policy indicated .3. The facility will make every effort to support each resident in exercising his/her right to assure that the resident is always treated with respect, kindness, and dignity 3.1-9(a)

Based on record review and interview, the facility failed to notify the physician of an elevated heart rate and seizure activity and missed medications for 2 of 7 residents reviewed for pharmaceuticals. (Resident N and E) Findings include: 1. The record for Resident N was reviewed on 10/30/2024 at 11:45 A.M. Diagnoses included, but were not limited to: unspecified dementia, anxiety, depression, hypertension, diabetes mellitus, atrial fibrillation and chronic venous hypertension. Physician Orders for Resident N, dated 1/2/2024, included Eliquis (anticoagulant) 2.5 mg (milligrams) 1 tablet twice a day for atrial fibrillation (an irregular heart rhythm that begins in the heart's upper chambers or atria). A current Care Plan, reviewed 8/21/2024, indicated Resident N had a diagnosis of atrial fibrillation. Interventions included but were not limited to: observe for and report heart palpitations, irregular heartbeat and tachycardia (a heart rate that is faster than a hundred beats per minute), and notify physician with any significant changes. A Nursing Progress Note, dated 10/22/2024 at 10:10 A.M., indicated RN 1 assessed Resident N for anxiety and found Resident N to have a heart rate of 211. A Nursing Progress Note, dated 10/22/2024 at 10:20 A.M., indicated Resident N's heart rate was now 176 bpm (beats per minute). A Nursing Progress Note, dated 10/22/2024 at 10:30 A.M., indicated Resident N had a heart rated of 181 bpm. A Nursing Progress Note, dated 10/22/2024 at 11:10 A.M., indicated Resident N had a heart rate of 100 bpm. There was no documentation the physician was notified of Resident N's elevated heart rates. During an interview, on 10/31/2024 at 2:20 P.M., RN 1 indicated a change in condition for a resident included but was not limited to: a change in vital signs, out of range blood sugars or deterioration in the resident's physical assessment. During an interview, on 10/31/2024 at 2:28 P.M., LPN 1 indicated if a resident had a change in condition, the nursing staff would notify the physician, the Director of Nursing (DON) and the resident's representative or family. 45120 2. A record review for Resident E was completed on 10/30/2024 at 2:07 P.M. Diagnoses included, but were not limited to: Lennox-Gastaut syndrome (severe form of epilepsy), severe intellectual disabilities, autistic disorder and schizophreniform disorder. Resident E was admitted to the facility on [DATE]. A record review for Resident E was completed on 10/30/2024 at 2:07 P.M. Diagnoses included, but were not limited to: Lennox-Gastaut syndrome (a rare, severe and lifelong form of epilepsy that starts in early childhood), severe intellectual disabilities, autistic disorder, schizophreniform disorder, and epilepsy. An Admission Minimum Data Set (MDS) assessment, dated 8/23/2024, indicated Resident E had severe cognitive disability and received medications of an antipsychotic, antianxiety and antidepressant. Physician Orders included, but were not limited to: -Clobazam (anti-seizure medication) 20 milligrams at bedtime starting 8/29/2024, given in the morning from 8/17/24-8/28/24. -Fycompa (anti-seizure medication) 30 milliters equals15milligrams at bedtime starting on 8/ 817/2024. -Lamotrigine (anti-epileptic medication) 200 milligrams 2 tabs twice daily starting 8/17/2024. -Rufinamide (anti-convulsant medication) 40 milligrams per milliliter 40 milliliters equals 1600mg twice daily starting 8/17/2024. A review of the August the Medication Administration Record (MAR) indicated the following medication had been missed when signed out for Resident E: -Fycompa had missed doses on 8/17/2024, 8/18/2024, 8/19/2024, 8/23/2024, 8/25/2024, 8/26/2024, 8/28/2024 and 8/31/2024. A Nursing Progress Note, dated 8/20/2024 at 2:09 P.M., indicated Resident E had three noted seizures and the seizure activity was quickly reversed using a magnet. A Nursing Progress Note, dated 8/22/2024 at 4:08 P.M., indicated Resident E had seizure activity tonic-clonic (tonic: a stiffening phase, clonic: a twitching or jerking phase) lasting less than one minute twice during the shift. A Nursing Progress Note, dated 8/29/2024 at 5:58 P.M., indicated Resident E experienced a seizure, which lasted about 10 seconds. The magnet bracelet was used which reversed the seizure activity immediately. A review of the September MAR indicated the following medication had been missed when signed out for Resident E: -Fycompa had missed doses on 9/7/2024, 9/17/2024, 9/27/2024, 9/28/2024, 9/29/2024 and 9/30/2024. A Nursing Progress Note, dated 9/03/2024 at 8:46 P.M., indicated staff had observed a small seizure that the resident came out of within seconds. A Nursing Progress Note, dated 9/29/2024 at 9:26 P.M., indicated the pharmacy was contacted related to Resident E's medication, Fycompa, needing refilled. The pharmacist indicated the medication was currently out of stock. The pharmacist indicated the medication may be available 9/30/2024 at 10:00 A.M. A review of the September MAR indicated the following medication had been missed when signed out for Resident E:-Fycompa doses were missed on 10/4/2024, 10/13/2024, 10/18/2024, 10/19/2024, 10/21/2024, 10/30/2024 and 10/31/2024. A Nursing Progress Note, dated 10/05/2024 at 10:37 P.M., indicated Resident E had multiple episodes of seizures from 9:30 P.M. to 10:00 P.M., with a duration of one minute and intervals of 2-3 minutes between seizure activity. A Nursing Progress Note, dated 10/07/2024 at 6:00 P.M., indicated a CNA had reported Resident E had experienced a possible seizure in the shower room with symptoms of staring off and not answering questions. A Nursing Progress Note, dated 10/22/2024 at 9:43 P.M., indicated Resident E was watching a movie and had a seizure. The nurse applied the magnet and Resident B responded well. A Nursing Progress Note, dated 10/29/2024 at 3:41P.M., indicated Resident E was in the shower room and a CNA stated, his head was lying on the sink when she turned around and notice [sic] he was having a seizure. A Nursing Progress Note, dated 10/30/2024 at 3:15 P.M., indicated Resident E had a seizure with minimal movement lasted 15 seconds with no adverse effects noted. During an observation, on 10/31/2024 at 8:33 A.M., Resident E was observed having an active seizure while in the television lounge. A Nursing Progress Note, dated 10/31/2024 at 2:28 P.M., indicated Resident E was out of his Fycompa and had missed a dose. A Nursing Progress Note, dated 10/31/2024 at 2:43 P.M., indicated Resident E had a less than 15 second seizure. A Nursing Progress Note, dated 11/01/2024 at 7:54 A.M., indicated Resident E had a short seizure while a CNA was assisting him with morning care. During an interview, on 10/31/2024 at 2:11 P.M., LPN 12 indicated she had not notified the MD of Resident B missing his doses of Fycompa or seizure activity. A policy was provided by the Executive Director, on 11/1/2024 at 2:09 P.M. The policy titled, Notification of Change of Condition, indicated, .To ensure appropriate individuals are notified of changes in condition .1. The facility must inform the resident, consult with the resident's physician; and notify consistent with his or her authority, the resident representative[s] when there is: b. A significant change in the resident's physical, mental, or psychosocial status. c. Needs to alter treatment significantly 2. Documentation of notification or notification attempts should be recorded in the resident electronic medical record. 3. The resident and/or representative [if applicable], and medical provider should be notified of a change in condition. The medical provider will provide guidance related to the change of condition 3.1-5(a)(2)

Based on observation, record review and interview, the facility failed to develop a care plan for seizures for 1 of 8 residents reviewed for medication. (Resident E) Finding includes: A record review for Resident E was completed on 10/30/2024 at 2:07 P.M. Diagnoses included, but were not limited to: Lennox-Gastaut syndrome (severe form of epilepsy), severe intellectual disabilities, autistic disorder and schizophreniform disorder. Resident E was admitted to the facility on [DATE]. A record review for Resident E was completed on 10/30/2024 at 2:07 P.M. Diagnoses included, but were not limited to: Lennox-Gastaut syndrome, severe intellectual disabilities, autistic disorder, schizophreniform disorder, and epilepsy. An Admission Minimum Data Set (MDS) assessment, dated 8/23/2024, indicated Resident E had severe cognitive disability and received medications of an antipsychotic, antianxiety and antidepressant. He had an active diagnosis of seizure disorder Current Physician's Orders for medications to treat seizures included, but were not limited to: -Clobazam 20 milligrams at bedtime starting 8/29/2024, given in the morning from 8/17/24-8/28/24. -Fycompa 30milliters equals15milligrams at bedtime starting on 8/ 817/2024. -Lamotrigine 200 milligrams 2 tabs twice daily starting 8/17/2024. -Rufinamide 40 milligrams per milliliter 40 milliliters equals 1600mg twice daily starting 8/17/2024. -Clonazepam 1mg three times a starting 8/16/2024. A Nursing Progress Note, dated 8/20/2024 at 2:09 P.M., indicated Resident E had three noted seizures and was quickly reversed with the seizure using magnet. A Nursing Progress Note, dated 8/22/2024 at 4:08 P.M., indicated Resident E had seizure activity tonic-clonic lasting less than 1 minute twice during the shift. A Nursing Progress Note, dated 8/29/2024 at 5:58 P.M., indicated Resident E experienced a seizure which lasted about 10 seconds. The magnet bracelet was used which reversed seizure immediately. A Nursing Progress Note, dated 9/03/2024 at 8:46 P.M., indicated staff observed a small seizure that the resident came out of within seconds. Resident E received 2 doses of clonazepam on 10/23/2024 based on the narcotic signature sheet. A Nursing Progress Note, dated 10/05/2024 at 10:37 P.M., indicated Resident E had multiple episodes of seizures from 9:30 P.M. to 10:00 P.M., with a duration of one minute and intervals of 2-3 minutes. A Nursing Progress Note, dated 10/05/2024 at 11:14 P.M., indicated Resident E was seen at the beginning of the shift being closely monitored. Resident B was in an active tonic seizures. Resident E was responsive and oriented to people around 10:00 P.M., and was to name nurses and CNAs on duty. About ten minutes Resident E stopped responding to verbal and tactile stimuli and was staring blankly in between an episode of seizures. Resident E was picked up from the EMS (emergency medical services) around 10:20 P.M. A Nursing Progress Note, dated 10/06/2024 at 5:37 A.M., indicated Resident E was returned to the facility at 1:34 A.M. for seizures. A Nursing Progress Note, dated 10/07/2024 at 6:00 P.M., indicated a CNA witnessed during a shower Resident E maybe having a seizure with symptoms of staring off and not answering questions. A Nursing Progress Note, dated 10/22/2024 at 9:43 P.M., indicated Resident E was watching a movie and had a seizure. The nurse applied the magnet and Resident E responded well. A Nursing Progress Note, dated 10/29/2024 at 3:41P.M., indicated Resident E was in the shower room and a CNA stated his head was lying on the sink when she turned around and notice he was having a seizure. A Nursing Progress Note, dated 10/30/2024 at 3:15 P.M., indicated a seizure with minimal movement lasted 15 seconds with no adverse effects noted. During an observation, on 10/31/2024 at 8:33 A.M., a surveyor witnessed an active seizure while Resident E was in the television lounge. A Nursing Progress Note, dated 10/31/2024 at 2:43 P.M., indicated Resident E had a less than 15 second seizure. A Nursing Progress Note, dated 11/01/2024 at 7:54 A.M., indicated Resident E had a short seizure this morning while CNA was assisting with morning care. There was no current care plan for seizures for Resident E. During an interview, on 11/1/2024 at 12:27 P.M., the Executive Director indicated Resident E should have his seizure medications without a disruption in administration. A policy regarding care plans was requested but not received prior to the survey exit. 3.1-35(a)

Based on record review and interview, the facility failed to ensure physician ordered medications were administered for 2 of 10 residents whose medications were reviewed. (Residents J & L) Findings include: 1. The record for Resident J was completed on 10/31/2024 at 10:16 A.M. Diagnoses included: Parkinson's disease, dementia, neurogenic bladder and diabetes and pain in joints. Current Physician Orders for Resident J included: Hydrocodone (narcotic pain medication) 5/325 mg (milligrams) 1 tablet every 6 hours for pain at midnight, 6:00 A.M., noon and 6:00 P.M. Resident J's narcotic Controlled Drug Record for the Hydrocodone, dated October 2024, indicated he had not received the 4 scheduled doses on 10/25/2024 and the midnight dose on 10/26/2024. During an interview, on 11/1/2024 at 8:45 A.M., the Administrator indicated the resident should have received the medication. 2. The record for Resident L was completed on 10/31/2024 at 11:26 A.M. Diagnoses included, but were not limited to Alzheimer's disease, hypertension, depression, dementia and chronic cluster headaches. Resident L's current Physician Orders' included: Lyrica (controlled pain medication) 50 mg 1 capsule three times a day for pain. The Controlled Drug Record for Resident L's Lyrica (pregabalin) 50 mg three times daily indicated the following missed doses: - 1 dose on 10/14/2024, 10/16/2024, 10/17/2024 and 10/2024. During an interview, on 11/1/2024 at 8:47 A.M., the Administrator indicated the residents should have received the medications. On 10/31/2024 at 2:33 P.M., the Administrator provided the policy titled,Controlled Medication, dated 5/30/2024, and indicated the policy was the one currently used by the facility. The policy indicated .4. When a controlled medication is administered, the licensed nurse administering the medication immediately enters the following information on the accountability record when removing dose from controlled storage a. Date and time of administration. b. Amount administered. c. Signature of the nurse administering the dose. 5. Administer the controlled medication and document dose administration on the MAR On 11/1/2024 at 3:15 P.M., the Administrator indicated she could not provide a policy for following physician orders. This citation relates to Complaint IN00445742. 3.1-37

Based on observation, interview and record review, the facility failed to ensure routine medications were available and dispensed according to physician's orders for 3 out of 8 residents reviewed for medication administration. (Residents M, L and C) Findings include: 1. The medical record for Resident M was reviewed on 10/30/2024 at 2:19 P.M. The diagnoses included but were not limited to: Alzheimer's disease, acute kidney failure, ventral hernia, urinary tract infection, frequent falls, depression, other artificial opening of the urinary tract, post-traumatic stress disorder, sepsis, neuromuscular dysfunction of the bladder, neurogenic bladder and obstructive uropathy. Physician Orders for Resident M included Mupirocin ointment 2% 1 application topically twice a day, dated 8/31/2024 until 10/30/2024, and Clonazepam 0.25 mg 1 tablet by mouth twice a day, dated 10/3/2024. The October MAR indicated Resident M did not receive Mupirocin as ordered on the following dates: 10/18/2024 Evening dose due to medication unavailable, 10/19/2024 Morning and evening doses due to medication unavailable, 10/21/2024 Evening dose due to medication unavailable, 10/22/2024 Morning dose due to medication unavailable, 10/23/2024 Evening dose due to medication unavailable, 10/25/2024 Morning dose due to medication unavailable 10/29/2024 Morning dose due to medication unavailable. The October MAR indicated Resident M did not receive Clonazepam as ordered on the following dates: 10/19/2024 Morning dose missed due to medication not available, 10/21/2024 Morning dose missed due to medication not available, 10/22/2024 Morning dose missed due to medication not available, 10/23/2024 Both doses missed due to medication not available, 10/24/2024 Morning dose missed due to medication not available, 10/25/2024 Morning dose missed due to medication not available, 10/26/2024 Morning dose missed due to medication not available, 10/27/2024 Morning dose missed due to medication not available, 10/29/2024 Morning dose missed due to medication not available. During an interview, on 11/1/2024 at 12:45 P.M., QMA 1 indicated the medication should always be double-checked with the MAR prior to administration. 38845 2. The record for Resident L was completed on 10/31/2024 at 11:26 A.M. Diagnoses included, but were not limited to Alzheimer's disease, hypertension, depression, dementia and chronic cluster headaches. Resident L's current Physician Orders included: Lyrica (controlled medication) 50 mg 1 capsule three times a day for pain. The Controlled Drug Record for Lyrica (pregabalin) 50 mg three times daily indicated the following: - an extra dose was received on 10/8/2024. - 1 dose was missed on 10/14/2024, 10/16/2024, 10/17/2024 and 10/2024, - an extra dose was received on 10/23/2024. The Medication Administration Record (MAR), dated 10/1/2024 thru 10/31/2024, indicated the schedued Lyrica medication was not available on the following days: 10/5/2025 for the 7:00 A.M. to 11:00 A.M. shift and the 11:15 A.M. to 3:00 P.M. shift. On 10/7/2024 for the 7:00 A.M. to 11:00 A.M. shift. During an interview, on 11/1/2024 at 8:47 A.M., the Administrator indicated the resident should have received the medication and should not have received the extra doses. 3. The record review for Resident C was completed on 10/30/2024 at 2:27 P.M. Diagnoses included but were not limited to: dementia, acute pain due to trauma, low back pain, and chronic kidney disease. Physician Orders for Resident C included the following: Valsartan (anti hypertensive medication) 40 mg 1 tablet every 12 hours at 8:00 A.M. and 8:00 P.M. The Medication Administration Record (MAR) for October 2024 indicated the Valsartan medication was not administered on the following dates: - 10/18/2024 1 dose of the medication was documented as not available. - 10/20/2024 1 does of the medication was documented as not available. - 10/19/2024 2 doses of the medication was documented as not available. During an interview, on 11/1/2024 at 8:47 A.M., the Administrator indicated the medications that were unavailable should have been pulled from the Pyxis (emergency dispensing machine) or the pharmacy should have been called for a STAT (immediate) delivery. During an interview, on 11/1/2024 at 1:58 P.M., the Administrator indicated the facility has no policy on medications being unavailable. The Administrator indicated that the nurse should call pharmacy and then notify the attending physician when a medication is unavailable On 10/31/2024 at 2:33 P.M., the Administrator provided the policy titled,Controlled Medication, dated 5/30/2024, and indicated the policy was the one currently used by the facility. The policy indicated .4. When a controlled medication is administered, the licensed nurse administering the medication immediately enters the following information on the accountability record when removing dose from controlled storage a. Date and time of administration. b. Amount administered. c. Signature of the nurse administering the dose. 5. Administer the controlled medication and document dose administration on the MAR This citation relates to Complaint IN00445742. 3.1-25(a) 3.1-25(e)(2) 3.1-25(e)(3)

Based on observation, interview and record review, the facility failed to ensure 1 of 5 residents reviewed were free from sexual and mental abuse. (Resident B) This deficient practice had the potential/likelihood of a negative psychosocial outcome, for Resident B, resulting from the facility's noncompliance to protect a resident, who had mild to moderate cognitive deficits from sexual abuse and from the perpetrator attempting to contact her, after he was instructed not to do so, for 1 of 5 residents reviewed for abuse resulting in the resident (Resident B) The immediate jeopardy began on 6/3/22 when Resident B reported the incidents of sexual abuse to a Certified Nurse Aide (CNA). The Administrator was notified of the immediate jeopardy at 2:30 P.M. on 6/27/22. The Immediate Jeopardy was removed and corrected on 6/9/22 when the facility implemented a systemic plan of action which included, but was not limited to: a complete/thorough investigation, all residents were assessed or interviewed for signs and/or symptoms of abuse, all staff in-services regarding abuse and notification, reviewed all grievances from past 90 days, all alert and oriented residents were interviewed/educated on abuse & notification process and family members of all the residents were notified of the abuse & notification process, audits and all plans of action were reviewed at a Quality Assurance/Performance Improvement meeting held 6/7/22 to ensure compliance. Finding includes: On 6/24/22 at 9:43 A.M., Resident B was observed sitting in a chair need the nurse's station. She was dressed and was observing staff as they walked by. Staff would speak to the resident, and she would respond appropriately. On 6/27/22 at 3:00 P.M., a review of the clinical record for Resident B was conducted. The record indicated the resident's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An Annual Minimum Data Set (MDS) Assessment, dated 5/13/22 indicated the residents Brief Interview for Mental Status (BIMS) score was 13, indicating mild cognitive deficits. The assessment indicated the resident required supervision/cueing of one person with toileting and physical help of 1 person with bathing. A Mood care plan, dated 5/7/21, and reviewed on 6/7/22, indicated the resident had depression, anxiety, and suspicious thinking regarding her money, mood swings and prefers to spend time in her room. Interventions included but were not limited to: .staff have put their phone numbers in [resident's name] phone so if [resident's name] wants to talk to someone she can call them. They share she likes to visit and they validate back to her. [resident's name] likes having this ability A self-reported incident #205, dated 6/3/22 at 7:30 P.M., indicated Resident B had reported CNA 2 .touched her sexually inappropriately on two occasions during her showers. When asked about why she didn't report earlier, and she replied that it was just eating at me An investigation was initiated, and CNA 2 was suspended. The resident was assessed, the medical doctor and family were contacted, as well, as the police. The incident follow-up, dated 6/8/22, indicated the employee was terminated for not cooperating with the investigation and attempting to contact the resident involved following his suspension. An unscheduled BIMS, dated 6/4/22, indicated a score of 9, which indicated the resident had moderate cognitive deficits. A form titled, CEO/Admin. Review of statements, indicated the following statements had been acquired during the investigation: 1. A statement was taken from CNA 4, on 6/3/22. CNA 4 indicated .during shower that resident made a statement about liking [name of CNA] The CNA questioned the resident as to why she made the comment and the resident replied, CNA 2 does more than just wash her and she doesn't like it. The CNA 4 immediately went to get a nurse. 2. A statement was taken from RN 5, on 6/3/22. RN 5 indicated she had been notified to come into the shower room and speak with Resident B. The resident stated CNA 2 gets fresh with me between the legs. RN 5 notified her unit manager, and the CEO (Chief Executive Officer) was notified of the allegations. A written statement, dated 6/4/22, by RN 3, indicated Resident B had been touch in her privates, her vagina and asked if it felt good. The resident told him it did to make him stop, and he did. Resident B told the RN the CNA 2 never used gloves. The second time the CNA inserted fingers into her vagina for 2-4 minutes and asked the resident if it felt good. The resident said no. The resident told the RN he then went around the curtain for 5-10 minutes to satisfy himself. Resident indicated to RN it sounded like he was masturbating. Then CAN 2 came back around the curtain, and he exposed himself to the resident. She told RN 3 she .saw his penis The resident told the RN .the entire thing shocks me An untitled typed note, dated 6/4/22, and signed by the Administrator and Unit Manager 6 indicated CNA 2 was approached as he was clocking in and asked to go to the Administrator's office. CNA 2 was informed of the allegations and his suspension during the investigation. He was informed he was to have no contact with anyone at the facility and could not come back to the premises unless he was invited. CNA 2 was escorted out of the facility. A form titled, CEO/Admin. Review of statements, dated 6/10/22, indicated, on 6/6/22, a statement was provided by CNA 2. The CNA denied any wrong doings. He stated as a caregiver his hand would be in private areas. The statement indicated .that he does the best job that he can, and individuals can get infatuated with caregivers. Also stated that residents can dream, hallucinate, and individuals have dreams that create false thoughts that they believe are real. Without knowledge of who the resident was went on to describe how resident would call him into her room to assist with TV. He feels he is misunderstood quite often and feels that communication during bathing was taken wrong and he is not out to hurt people verbally or physically. Stated that words and actions done were misinterpreted and he know that is the case here. He believes that resident has a guilty conscious about married men giving her showers and she has had dreams about him due to her minds condition On 6/6/22, an interview was conducted by the Administrator/CEO with CNA 2 and a witness (Unit Manager 6) and was included in the CEO review of statements. CNA 2 indicated he would never do anything like that when presented with the allegations. CNA made statements about dreams and hallucinations. He admitted he did not wear gloves when providing a shower but always had the washcloth between him and the resident. CNA 2 denied any sexual/inappropriate conversations. However, CNA indicated he had calmed a resident down with a kiss on the forehead or check but never on the mouth. CNA was questioned about a phone call to Resident B the night of his suspension and he indicated it was an accident. He allowed the Unit Manager to check his phone and the resident's phone number had been called from his phone. CNA indicated the phone call must have happened by accident. A Termination Notice, dated 6/9/22, indicated CNA 2 was notified by a phone call of his termination due to violation of company policy. On 6/27/22 at 9:43 A.M., forms titled C.N.A. Shower Sheet, were provided by Unit Manager 6. The forms indicated CNA 2 had showered Resident B 3 of the 9 times she received a shower, in the month of March. The Unit Manager 6 indicated the months of April, May and June Resident B did not have any more showers completed by CNA 2. On 6/27/22 at 10:19 A.M., an interview was conducted with Resident B and the Social Service Director (SSD). The resident was alert to self and place and indicated she was feeling fine. When asked about a situation she had experienced she looked over to the SSD and said nothing. Then looked back to surveyor and starred. The SSD explained, to the resident, the surveyor was part of the investigation and could be trusted. The resident indicated she just wanted to move on and not talk about (name of CNA 2) and referred to the incident as being molested. She indicated the incidents (2) happened over a month ago. She indicated the incidents made her feel like poop. She just wanted not to talk about it anymore and to move on and the interview was aborted. During an interview, on 6/27/22 at 10:27 A.M., the SSD indicated the resident was afraid to talk, to the Administrator, the day after the incident because she has a trust issue. The SSD was contacted by the Administrator to come to the facility and talk with the resident regarding the allegations. SSD indicated the resident never cried or showed any emotions when she described what had happened to her. She indicated the resident was concerned about others, who resided at the facility and just wanted to get it out of her mind. The SSD indicated once the resident knew he would no longer be working at the facility, she was fine. On 6/27/22 at 12: 15 P.M., the Administrator provided all shower sheets for May and June. A review of the facility's shower sheets indicated CNA 2 was not filling out his shower sheets or not providing care. The shower sheets and/or electronic documentation indicated for the month of May and June, CNA 2 had completed one shower in May, on a male resident and one shower, on a female, in June. The electronic Activities of Daily Living-bathing indicated 2 females were bathed on 5/31/22 by CNA 2. The Administrator indicated CNA 2 had worked the dementia unit however there were no CNA shower sheets completed by him for the months of May and June. On 6/24/22 at 1:15 P.M., the Administrator provided a policy titled, Abuse, Neglect and Misappropriation of Property, dated 5/27/16 and revised on 4/14/22 and indicated the policy was the one currently used by the facility. The policy indicated .Abuse Is the willful infliction of injury, unreasonable confinement, intimidation, or punishment, with resulting physical harm, pain, or mental anguish. Abuse includes physical abuse, mental abuse, verbal abuse, and sexual abuse, as defined below, and includes deprivation by a caretaker of goods and services that are necessary to attain or maintain physical, mental, and psychosocial well-being .This policy also presumes that all abuse, as defined in this policy, causes physical harm, pain or mental anguish to any resident, even if he or she does not understand the incident, or even if he or she is in a coma .Sexual abuse Includes sexual harassment, sexual coercion, or sexual assault. For purposes of this policy, sexual abuse includes, but is not limited to, any physical contact with a resident's body that is not reasonably related to appropriate provision of ordered care or services; sexually oriented comments or jokes The Past Noncompliance Immediate Jeopardy began on 6/3/22. The Immediate Jeopardy was removed and corrected on 6/9/22 when the facility had completed the investigation, assessed or interviewed all residents depending on their cognitive status, all staff in-servicing were completed regarding the abuse policy and notification of abuse, audits and all plans of action were reviewed at a Quality Assurance/Performance Improvement meeting held 6/7/22 to ensure compliance. This Federal tag relates to complaint IN 100. 3.1-27(a)(1)

Based on observation, interview and record review, the facility failed to implement interventions to ensure 2 of 3 residents were free from falls, which resulted in a fracture for both residents and the demise of Resident E. (Resident G and Resident E) Findings include: 1.On 6/28/22 at 2:24 P.M., a review of the clinical record for Resident G was conducted. The resident's diagnoses included, but were not limited to: Alzheimer's disease, repeated falls, history of falls, cognitive communication deficits and delusions. A Quarterly Minimum Data (MDS) Assessment, dated 3/11/22, indicated the Brief Interview for Mental Status (BIMS) score was 6 (score of 0-7 severe cognitive deficit), required extensive assistance of 2 persons with transfers, bed mobility and toileting. The assessment indicated the resident had no previous falls since last assessment in December of 2021. A Fall care plan, dated 1/16/20, indicated resident was at risk for falls due to dementia and weakness. The interventions included but were not limited to: fall risk assessment routinely and provide individualized toileting interventions based on needs and patterns. The care plan was updated, on 5/18/22, and included an intervention to use assist rails when turning & repositioning. An Activities of Daily Living (ADL) care plan, dated 1/16/20 indicated the resident required assist with ADL's including bed mobility, transfers and toileting related to Alzheimer's dementia. The interventions included but not limited to: assist resident with transfers as indicated. A Fall Risk Assessment, dated 3/5/22, indicated the resident scored an 11, with a score of 6-13 signifying the resident was at moderate risk for a fall. A CNA Assignment sheet, dated 4/18/22, indicated the resident was a 2 assist with mobility/transfers. A Progress Note, dated 5/14/22 at 8:14 A.M. indicated, at 1:30 A.M., the nurse was called into Resident G's room by QMA 7. The noted indicated .QMA stated that res [resident] was laying on her left side in bed getting brief and bed linen changed, res[resident] moved self forward and fell on the floor on her knees, then laid self down on her right side. Res [resident] crying in pain it hurts, res [resident] noted to have a large lump/swelling at the left lower thigh above the knee, site painful with a light touch A self-reported incident #204, dated 5/14/22, indicated Resident G had been receiving care by a QMA 7. The resident was on her left side, facing away from the QMA, when the resident moved her legs over the side of the bed and fell to the floor. The resident was sent to local ER and it was determined the resident had a left femur fracture. The resident returned to the facility on [DATE] after a surgery. A Hospital ER report, dated 5/14/22, indicated the patient fell in a nursing home and was brought to the local hospital. The patient was a poor historian with advanced dementia, can not hear and denied pain. An x-ray was obtained, and the resident received a displaced left femur fracture. The report indicated the resident would need an open reduction total fixation (type of surgery used to fix broken bones) of the left femur. During an interview, on 6/29/22 at 9:21 A.M., the MDS Coordinator indicated the transfer and bed mobility information is not on the care plan, the information goes onto the CNA assignment sheets and were updated as the plan of care changes. On 6/29/22 at 9:56 A.M., the resident was observed in her bed. She was dressed and her eyes were closed. The bed was in the low position and a mat was on the floor, next to her bed. The bed had assist bars, on bilateral sides of the bed, which fitted the bed correctly with no gaps. Resident remained sleeping. A form titled Coaching & Counseling Session, dated 5/16/22, indicated the resident was rolled away from the QMA, instead of towards her. The QMA was counseled to roll residents towards her and to ask for help. An Indiana State Department of Health Nurse Aide Curriculum, dated 7/1998 and revised on 11/18/15, indicated on page 227 .Procedure #55: Occupied Bed .7. The caregiver will make the bed one side at a time. The caregiver will raise the side rail on the far side of bed. (if rail not use, ensure there is a second caregiver on the opposite side of the bed to ensure that the resident does not roll over the side of bed). Assist resident to turn onto side moving away from you toward raised side rail (or second caregiver) On 6/24/22 at 1:15 P.M., the Administrator provided a policy titled, Falls Policy, dated 6/1/15 and revised on 6/9/22, and indicated the policy was the one currently used by the facility. The policy indicated .The intent of this policy is to ensure the facility provides an environment that is free from accident hazards over which the facility has control to prevent avoidable falls 2.On 6/27/22 at 2:32 P.M., a review of the clinical record for Resident E was conducted. The resident's diagnoses included, but were not limited to: dementia, history of falls, [CONDITION(S)] disease, [CONDITION(S)] and [CONDITION(S)]. The resident had a Do Not Resuscitate status. A Quarterly Minimum Data (MDS) Assessment, dated 3/11/22, indicated the Brief Interview for Mental Status (BIMS) score was 6 (score of 0-7 severe cognitive deficit), required extensive assistance of 2 persons with transfers, had 1 fall since last assessment on 12/12/21 and was frequently incontinent of bowel and bladder. A fall care plan, dated 7/8/21, indicated the resident was at risk for a fall due to weakness, [CONDITION(S)], history of falls, left eye [CONDITION(S)] and dementia. The interventions (with date implemented) included, but were not limited to: do not leave resident on toilet or up in wheelchair when in room (4/3/22), ask wife to notify staff when leaving, so staff can lay him down to rest (2/9/22), resident getting on floor and crawling out of room due to delusions (1/6/22), check frequently for toilet needs at night (12/15/21), check resident frequently when in his room (11/29/21), resident will use call light for assistance with transfer (11/26/21) and assist with transfers (7/28/21). A Fall Risk Assessment was completed on 4/3/22 and the resident's score was 28. The assessment indicated a score greater than 13 placed the resident at high risk for fall. A self-reported incident #201, dated 4/17/22, indicated Resident E had an unwitnessed fall and was found lying on the floor, in the dining room, by a CNA. The CNA immediately called for a nurse, who assessed the resident and sent him to a local hospital. A Statement from CNA 8, undated, indicated after breakfast she was taking residents out of the dining room and was out of dining room, approximately 3 minutes and when she returned Resident E was found on the floor. A Progress Note, dated 4/12/22 at 9:51 P.M., indicated .Resident exhibiting increasing confusion and delusional behaviors. Was looking over his left shoulder and speaking to someone this evening, when asked who he was talking to he stated [person's name] Resident asked this writer So what ever happened to [a person's name] 2nd wife? This writer asked who [person's name] was and resident stated [person's name], he got married today, the bride's gown was beautiful but the girl, well I don't know. Didn't you go to the wedding? Resident is noted to be grabbing at things in the air and holding them between his thumb and fingers as well as bending over and picking things up off the floor that are not there. Resident stated It's like a string of [NAME], I'm the only one that can see it or feel it then handed nothing to this nurse to discard in the trash. Resident will speak out random sentences during conversation that are not related to the subject of the conversation. Stated We believe this nursing home will be a good investment, I'm glad we bought it and told this nurse I bought this place, I own it now Resident is increasingly restless and anxious. Becomes tearful at times stating, My wife had a stroke Resident insisting His wife and daughter just walked down the hall way and that he needs to get to them. Wife and daughter are not in the facility. Resident is not easily redirected and becomes agitated. Resident frequently attempting to self transfer this shift and was observed standing and taking a few steps till staff intervened and assisted resident back to w/c [wheelchair]. Resident refused supper this evening however did eat snacks. Assisted to bed at 21:30 and is currently resting quietly there with TV on A Progress Note, dated 4/17/22 at 9:05 A.M. indicated .Staff including this writer were taking residents out of the south dining room following breakfast. When CNA returned to the dining room to get another resident, she found resident on the floor face down. This nurse was coming around the nurses station toward the dining room when the cna yelled for this writer and said that resident was on the floor. Staff had not been out of the room for more then 3-4 minutes. Upon arrival, resident was mostly face down with the right arm pinned back behind him. Bleeding noted from right side of head On 6/28/22 at 4:47 P.M., an interview was conducted with Unit Manager 6 and CNA 8. CNA 8 indicated she was working the day Resident E fell and she was the one who found him in the dining room. She indicated herself and other staff members were taking residents out of the dinining room. She indicated Resident E was finished eating and was waiting on staff to take him to the nurse's station or to the common area. She had taken another resident to the common area and was gone from the dining room maybe 2-3 minutes, when she returned, she seen something on the floor and it was Resident E. CNA called for the nurse who came and assessed the resident, 911 was called and resident left the facility by ambulance. A hospital emergency room (ER) Report, dated 4/17/22, indicated resident presented to the ER with a laceration over his right temple. The resident had apparently slipped out of his chair and hit his head on the floor. The resident had no loss of consciousness, taking [MEDICATION(S)] (blood thinner) for [CONDITION(S)] and complained of right shoulder pain. The exam indicated the resident sustained a 4 cm full-thickness laceration over the right temple, pupils were equal/round/reactive to light (PERRL) and had an abrasion of right shoulder. A CT (Computed Tomography-type of x-ray) of the head indicated the resident had sustained an acute subdural and subarachnoid hemorrhage (bleeding) to the left temporal lobe of the brain and a fracture of the sphenoid bone. The resident's case was discussed with the family, the family physician and a neurosurgeon and it was determined to transfer the resident to another hospital for further evaluation and treatment. A History & Physical (H&P) from the trauma hospital, dated 4/17/22, indicated Resident E had suffered a ground level fall, was sent to the local hospital and was later transferred to the trauma hospital for an evaluation. A CT of the brain showed a moderate size subarachnoid and intracerebral hemorrhage. A neurosurgeon met with the family and discussed the different treatment options. At the conclusion, of the discussion, the family decided to proceed with comfort measures. The exam indicated the resident did not open his eyes, was not responding to verbal stimuli, breathing with an open mouth, using abdominal accessory muscles, with course breath sounds. The resident was admitted to the hospital with a hospice consult. The resident passed away the next day. This Federal tag relates to complaint IN 864. 3.1-45(a)(2)

Based on observation, record review and interview, the facility failed to ensure there was adequate supervision prevent a fall with injury for 1 resident reviewed for accidents in a sample of 1. This occurred when Resident #65 assisted Resident #33 to the bathroom. Resident #33 fell and sustained a Fractured Right Femur. In addition, the facility failed to ensure the handrails on 3 of nursing units were free from splintered areas and 1 of 3 halls was free from accessible chemicals. Finding includes: 1. The clinical record for Resident #33 was reviewed on 10/07/2015 at 3:07 P.M. Resident #33 was admitted to the facility, on 01/11/14, with diagnoses, including but not limited to: Alzheimer's dementia, osteoarthritis and muscle weakness. A reportable fall investigation, completed on 08/14/15 indicated on 08/13/15 at 5:17 P.M., Resident #33 was found on the floor. The incident report and investigation indicated Resident #65 had turned off the wheelchair alarms and unfastened a seatbelt for Resident #33 and had attempted to assist Resident #33 to transfer to the toilet. Resident #65 had then alerted CNA (Certified Nursing Assistant) #57 when Resident #33 had ended up falling to the floor. Both residents resided on the secured dementia unit at the time of Resident #33's fall. Resident #33 was transferred to an acute care facility and diagnosed with [REDACTED]. The nursing progress notes for Resident #65 on July 16, 23 and 31, 2015, indicated the resident had been observed attempting to help other resident's to the bathroom or to bed and had to be redirected. Resident #65 would become very upset when redirected from that activity. The behavior tracking for Resident #65 for August and September 2015 indicated the resident was being monitored for delusions, yelling at other, pacing, and tearfulness. There was no care plan intimated specific to the resident's behavior of attempting to assist other residents with transferring and toileting needs. Observation of the secured dementia unit, on 10/07/15 at 5:00 P.M., indicated the unit was u-shaped with a kitchenette and television area on end of the u-shape, a dining room at the end, and the resident rooms and hallway on the other end of the u-shape. Resident #65 was observed seated in a chair beside her bed awake. She later was observed to ambulate independently out of her room and seat herself on the couch. During an interview, on 10/07/2015 at 3:15 P.M., CNA #57 indicated on the evening of 08/13/15 he was the only staff member working on the dementia unit. He indicated he was around the corner by the kitchenette at the sink, washing his hands, when Resident #65 came to get him to let him know that Resident #33 had fallen. He indicated when he was working by himself and needed to help individual residents or was at the sink, he could not possible supervise the other residents. CNA #57 confirmed Resident #65 then told him she had been attempting to help Resident #33 and had turned off the alarms. He indicated the normal staffing for the dementia unit was 2 staff but sometimes there was only 1 staff member scheduled. 2. On 10/1/2015 at 9:14 a.m., a container of disinfectant wipes was observed by the TV in room 216. During a tour of the facility on 10/5/2015 from 9:10 a.m. to 10:12 a.m. accompanied by the Maintenance Supervisor, the following was observed: The handrails located on the North Unit, Serenity Unit, and the South Unit, had rough and jagged areas. There was a bottle of antibacterial wipes sitting on a nightstand in room 216. During an environmental tour on 10/5/2015 at 2:37 p.m., the Maintenance Director indicated that he had identified the handrails had rough areas and indicated that the antibacterial wipes located on the nightstand in room 216 were not supposed to be there. On 10/7/2015 at 11:32 a.m., the Maintenance Director provided a policy titled, Accident Prevention, dated 01/2005, and indicated that policy was the one currently used by the facility. The policy indicated .8. Keep all bottles out of residents' reach and have bottles labeled. Keep janitorial closets locked at all times. Do not spray any cleaning chemical in the direction of a resident . On 10/7/2015 at 11:32 a.m., a form titled, LOGBOOK DOCUMENTATION, provided by the Maintenance Director, indicated that the handrails had been checked on September 11, 2015 by the Maintenance Director. 3.1-45(a)(1) 3.1-45(a)(2)

Based on observation, record review, and interview, the facility failed to assess and provide care for a resident in pain in a timely manner for 1 of 11 residents reviewed for pain in the sample of 12, which resulted in the resident experiencing unrelieved pain. (Resident #K) The facility also failed to ensure treatment and services were provided for skin tears and lacerations for 1 of 3 residents reviewed for skin conditions in the sample of 12. (Resident #G) Findings include: 1. Resident #K's record was reviewed on 7/18/12 at 3:43 p.m. Resident K's [DIAGNOSES REDACTED]. The resident was admitted to the facility on [DATE]. On 7/18/12 at 10:20 a.m., Resident #K was observed moaning in bed. SS #1 was in the room speaking with a family member of the room mate. SS #1 indicated she was going to get the nurse because the resident had been moaning. The resident indicated pain by nodding her head yes and rubbing the left lower quadrant of her stomach. SS #1 was observed turning on the call light and informed the resident she needed to use the call light if she needs assistance. At 10:23 a.m., LPN #1 was observed walking by the resident's room two times. At 10:25 a.m., CNA #3 walked into the resident's room and then was observed going to the location of LPN #1. LPN #1 did not address the resident's pain as she went into another resident's room to do a dressing change. CNA # 1 and ADON went to the resident's room at 10:35 a.m. RN #1 was observed asking CNA #1 if the resident indicated what was wrong and proceeded to walk down her responsible corridor. The Admissions Coordinator was observed entering Resident #K's room at 10:45 a.m. and then to the location of LPN #1. RN #1 was observed getting a resident from the activity room and walked down her responsible hallway. The resident's call light was observed turned off at 10:55 a.m. as the Admissions Coordinator and SS #1 walked out of the resident's room. No staff were observed going into the resident's room between 10:55 a.m. and 11:27 a.m. The resident continued to moan. From 11:27 a.m. to 11:35 a.m., LPN #1 came out of a resident's room multiple times to go to the medication cart before going to the lunch room. CNA #1 and #3 returned to Resident K's room to assist her room mate at 11:40 a.m. At 11:45 a.m., LPN #1 was observed bringing Resident #K's lunch and asked her how her pain was. The resident was observed to still be moaning. LPN #1 was observed pulling the resident's curtains, walked out of the room and walked back to the dining room where she was observed passing out trays. LPN #1 was interviewed at this time regarding the resident's pain. LPN #1 indicated a nurse from the hospital told her the resident moaning is "something she does" and no one has informed her of the resident's pain. She also indicated the resident receives scheduled pain medication, and she gave her Tylenol between 8 a.m. and 9 a.m., so it was not time for the resident to have anymore pain medication. At 12:30 p.m., Resident #K continued to moan in discomfort. The resident indicated she was in pain by moving her hand toward her pelvic area when asked where her pain was. During this time, the DON was made aware and she indicated she will make sure the resident receives pain medication right away. The current Pain Monitoring Flowsheet for 7/18/12 was reviewed on 7/20/12. The flowsheet indicated on 7/18/12 at 9:00 a.m. the resident's pain rating as a "7" which meant the resident had moderate to severe pain. Resident K received Tylenol at that time for pain in the peri area. The post pain rating for the above dose of Tylenol indicated a "2" which meant the resident continued to be in slight pain. The time the above post pain rating was completed was not documented on the flowsheet. At 1:30 p.m., the resident received Tylenol for "c/o (complaints of) headache" at a level of "6" which meant moderate pain. No post pain rating was written. The 7/2012 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. There were no Physician orders for any pain medications to be given routinely. The MAR indicated [REDACTED] The Pain Interdisciplinary Care Plan for Resident #K indicated the resident had severe, acute pain often AEB (as evidenced by) crying/moaning and facial grimace. The goal indicated "Resident will state/demonstrate relief or reduction in pain intensity within 30 minutes after receiving interventions". The interventions indicated to "...report changes in pain location/type frequency/intensity to physician...Notify the resident's physician if they do not state/demonstrate relief or reduction of pain after one hour of receiving the first intervention..." 2. On 7/19/12 at 1:25 p.m., Resident #G was observed sitting in a wheelchair in her room. LPN#1 entered the resident's room to render a treatment to a laceration on her left lower leg. The resident lifted her left pant leg and a scabbed laceration was observed to the front of her left shin area. There was no dressing or bandage over the area. At this time, the resident indicated the dressing had been off since her shower this morning. The record for Resident #G was reviewed on 7/18/12 at 1:00 p.m. The resident's [DIAGNOSES REDACTED]. A Physician order was written on 7/16/12 for staff to apply Steri Strips to wound to approximate the edges for wound closure, then cover with calcium alginate and wrap the area with Kerlix (a rolled bandage to wrap around wounds) every day for 7 days. The 7/12 Resident Progress Notes were reviewed. An entry made by Nursing on 7/15/12 at 9:00 p.m. indicated the resident was adjusting herself in the wheel chair and a Kleenex box was knocked off the table hitting her left lower extremity and causing a laceration measuring 1.2 centimeters. When interviewed on 7/19/12 at 1:27 p.m., LPN #1 indicated she was not aware the resident's dressing was not in place. The LPN indicated CNA #4 was assigned to care for the resident today. LPN #1 indicated the CNA had not informed her the resident's dressing was off and the resident should have had a dressing in place as ordered by the Physician. When interviewed on 7/19/12 at 1:30 p.m., CNA #4 indicated she had given the resident a shower around 7:15 a.m. this morning. The CNA indicated the bandage was falling down the resident's leg and the resident removed the bandage. CNA #4 indicated she did not tell the Nurse the bandage was off. When interviewed on 7/19/12 at 2:40 p.m., the Director of Nursing indicated the resident should have had a dressing in place as ordered by the Physician. This federal tag relates to Complaint IN 790. 3.1-37(a)

Based on record review and interview, the facility failed to obtain a urinalysis in a timely manner for a resident tensing and complaining of pain upon urination. This resulted in a delay in the treatment of [REDACTED]. (Resident #C) . Findings include: Resident #C's record was reviewed on 7/17/12 at 3:40 p.m. Resident #C's [DIAGNOSES REDACTED]. A care plan dated 4/19/12 indicated the resident displayed severely impaired decision making, rarely or never was understood when speaking, had difficulty following directions, and had trouble focusing. There were no care plans related to urinary tract infections. A nursing note on 4/28/12 at 2:50 p.m. indicated (Resident #C's) "Dghts (sic) (daughter) was here and said that when (Resident #C) voids (urinates) he tenses (arrow pointing up) up, starts yelling. When daughter asked him if it hurts when he urinates, (Resident #C) said yes. MD (doctor) faxed req (requested) U/A (urinalysis)." At 3:00 p.m., the nursing note indicated the resident had "foul smelling urine" and "fluids encouraged." At 5:05 p.m., the nursing note indicated "order rcd (received) for U/A (urinalysis). No c/o (complaints)." A nursing note on 5/1/12 at 2:10 a.m. indicated "UA obtained per straight cath (catheter). Urine cloudy & (and) brownish. No (0 with line through it) odor." There was no documentation indicating why there was a delay in obtaining the ordered urinalysis. There was no documentation of any further assessment of the resident's above complaints of discomfort or any further documentation of any assessments of the resident's urine in the nursing notes between 4/28/12 and 5/1/12. Results of the 5/1/12 Urinalysis were positive for a large amount of occult blood and leukocytes. Bacteria and white blood cells were present. A physician's orders [REDACTED]. The final Culture and Sensitivity was reported to the facility on [DATE]. The culture indicated the organism was resistant to the Cipro. [MEDICATION NAME] discontinued and new orders were given for [MEDICATION NAME] (another type of antibiotic) 100 milligrams twice day for 7 days, and Keflex 250 milligrams four times a day for 7 days was ordered on [DATE]. Interview with the ADON on 7/20/12 at 11:30 p.m. indicated she was unable to find faxes or documentation why there was a delay in the urinalysis. This federal tag relates to Complaint IN 790. 3.1-41(a)(2)

Based on observation, interview, and record review, the facility failed to provide effective pain management to control or lessen a resident's severe pain when moved, or turned and positioned in her bed related to an irreparable fractured right hip for 1 of 11 residents reviewed for pain in a sample of 19. Resident: #40 Findings include: Resident #40's clinical record was reviewed on 5/16/11 at 2:35 P.M., and indicated [DIAGNOSES REDACTED]. A physician's orders [REDACTED].M., indicated, "[MEDICATION NAME] 5/325 ([MEDICATION NAME] 5mg (milligram)-325 mg APAP ([MEDICATION NAME])) tablets. Give i (one) PO (by mouth) TID (three times/day) 6 A.M., 2 P.M., 10 P.M. Keep PRN (as needed) [MEDICATION NAME] order (every 4 hours) for breakthrough pain...." Resident #40 also had an order for [REDACTED]. During initial tour of the locked dementia unit on 5/16/11 at 7:00 A.M., while accompanied by LPN # 2, Resident #40 was observed lying in her bed. The resident was grimacing and indicated she was having pain at the time. LPN #2 indicated the resident had a recent fall and sustained an irreparable fractured right hip. Resident #40 was observed on 5/16/11 at 12:25 P.M., screaming out in pain when she was pulled up in her bed by LPN #2 and CNA #5. During interview with LPN #2 at the time, she stated, "We need to get some of the PRN ([MEDICATION NAME]) in her." Review of Resident #40's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED].M., indicated she had been medicated with [MEDICATION NAME] (narcotic pain medication) 5 mg. (milligram) at 6:00 A.M. (scheduled dose). She received 650 mg. of [MEDICATION NAME] (over the counter [MEDICATION NAME]) and 100 mg. of [MEDICATION NAME] (non-narcotic pain medication) at 8:00 A.M. LPN #2 medicated Resident #40 with the PRN (as needed) [MEDICATION NAME] 5 mg. at 12:30 P.M., for her breakthrough pain. On 5/16/11 at 4:50 P.M., Resident #40 indicated in an interview she was having "bad" pain in her right hip and was fearful of being moved in bed. Review of her MAR, at the time, indicated she had not been given her 2:00 P.M. scheduled dose of [MEDICATION NAME]. Instead, she received another dose of the 650 mg. [MEDICATION NAME] and 100 mg. of the [MEDICATION NAME] at 2:00 P.M. She did not receive the PRN dose of [MEDICATION NAME] until 4:00 P.M. The resident had received a PRN dose at 12:30 p.m. of the [MEDICATION NAME]. A "Resident Event Report Worksheet," dated 5/3/11, indicated, "...Event date: 5/3/11...Event Nature: Fall with significant injury...Event Adverse effect: Fracture R (right) hip...Pain R hip...Res (Resident) sitting in lounge area on alz (Alzheimer) unit. QMA (Qualified Medication Aide) in a room with another res. and nurse in office on phone. Res. disengaged personal alarm and stood up to amb (ambulate). Nurse saw this and tried to get to res., but she fell on R side before he could reach her." A Nurse's Note, dated 5/3/11 at 9:30 P.M., indicated, "Res. was sitting in Dayroom. Disengaged her Mobility Monitor. Observed standing in Dayroom got up to go to rm (room). Res. lost bal (balance) et (and) fell to floor on R side...11:00 P.M.-Res. (resident) immobilized on long board et (and) transferred to ER (emergency room ) for eval (evaluation) and tx (treatment)." A hospital report, dated 5/04/11 at 12:14 A.M., indicated, "...Right inter-trochanteric [MEDICAL CONDITION] femur (hip), closed...." A Social Service Note, dated 5/17/11 at 1:03 P.M., indicated, "...Was seen by specialist, Dr. (Name), 5/12/11. Physician stated to dtr. (daughter) that surgery was not feasible d/t (due to) deterioration of (Resident #40's) bones (this was told to this writer by dtr. today during visit to her mother)...." Further review of Nurse's Notes indicated the following: "5/2/11 at 2:00 P.M.-Up with assist of one with walker to meals and BR (bathroom)...5/4/11 at 8:30 P.M.-Res. crying out in pain, grabbing R hip. [MEDICATION NAME] given after repositioning. Unsuccessful...c/o's (complains of) pain with turning to change pads...agitated with staff while turning. Pain #8-#9 (pain scale 0-10 with 10 being 'worst pain that can be imagined') when moving...5-5-11 at 7:30 P.M.-...Medicated for pain #9 at 6P (P.M.) with [MEDICATION NAME] severe pain when T & R (turned and repositioned)...5-6-11 at 9:00 P.M.-...Cries out loudly grabbing at staff members in severe pain whenever being T & R or ever putting HOB (head of bed) up or down...5/7/11 at 10:50 P.M.-T & R q (every) 2 hours-cries out loudly, grabbing staff arms and clothing-severe pain when being T & R...5/8/11 at 2:00 P.M.-...much discomfort when moved feet up...medicated x 1 between routine [MEDICATION NAME] dose...5/8/11 at 8:00 P.M.-...cont. (continues) to be in severe pain when turned despite pain meds...5/9/11 at 3:53 A.M.-...Cont. to show s/s (signs and symptoms) of pain when moved. PRN medication given...5/9/11 at 1:45 P.M.-...when res. turned yells out at staff, facial grimacing...5/9/11 at 6:19 P.M.-...yells out with P.M. care, routine and PRN meds given...5/10/11 at 2:00 P.M.-...as long as still no pain on routine pain med...5/11/11 at 2:00 P.M.-...much discomfort when turned...5/11/11 at 9:30 P.M.-...severe pain when care is being given...5/12/11 at 3:50 P.M.-...cont. in pain when T & R...5/12/11 at 7:50 P.M.-...Medicated for pain #9 at 1800 (6:00 P.M.) with some relief obtained-cont. to moan-cry out, tear at staff's clothing when being T & R...5/13/11 at 6:30 A.M.-...Repositioned and changed and the c/o's of Rt (right) hip pain with care...5/13/11 at 2:25 P.M.-...Res. yell (sic) out some in pain when turned or repositioned by ii (2) assist...5/14/11 at 6:00 A.M.-...Resists being turned due to increased Rt leg pain with movement...5/14/11 at 9:22 P.M.-...severe pain when T & R (moaning, crying out, tearing at clothing)...5/15/11 at 7:30 P.M.-...uncomfortable when T & R...5/16/11 at 2:50 P.M.-...Routine pain meds as ord. (ordered), during repositioning after lunch res. pulled up in bed, yelling out, "My leg, No No," was given PRN med at 12:30 with lunch then routine pain meds at 1400 (2:00 P.M.) et [MEDICATION NAME] routine at 1450 (2:50 P.M.), during incont. (incontinence) care et repositioning seemed much more comfortable...5/17/11 at 2:00 A.M.-...Yelling out with pain...." The Nurse's Notes lacked documentation to indicate the physician had been notified of the ongoing pain. During interview with Resident #40 on 5/17/11 at 9:10 A.M., she indicated she was having pain in her right hip, but was unable to rate her pain on the 0-10 pain scale. The MAR indicated [REDACTED].M., but did not control her pain. Review of the Nurse's Notes indicated, "5/17/11 at 3:45 P.M.-...Yells out when moved...5/17/11 at 9:45 P.M.-Resident has lots of pain with any movement...5/18/11 at 10:00 A.M.-...Res. c/o pain R hip. Pain when pulled up in bed with 2 assist. Dr. (Name) called with report et notified. New order received...." Resident #40's MAR indicated [REDACTED]'s) on 5/04/11: 12:30 and 8:30 P.M. (no routine [MEDICATION NAME] given on 5/04/11); 1 x on 5/05/11: 6:00 P.M.; 3 x's on 5/06/11: 2:00 A.M., 10:00 A.M., and 6:00 P.M.; 1 x on 5/07/11: 10:15 A.M.; 3 x's on 5/08/11: 2:00 A.M., 10:00 A.M., and 6:00 P.M.; 1 x on 5/09/11: 2:00 A.M.; 1 x on 5/11/11: 6:00 P.M.; 1 x on 5/13/11: 6:00 P.M.; 1 x on 5/14/11: 6:00 P.M.; 2 x's on 5/16/11: 12:30 P.M. and 4:00 P.M.; 1 x on 5/17/11 at 2:00 A.M. Resident #40 received a total of 17 doses of the PRN [MEDICATION NAME] (for breakthrough pain) over the 15 day period of 5/04/11 through 5/18/11. The Director of Nursing (D.O.N.) indicated in an interview on 5/18/11 at 11:15 A.M., a physician's orders [REDACTED]. to be administered every two hours for breakthrough pain. "The [MEDICATION NAME] ([MEDICATION NAME]) wasn't controlling her pain. We were using the PRN [MEDICATION NAME], but it wasn't doing the job. We just gave her a dose of the [MEDICATION NAME] to help control her pain. We are going to reposition her in about 30-35 minutes to see how she does." A Physician Order, dated 5/18/11, indicated, "[MEDICATION NAME] Suspension 20mg/ml (milliliter) give 5 mg. PO or sublingual Q 2 hrs (hours) for breakthrough pain." During observation of Resident #40 on 5/18/11 at 11:35 A.M., CNA #15 and the D.O.N. were observed providing incontinence care. CNA #15 reached across the bed, grabbed Resident #40's right femur (large thigh bone) and pulled Resident #40 towards her while the D.O.N. pushed on Resident #40's right hip to aid in turning her onto her left hip. Resident #40 moaned slightly, but did not scream out in pain. CNA #12 and CNA #14 were observed providing incontinence care to Resident #40 on 5/19/11 at 1:10 P.M. Resident #40 moaned when the head of her bed was lowered to a flat position and screamed out in pain when her legs were touched. Resident #40 was rolled onto her right hip so she could be washed. She screamed out in pain as she was rolled. CNA #14 then reached across the bed and pulled on Resident #40's right thigh while CNA #12 pushed on her right hip to turn her over onto the left hip. Resident #40 screamed out in pain and yelled "My leg. My leg. No. No." During interview with the D.O.N. on 5/19/11 at 1:35 P.M., she indicated staff wanted to control Resident #40's pain, but did not want to "snow" her. When queried why the doctor had not been notified of the situation, the D.O.N. indicated she was going to consult a "palliative care" physician to evaluate Resident #40 and suggest treatment to control her pain. Resident #40's Care Plan, dated 5/10/11, indicated, "Problem: Fracture: Right Hip Resident Fall. Goal: Resident will have no complications and minimal pain from [MEDICAL CONDITION]. Approach: ...Administer pain medication as ordered and check for effectiveness and notify doctor if resident not getting relief...." A facility policy titled "Pain Management," revised 4/28/09, indicated, "Policy: The center's practice is to assist each resident with pain or that has a potential for pain to maintain or achieve the highest practicable level of well being and functioning through pain management...6. The center provides orientation and ongoing staff education to correct misconceptions, myths, and biases about pain. Training my (sic) include, but is not limited to: ...b. recognizing and assessing pain, reporting and documenting findings, and monitoring interventions...." 3.1-37(a)

Based on observation, interview, and record review, the facility failed to prevent the development of multiple or recurrent stage II pressure ulcers for 3 of 3 residents reviewed for pressure ulcers in a sample of 19. Residents: # 54, # 80, # 92 Findings include: 1. The clinical record for Resident # 80 reviewed on 5/16/11 at 10:45 A.M., indicated [DIAGNOSES REDACTED]. During initial tour on 5/16/11 at 6:35 A.M., accompanied by LPN # 16, she indicated that Resident # 80 was a diabetic with open areas to both her heels. She indicated that she was using heel cushions and heel boots and that she was currently seeing a wound specialist. Resident # 80's readmitted was 1/11/11. Resident # 80's initial MDS (Minimum Data Set), dated 1/21/11, indicated "...bed mobility...extensive assistance...one person physical assist...transfer...extensive assistance...two person physical assist..." A Resident Progress Note, dated 3/4/11 at 1200 (12:00 P.M.), indicated, "8 x 7 intact blister to L (left) heel et. (and) bottom of foot. Bottom of foot purple in color. Possible deep tissue injury. Dr. (Name) notified for tx. (treatment) request et. vitamin supplements...." A "Weekly Pressure Ulcer Condition Report", dated 3/4/11, indicated, "...location...heel & bottom of L foot...date of first observation 3/3/11...Size 8 x 7...Stage/Depth...Stage II - Partial thickness skin loss involving epidermis &/or dermis...Skin Color Surrounding Wound...Bright red &/or blanches to touch...5/19/11...Size 2.8 x 2.8...Unstageable...Skin Color...Bright red &/or blanches to touch..." A Resident Progress Note, dated 3/6/11 at 0530 (5:30 A.M.), indicated, "During AM care it was noted that res. (resident) has an area on the R (right) outer aspect of heel measuring 3.6 x 3.0. Res. c/o (complaining of) pain if area was touched. PRN (as needed) Tylenol (pain medication) given at this time. MD (Medical Doctor) notified of area, tx. requested. ADON (Assistant Director of Nursing) notified. Therapy notified...." A "Weekly Pressure Ulcer Condition Report", dated 3/6/11, indicated, "...location...heel Right...date of first observation 3/6/11...Size 3.6 x ...Stage/Depth...Stage II - Partial thickness skin loss involving epidermis &/or dermis...Skin Color Surrounding Wound...Pink...5/19/11...Size 1.5 x 2.0...Stage II...Skin Color...Pink..." A Resident Progress Note, dated 3/10/11 at 0820 (8:20 A.M.), indicated, "Wound nurse measured et. assessed et. Dr. (Name); stage II pressure ulcer 8.2 x 7.4 x skin intact L heel et. stage II R heel 2.4 x 3.0 x skin intact. [MEDICATION NAME] applied to both areas. No odor, drainage. Minimal swelling noted bil (bilateral) ankles et. tops of feet....use airboots at all times....Preventative measures...keeps heels a float..." Review of a "Wound Consult Note," dated 3/10/11, indicated, "I was asked to see the patient for wound care due to blisters on both heels, the left worse than the right. These apparently have come up spontaneously recently....We will obtain noninvasive arterial studies with toe pressures...." A "Vascular Flow Study," dated 3/15/11, indicated, "...Absolute toe pressures right lower extremity...this suggests adequate arterial perfusion for wound healing....Absolute toe pressures...left foot digits, which suggests adequate arterial flow for wound healing...." Review of a "Nursing Home Visits/Home Care," dated 4/16/11, indicated, "She has had healing of the heel ulcer...We'll aggressively try and prevent further pressure sores...." A "Wound Care Note," dated 4/22/11, indicated, "...The patient's non-invasive arterial studies appears to show circulation to be adequate for healing...." During observation of Resident # 80's stage II pressure ulcers on 5/20/11 at 1:50 P.M., LPN # 9 uncovered Resident # 80's feet. The Heelz up cushion was underneath the resident's thighs. The resident was wearing airboots which were resting on the bed. The right heel was purplish, red in color with no open area. The left heel wound appeared the size of a quarter with a dark black center (eschar). On 5/20/11 at 9:15 A.M., the ADON indicated they are unsure why Resident # 80 developed pressure ulcers. Interview with LPN # 9 on 5/20/11 at 1:50 P.M., she indicated Resident # 80's heels are to be kept up off the bed when she is in bed. She further indicated the Heelz up cushion slides around and doesn't stay under her legs. A Care Plan, initiated 3/4/11, updated 4/19/11, indicated, "...Problem...Stage II pressure ulcer with possible deep tissue injury L heel et. bottom of L foot...Approach...Keeps heels a float...Heez (sic) up cushion to bed..." Another Care Plan, initiated 3/7/11, updated 4/19/11, indicated, "...Problem...Stage II R heel with possible deep tissue injury ...Approach...Keeps heels a float in bed...Heez (sic) up cushion to bed..." 2. Resident # 54's record was reviewed on 5/18/11 at 8:50 a.m. The Resident's record indicated [DIAGNOSES REDACTED]. During an interview on 5/16/11 at 7:00 a.m., with the ADON (Assistant Director of Nursing) regarding Resident # 54's skin condition, she indicated the resident had no skin problems or open areas and received total care. The Resident's record indicated she developed a pressure ulcer on 4/16/11 on her left buttocks. Nurses note, dated 4/16/11 at 6:50 a.m., indicated " Resident found with 0.1 cm (centimeter) by 0.1 cm, < (less than) 0.1 cm D (depth). Open area no c/o (complaints of) Requested tx (treatment) and to be measured wkly (weekly) until healed...." The record indicated on 4/23/11 the pressure area was healed. Review of nurse note dated 5/17/11 at 7:34 a.m., indicated "...resident has a 0.6 by 0.5 cm area to to (sic) lt (left) side of buttocks. MD (medical doctor) was notified via fax and tx (treatment) requested." A care plan, dated 3/15/10 and updated on 4/5/11, indicated "Problem: At risk for skin breakdown, impaired mobility... Goal; Will be clean, dry and free of skin breakdown...Approach; Assist to reposition frequently, (Resident) chooses not to lay down between meals, peri care and moisture barrier after each incontinence, alternating air pressure mattress on bed, pressure relief cushion in W/C (wheelchair). A care plan, dated 3/15/10 and updated on 4/5/11, indicated "Problem: At risk for skin breakdown..." A plan of care dated 3/15/11 and updated on 4/5/11, indicated "Problem: Significant weight loss (March 2010) Leaves 25% or more uneaten most meals, at risk for choking, dx (diagnosis) hiatal hernia, dx: dysphagia....Approach: ...Notify RD (registered dietitian) and MD (medical doctor) of significant weight changes, abnormal labs, skin breakdown...." The Resident's quarterly MDS (minimum data set) assessment, dated March 3, 2011, indicated she transferred with a Parker lift and 2 assistance of staff and used a wheelchair for mobility. The Resident needed total assistance for bathing and dressing. May 2011's Meal Intake Record for Resident # 54 indicated she refused many of her meals and the alternates. May 4th through the 9th, the resident refused her dinner meals and the alternates. The Resident's meal intake for the month of May was less than 25%. Nurses notes for May 2011 lacked documentation to indicate the dietitian or the physician had been notified of the resident not eating for several days in a row. The resident's record indicated the dietitian updated a note on 5/19/11 after a resident record review. The dietitian's note failed to indicate the resident had an open area. 3. Resident #92 record was reviewed on 5-19-2011 at 1:55 p.m. Resident #92's [DIAGNOSES REDACTED]. Resident #92 was admitted to facility on 7/29/2008 and has used a power chair for mobility. The "Resident Progress Notes," dated 1/4/11 at 8:20 a.m., stated, "Res (resident) was found c (with) 2 new bruises this am (morning), on back of heels bilaterally. R (right) bruise measures 1.2 c.m. x 0.5 c.m., L (left) bruise measures 1 c.m. x 0.4 c.m...." The "Weekly Pressure Ulcer Condition Report," stated, "...date of first observation 1/4/11...Assessment 1/4/11...stage 1...edges distinct...white/gray non-variable tissue &/or non-adherent yellow...necrotic tissue...non visible...exudate amount...1-none...." The "Weekly Pressure Ulcer Condition Report," stated, "...date 1/21/11...stage 2 blister...." The "physician's orders [REDACTED]. The "Comprehensive Care Plan Report," updated on 5/3/11, indicated that Resident #92 was, "...At risk for skin breakdown...Will be clean, dry & free of skin breakdown...." There was no documentation regarding prevention or treatment of [REDACTED]. An interview was conducted on 5/19/11 at 4:45 p.m. with LPN #3. LPN #3 was unable to find a care plan addressing prevention or care of heel pressure ulcers. LPN #3 indicated that the documentation should be on the chart. The policy titled, "Pressure Ulcer Prevention" dated 4/28/09 was reviewed on 5/24/11 at 3:40 p.m. stated, "Policy- A resident who enters the center without pressure ulcers and/or other non-pressure ulcers does not develop pressure ulcers and/or other non-pressure ulcers, unless the individual's clinical condition demonstrates that they were unavoidable. The center provides care and services to: a. Promote the prevention of pressure ulcer development b. Promote the healing of pressure ulcers that are present (including prevention of infection to the extent possible); and c. Prevent development of additional pressure ulcers...15. Develop care plan on the degree and areas of risk and update as necessary...." 3.1-40(a)(1) 3.1-40(a)(2)

Based on observation, interview, and record review, the facility failed to provide the necessary supervision to prevent a fall which resulted in an irreparable fractured hip (Resident #40) for 1 of 5 residents reviewed for falls in the sample of 19, failed to provide supervision to prevent resident to resident altercations (Residents: #45, #58, #68) for 1 of 1 residents in the sample of 19 and 2 of 2 residents in the supplemental sample of 30 reviewed for incidents. The facility also failed to provide a hazard free environment related to unsecured steak knives and unsecured barrels containing soiled linens and soiled incontinence briefs. This hazard had the potential to affect 10 of 79 residents observed wandering on the North and South units and 15 of 15 residents residing on the dementia unit. Findings include: 1. Resident #40's clinical record was reviewed on 5/16/11 at 2:35 P.M. and indicated [DIAGNOSES REDACTED]. During initial tour of the locked dementia unit on 5/16/11 at 7:00 A.M., while accompanied by LPN # 2, she indicated Resident #40 had sustained an irreparable fractured right hip from a recent fall on the unit. Resident #40 had facial grimacing and indicated she was having pain at the time. A "Resident Event Report Worksheet," dated 5/3/11, indicated, "...Event Nature: Fall with significant injury...Event Adverse effect: Fracture R (right) hip...Pain R hip...Res (Resident) sitting in lounge area on alz (Alzheimer) unit...." The report indicated Resident #40 was left unsupervised in the central living area of the dementia unit. "QMA (Qualified Medication Aide) in a room with another res. and nurse in office on phone. Res. disengaged personal alarm and stood up to amb (ambulate). Nurse saw this and tried to get to res., but she fell on R side before he could reach her." LPN #3 indicated in an interview on 5/17/11 at 3:00 P.M., Resident #40 fell next to the small sofa. "There were two staff on duty, but they were busy at the time of the fall." During observation of the dementia unit on 5/16/11 at 8:00 A.M., the nurse's station was observed to have a windowed wall separating the nurse from Resident #40 at the time of the fall. Review of Nurse's Notes indicated the following: "5/2/11 at 2:00 P.M.-Up with assist of one with walker to meals and BR (bathroom)...5/3/11 at 9:30 P.M.-Res. was sitting in Dayroom. Disengaged her Mobility Monitor. Observed standing in Dayroom got up to go to rm (room). Res. lost bal (balance) et (and) fell to floor on R side...." "Post Fall Evaluations" indicated Resident #40 sustained previous falls: 6/09/10 at 1:55 A.M.-Res (resident) found sitting on the floor with feet on the floor and knees up with pants and brief at her ankles...Fall History...5/23/10...; 7/17/10 at 11:40 A.M.-Resident in dining room. Went to get up from chair, lost balance...did not hit head, has been unsteady on feet lately...; 2/19/11 at 7:45 P.M.-Found sitting on floor in front of chair...Location of resident prior to fall: wheel chair...; 3/5/11 at 7:45 P.M.-Found sitting on floor in front of DR (dining room) bathroom...." A Care Plan, dated 5/02/11, indicated, "Problem: At risk for falls...non-compliant with safety measures secondary to Dementia diagnosis/ Goal: Will be free from falls with injury. Approach: ...assist with ambulation and transfers. Mobility monitor on while up and in chair...." 2. Review of the Resident to Resident incidents of abuse, dated 7/9/10, indicated, Date of Alleged incident - 7/3/10 at 12:30 P.M., Resident # 58 was slapped on the right side of her face by another resident who was supposed to be on 1 on 1 supervision at the time, however, the nurse providing 1 on 1 was on the telephone at the time of the incident. 3. Review of the Resident to Resident incidents of abuse, dated 8/8/10, indicated, Date of Alleged incident - 8/7/10, untimed, RN # 38 was walking down the south hallway towards the nurses station when she saw Resident # 68 right leg being held down by another resident with his right hand as he hit her with his left hand. 4. Review of the Resident to Resident incidents of abuse, dated 10/23/10, indicated, Date of Alleged incident - 12/20/10, untimed, Resident # 45 suffered a fall and bruise to the right forearm. The nurse on the unit was in the lounge area when she heard Resident # 45 yell, "Get out of here". As she started towards the room, she heard the Resident say, "Stop pushing me, you're going to make me fall." When the nurse entered the room, she saw Resident # 45 on the floor of her room with a male resident standing over her. A facility policy titled "Abuse", revised 10/31/09, indicated, "Verbal...physical...and neglect of the resident...are strictly prohibited....Prohibitions on abuse apply to...residents...Identify residents most at risk of neglect and abuse, may include...Residents who have dementia...psychosocial, interactive, and/or behavioral dysfunction...." 5. During an environmental tour of the facility on 5/20/11 at 2:30 p.m., accompanied by the Maintenance Director # 41 and the Housekeeper # 42, an observation was made of the Occupational Therapy room door open. In the room an observation was made of 2 serrated steak knives in a basket in an unlocked cupboard. An observation was made of 10 residents wandering unsupervised. There wasn't any staff member present in the Occupational Therapy room. Residents pass by the Occupational Therapy room to visit the Therapy Department on a daily basis. In the unlocked Alzheimer's unit bathroom that is used by the residents, an observation was made of two large 50 gallon containers. The containers were marked, one was for trash the other was for soiled linen. The large containers had a plastic lid that could easily be lifted off. Alzheimer's residents freely use this bathroom, the bathroom door was observed to be left open. During an interview with CNA # 28 on 5/20/11 at 2:50 p.m. regarding the two large containers accessible to residents, she stated "I wouldn't want my parents near those, they could get into them and they are contaminated." 3.1-45(a)(1) 3.1-45(a)(2)

Based on observations, interviews and record review, the facility failed to ensure a resident maintained a normal weight related to a resident losing a significant amount of weight in one month (28.6 pounds) and by not putting an immediate intervention in place to aid in nutrition for 1 of 6 residents reviewed for weight loss in a sample of 19. (Resident # 54) Findings include: Resident # 54's record was reviewed on 5/18/11 at 8:50 a.m. The Resident's record indicated [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. A physician's orders [REDACTED]. DX (diagnosis) Nutritional supplement. The Resident's form titled "Individual Resident Weight History" indicated the weights on the following dates: 1/9/11- weight was 141 2/9/11- weight was 155.2 3/6/11- weight was 156.7 4/11- weight was 155.5 5/11- weight was 128.5 the reweight was 126.9 Total weight loss from April to May was 28.6 pounds. Nurses notes, dated 4/17/11 to 5/15/2011, lacked documentation indicating the physician had been notified of the significant weight loss for May so further physician intervention and orders could be obtained. The Resident's plan of care, dated 3/15/10, indicated "Problem: Significant weight loss (March 2010) Leaves 25% or more uneaten most meals, at risk for choking Dx (diagnosis) Hiatal Hernia, Dx: Dysphagia...Approach:...Notify RD (Registered dietitian) and MD (Medical Doctor) of significant weight changes...." The Resident's record lacked documentation indicating the Dietitian had been notified of the significant weight loss so an intervention could have been put in place immediately. The resident's record was reviewed on 5/18/11 at 8:50 a.m., with a concern shared for weight loss. On 5/19/11, the resident's record indicated a note from the Dietitian was added to the resident's record. The Dietitian's note acknowledged the recent significant weight loss and to increase the House Supplements and add weekly weights to monitor...." The resident's form titled "Individual Resident Meal Intake Record" dated March 2011, indicated the Resident was eating greater that 25% of her meals for breakfast. For lunch and dinner her intake averaged 25% of her meals. The March documentation for the a.m. and p.m. snacks indicated the Resident consumed nearly all of the food and fluids offered. The Resident's form titled "Individual Resident Meal Intake Record" dated April 2011, indicated from April 9th to the 15th, the resident had refused her supper and also the alternate. The resident's record lacked documentation to indicate the dietitian or the physician had been notified. On April 28th the form indicated Resident # 54 refused all three meals that day. The April meal intake form indicated for the entire month of April, her intake was less than 25% with refusal of many of the meals and alternates. The nurses notes lack documentation to indicate the physician or the dietitian had been notified so further interventions could have been tried. May 2011's Meal Intake Record for Resident # 54 indicated she refused many of her meals and the alternates. May 4th through the 9th, the Resident refused her dinner meals and the alternates. The Resident's meal intake for the month of May was less than 25%. Nurses notes for May 2011 lack documentation to indicate the dietitian or the physician had been notified of the Resident not eating for several days in a row. The Resident's record indicated Resident # 54 needed extensive assistance with meals. On 5/17/11 at 1:00 p.m., Resident # 54 was observed in the dining room. The resident was observed refusing to eat her pureed lunch. Observation was made of staff attempting to assist the Resident with her meal, she refused to eat. No alternative was observed being offered. Staff was observed to give up quickly when the resident refused to eat. During an interview with CNA # 5 on 5/17/11 at 1:20 p.m. regarding resident # 54 not eating, she indicated it was difficult for staff to get her to eat. During an interview with the Director of Nursing on 5/19/11 at 5:00 p.m., regarding weight loss for Resident # 54, she indicated it should have been addressed more timely. The facility's policy titled "Nutritional Risk, Nutritional Problem and/or Significant Change" dated 10/31/10, indicated "...Significant Change, a decline or improvement in a patient's status that: a. Will not normally resolve itself without intervention by staff or by implementing standard diseased-related clinical interventions, is not "self-limiting", b. Impacts more than one area of the patient's health status; and c. Requires interdisciplinary review of the care plan ...." 3.1-46(a)(1)

Based on observation, interview, and record review, the facility failed to perform the necessary suctioning to adequately clean the airway of a medically compromised and totally dependent resident with copious amounts of secretions which resulted in the resident violently coughing and struggling for breath. This deficient practice affected 1 or 1 residents receiving suctioning in a sample of 19. (Resident #27) Findings include: Resident #27's record was reviewed on 5-16-2011 at 10:15 a.m. Resident #27's [DIAGNOSES REDACTED]. Resident #27 was admitted with a [MEDICAL CONDITION] on 10/06/2003. On 5/16/11 at 6:11 p.m., RN #6, RN #7, RN #8, and ADON were observed cleaning and repositioning Resident #27. Resident #27 was observed with a tracheotomy and oxygen at 4 liters delivered through tracheotomy mask. Once care was completed all of the staff except the ADON left the room. At 6:30 p.m., when exiting the room a large amount of mucus was noted inside of the outer cannula of the tracheotomy. The ADON was asked to lift the sheet to allow observation of the nail beds. Resident #27's nail beds were blue/gray in color and the fingers were mostly blue in color. Resident #27 was also noted to be experiencing a violent cough. The inner lumen of the oxygen tubing was noted to be completely obstructed with mucus. At 6:42 p.m., RN #8 was requested to return to the room with a biox (to test blood oxygen levels), Resident #27's biox was 84%. At 6:49 p.m., RN #8 brought suction equipment to room. Resident #27 observed coughing and gagging. At 6:52 p.m., Sterile technique was broken by RN #8 when sterile gloves were not donned with proper technique. At 6:54 p.m., Resident #27's biox is 87%, oral mucus secretions visualized, Resident #27 was observed gagging. At 6:57 p.m., RN #8 began suctioning but broke sterile technique when the tip of the suction tubing touched the resident's sheet, the ADON left to retrieve more equipment. The biox was 86%, mucus was observed gurgling from resident's mouth. At 7:05 p.m., The ADON was unsure of what equipment to retrieve, returns for assistance from RN #8. At 7:11 p.m., Suction equipment was brought to Resident #27's room. The resident was coughing violently, gagging, and flailing forward in bed. Biox was 89%. RN #8 indicated that he does not know this man, and he had only been on this floor for a couple of weeks. RN #8 was observed completing tracheotomy suctioning on Resident #27. RN #8 failed to dip the suction catheter into sterile water before use to check for functioning equipment and lubricate the suction catheter before beginning the procedure. RN #8 then suctioned while inserting the catheter into the tracheotomy. Suctioning was longer than 10 seconds and not intermittent. RN #8 did not wait for thirty seconds between suctioning episodes. At 7:13 p.m., Biox up to 89%, DON now to resident's room. Requested different biox to compare results. At 7:18 p.m., Different biox brought to room, Resident #27's biox was then 93%. Resident was then cleaned and repositioned in bed. A review of the "Comprehensive Care Plan Report," dated 4/5/11, indicated that, "...Problem...At risk for respiratory distress...Goal...Will have no or minimal Respiratory Distress...Approach...Oxygen as ordered, monitor & report s/sx (signs and symptoms) of shortness of breath, labored breathing and/or cyanosis (lack of oxygen), measure oxygen saturation as ordered, Lung assessment as ordered and prn (as needed)...suction as needed...Keep Physician and Family informed as needed...." The "Treatment Record" for May of 2011 stated, "...Oxygen [MEDICAL CONDITION](tracheotomy) mask to maintain oxygen saturation 90% or greater...." The "Medication Record" dated May 2011 stated, "...May suction oral cavity as needed...." The "Medication Record" dated May 2011 stated, "...May [MEDICAL CONDITION] (as needed) for increase secretions...." The "Medication Record" dated May 2011 stated, "...O2 (oxygen) [MEDICAL CONDITION] keep O2 saturation greater than 90%...." On 5/17/11 at 7 p.m., RN #8 verified that Resident #27 experienced a decline in respiratory function on 5/16/11 from 6:11 p.m. until 7:18 p.m. RN #8 indicated a respiratory assessment was not completed prior to suctioning or immediately after this incident by staff to determine lung function/sounds. RN #8 also indicated the physician should have been notified. The policy titled, "Comprehensive Assessment" dated 3/05/08 was reviewed on 5/24/11 at 2:30 p.m. stated, "...Definition- Assessment Data- Resident data collected so that an analysis/evaluation of the resident's physical and mental condition or abilities may be determined by the appropriate discipline. Data is documented on assessment forms. Data may include, but is not limited to: Vital signs...Resident changes...Observation of symptoms...Pulse oximetry...Response to treatment...Effectiveness of treatment ...Oral status...." On The policy titled, "Endotracheal Care & Suctioning" dated 10/31/07 was reviewed on 5/24/11 at 4:15 p.m. stated, "...Rationale: Suctioning of the resident's airway removes increased secretions and prevents airway obstruction and aspiration...Procedure...4. wash hands. 5. Open suction catheter package. 6. Put on goggles and sterile gloves and remove suction catheter. 7. With the un-sterile hand, disconnect the resident from the aerosol or oxygen. 8. Gently pass the suction catheter down the endotracheal tube until resistance is met then withdraw the catheter slightly. 9. Apply suction while removing the catheter. 10. Re-oxygenate the resident...11. Repeat steps 8-10 until all secretions have been removed or up to the resident's tolerance of the procedure...Assessment of Outcome...12. Determine if suctioning has been successful by one or more of the following: a. Removal of secretions; b. Improvement of breath sounds...e. clearing of cough...13. When completed, place resident back on the aerosol or oxygen...Documentation of Guidelines-...2...a. Respiratory status...3...a. Date and time of physician notification...4. Notification of family member/responsible party...." 3.1-47(a)(5)