Every finding on record at Southpointe Healthcare Center

Based on observation, interview, and record review, the facility failed to ensure a self-medication administration assessment was completed for 1 of 2 residents reviewed for medications left at the bedside. (Resident 9) Finding includes: During an observation on 2/25/26 at 11:30 a.m., Resident 9 was observed in his room while sitting in his wheelchair next to the over the bed table. On top of the over the bed table and on the bedside table, located approximately three feet from the over the bed table, the following topical medications were observed: - One small sized bottle of nystatin topical powder and it was approximately one-third full of the medication. The bottle contained a pharmacy label that identified the resident's name, dated 7/21/25 for when the medication was filled, and the following instructions were listed on the label apply to groin topically 2 times per day for yeast. The pharmacy label lacked any language regarding Resident 9's ability to self-administer the medication. - One medium sized bottle of nystatin topical powder and it was approximately half full of the medication. The bottle contained a pharmacy label that identified the resident's name, dated 6/1/25 for when the medication was filled, and the following instructions were listed on the label apply to groin topically 2 times per day for yeast. The pharmacy label lacked any language regarding Resident 9's ability to self-administer the medication. - One 14-ounce container of Aquaphor Advanced Therapy Cream and it was approximately half full of the medication. The container had a pharmacy label that identified the resident's name, and dated 12/29/25 for when the medication was filled, and the following instructions were listed on the label apply to affected area topically at bedtime for dry skin. The pharmacy label lacked any language regarding Resident 9's ability to self-administer the medication. - One three-ounce can of Pro-Care Antifungal Powder and it was approximately half full of the medication. The can lacked a pharmacy label or resident identification information on the can. - One six-ounce tube of Triad Hydrophellic Wound Dressing and it was approximately half full of the medication. The tube lacked a pharmacy label or resident identification information on the tube. - One 1.76-ounce tube of Voltaren Arthritis Pain Cream and it was approximately one-third full of the medication. The tube lacked a pharmacy label or resident identification information on the tube. No staff were visible during that time. During an interview at that time, Resident 9 indicated he kept the medications in his room and administered the various medications when he needed it. On 2/26/26 at 9:00 a.m., Resident 9 was observed to not be in his room. Resident 9's room was observed. The same topical medications, as listed above, were observed on his over the bed table and on the bedside table. No staff were visible during that time. On 2/26/26 at 2:20 p.m., Resident 9 was observed to not be in his room. Resident 9's room was observed. The same topical medications, as listed above, were observed on his over the bed table and on the bedside table. No staff were visible during that time. On 2/26/26 at 2:25 p.m., Resident 9 was observed to not be in his room. During an observation of Resident 9's room with Licensed Practice Nurse (LPN) 3, the same topical medications, as listed above, were observed on his over the bed table and on the bedside table. No other staff were visible during that time. During an interview at that time, LPN 3 indicated Resident 9 had not been assessed by the nursing staff to determine if he could self-administer his medications and he did not have a physician's order for self-administering his medications. Based on facility policy, Resident 9's medications should not have been left at the bedside. On 2/26/26 at 2:35 p.m., Resident 9's clinical record was reviewed. The diagnoses included, but were not limited to, type 2 diabetes with neuropathy (nerve damage due to uncontrolled diabetes) and osteoarthritis (painful, swollen, stiff joints). Current Physician orders, dated February 2026, included, but were not limited to, the following: - Nystatin powder, apply to groin topically two times a day for Yeast for 6 months.start date 1/15/26.with an end date of 7/15/26 . - Aquaphor External Ointment (Emollient), apply to affected area topically at bedtime for dry skin.start date 12/29/25. and no end date was noted. The Annual Minimum Data Set (MDS) assessment, dated 12/6/25, indicated Resident 9 was moderately cognitively intact. Resident 9's clinical record lacked a facility self-administration of medication assessment and a physician's order allowing the resident to self-administer his own medications. During an interview on 3/2/26 at 8:10 a.m., the Executive Director (ED) indicated Resident 9's clinical record did not have any self-administering medication assessments or physician orders to self-medicate. No medications should have been left at Resident 9's bedside. On 3/2/26 at 8:05 a.m., the ED provided a copy of an undated Resident Self-Administration of Medications policy and indicated it was the current policy in use by the facility. A review of the document indicated, .resident may not self-administer medications until the assessment is completed by the IDT [Interdisciplinary Team] and determined to be safe to so do .physician/provider order is required for residents to self-administer medications . 410 IAC (Indiana Administrative Code) 16.2-3.1- 11(a)

Based on observation, interview, and record review, the facility failed to ensure a resident with urinary incontinence received care in accordance with professional standards of care for 1 of 4 residents reviewed for incontinence care. (Resident B) Findings include: On 2/11/25 at 7:52 p.m., observed Resident B's call light on. At that time, Resident B indicated that she felt nasty because she needed her incontinence brief changed. On 2/11/25 at 7:56 p.m., LPN 1 was notified that Resident B wanted to have her incontinence brief changed and felt nasty. On 2/11/25 at 7:58 p.m., observed LPN 1 enter Resident B's room. On 2/11/25 at 8:04 p.m., observed LPN 1 exit Resident B's room, push the medication cart to another resident's room, and started preparing medications again. At that time, Resident B indicated LPN 1 told Resident B she couldn't change her incontinence brief because she had call lights to answer. Resident B indicated she had turned on her call light at approximately 7:00 p.m. During an interview on 2/11/25 at 8:11 p.m., LPN 1 indicated she shouldn't have told Resident B she needed to come back to change her incontinence brief. LPN 1 should have changed Resident B's incontinence brief. On 2/11/25 at 8:15 p.m., no staff were observed to assist Resident B with incontinence care. The clinical record for Resident B was reviewed on 2/12/25 at 8:23 a.m. The diagnoses included, but were not limited to, diabetes, chronic kidney disease, and anxiety. A quarterly Minimum Data Set (MDS) assessment, dated 1/4/25, indicated Resident B was cognitively intact, was dependent for toileting hygiene, and required substantial/maximal assistance to be able to roll left to right. Resident B was always incontinent of bladder. A care plan, dated 5/10/24, indicated Resident B was at risk for adverse effects of incontinence due to incontinent of urine related to need for assistance with bed mobility, transfers and toileting. The interventions included, but were not limited to, check Resident B for incontinence. Wash, rinse, and dry the perineum. On 2/12/25 at 11:06 a.m., the Administrator provided a copy the nurse's job description, dated 6/25/05, and indicated this was the current job description for the nurse. A review of the job description indicated the nurse provides personal nursing care for residents and assures that care standards are met, and the highest degree of quality resident care is provided at all times. This citation relates to Complaint IN00452156. 3.1-41(a)(2)

Based on interview and record review, the facility failed to administer pneumococcal vaccinations for 2 of 5 residents reviewed for pneumococcal vaccinations. (Resident 84, Resident 90) Findings include: 1. On 12/3/24 at 11:15 a.m., Resident 84's clinical record was reviewed. The diagnoses included, but were not limited to, type 2 diabetes and heart failure. Resident 84 was above the age of [AGE] years old. On 12/6/24 at 9:15 a.m., the DON (Director of Nursing) provided a copy of Resident 84's pneumonia vaccine record, dated 10/24/24. A review of the record indicated, on 10/24/24, Resident 84's POA (Power of Attorney) provided verbal consent to the facility for Resident 84 to receive the pneumonia vaccine. Resident 84's clinical record lacked documentation that Resident 84 had received the pneumonia vaccine. 2. On 12/3/24 at 11:30 a.m., Resident 90's clinical record was reviewed. The diagnoses included, but were not limited to, type 2 diabetes mellitus, congestive heart failure, chronic obstructive pulmonary disorder, and both acute and chronic respiratory failure. Resident 84 was above the age of [AGE] years old. On 12/6/24 at 9:15 a.m., the DON provided a copy of Resident 90's pneumonia vaccine record, dated 9/13/24. A review of the record indicated, on 9/13/24, Resident 90 signed the consent form to receive the pneumococcal vaccination. Resident 90's clinical record lacked documentation that Resident 90 had received the pneumonia vaccine. During an interview on 12/6/24 at 10:45 a.m., the DON indicated that the pneumococcal vaccinations should have been administered by this time for Resident 84 and Resident 90. On 12/3/24, the Administrator provided an undated policy titled Resident Pneumococcal Vaccines and indicated it was the policy currently in use. A review of the policy indicated that residents would be offered the pneumococcal vaccine unless medically contraindicated or the resident had already received vaccinations per CDC (Centers for Disease Control and Prevention) recommendations. On 12/9/24 at 8:00 a.m., a review of the CDC guidelines at the following website regarding pneumococcal vaccine timing for adults (https://www.cdc.gov/vaccines/hcp/imz-schedules/adult-notes.html#note-pneumo), dated 11/21/24, indicated that chronic conditions, including diabetes mellitus, chronic cardiovascular diseases, and chronic respiratory diseases are all underlying medical conditions where the pneumococcal vaccine is recommended in addition to being recommended for all adults [AGE] years of age and older. 3.1-13(a)

Based on interview and record review, the facility failed to ensure care plans were revised for 1 of 24 residents reviewed for advanced directives. (Resident 90) Finding includes: The clinical record for Resident 90 was reviewed on 12/3/24 at 11:30 a.m. The diagnoses included, but were not limited to, type 2 diabetes, Alzheimer's disease, congestive heart failure, and chronic obstructive pulmonary disorder. A physician's order, dated 9/16/24, indicated the resident's code status was DNR (do not resuscitate). An Indiana Physician Orders for Scope of Treatment form, dated 9/16/24, indicated that the resident had elected a DNR code status. A care plan, initiated 7/23/24, indicated Resident 42 had a full code status (full code status means that a medical professional will perform all possible life-saving measures if a patient's heart stops or they stop breathing, including cardiopulmonary resuscitation). During an interview on 12/6/24 at 10:45 a.m., the DON (Director of Nursing) indicated that Resident 90's code status was DNR and the care plan should have been revised to reflect the resident's current code status. On 12/6/24 at 12:05 p.m., the DON provided an undated policy titled Plan of Care Overview and indicated it was the current policy in use by the facility. A review of the policy indicated that resident care plans were to be resident centered, reviewed quarterly and/or with significant changes in care, and were to support the resident's goals, choices, and preferences to meet the psychosocial, physical, and emotional needs and concerns of the resident. 3.1-35(d)(2)(B)

Based on record review and interview, the facility failed to complete the drug disposition for 1 of 3 clinical records reviewed for discharged residents. (Resident E) Findings include: On 5/22/24 at 1:12 p.m., the clinical record of Resident E was reviewed. Diagnosis included, but was not limited to, hypertension. A Physician's Order Summary Report, dated March 2024, included but was not limited to: - Amlodipine (a medication used to treat high blood pressure) 10 mg (milligrams) daily. - Atorvastatin (a medication used to treat high cholesterol) 40 mg daily. - Clonazepam (a medication used to treat anxiety) 0.5 mg daily. - Duloxetine (a medication used to treat depression) 60 mg daily. - Gabapentin (a medication used to treat nerve pain) 300 mg daily. - Metoprolol (a medication used to treat high blood pressure) 200 mg daily. A Discharge Summary, dated 3/19/24 indicated Resident E was to be discharged to home on 3/20/24. Resident E's clinical record lacked a medication release form listing all medications that were sent home with the resident/family. During an interview on 5/23/24 at 12:10 p.m., the Director of Nursing indicated the facility had not been providing a drug disposition record that included the medication name and number of pills that were provided to the resident at the time of the discharge. On 5/22/24 at 1:25 p.m., the Director of Nursing provided a policy titled Discharge with Medications, dated September 2018, and indicated it was the current policy being used by the facility. A review of the policy indicated Procedures .9. the nurse documents the number of doses each medication discharged to the patient or responsible party on the Medication Release Form. This citation relates to Complaint IN00430121. 3.1-25(p)

Based on observation, interview, and record review, the facility failed to ensure intravenous (IV) tubing was initialed or dated for 3 of 3 residents reviewed for IV therapy. (Resident 65, Resident 139, Resident 24) Findings include: 1. During an observation on 1/4/24 at 11:30 a.m., observed an IV pole in Resident 65's room next to the residents bed. The resident's used tubing hanging on the IV pole was not dated or initialed. On 1/5/24 at 10:45 a.m., the same was observed. On 1/5/24 at 11:00 a.m., the clinical record for Resident 65 was reviewed. The diagnoses included, but were not limited to, sepsis, acute infections, and urinary tract infection. The physician orders, dated January 2024, included but were not limited to: - Change administration set (tubing) every 24 hours for intermittent infusions, one time a day for IV care, label with date/time/initials, initiated on 12/30/23. 2. During an observation on 1/5/24 at 10:45 a.m., an IV pole was observed in Resident 139's room next to the residents bed. The resident's used tubing on the IV pole was not dated or initialed. On 1/5/24 at 1:40 p.m., the same was observed. On 1/8/24 at 9:07 a.m., the same was observed. On 1/8/24 at 10:00 a.m., the clinical record of Resident 139 was reviewed. The diagnoses included, but were not limited to, chronic kidney disease. The physician orders, dated January 2024, included but were not limited to: - Change administration set (tubing) every 24 hours for intermittent infusions, one time a day for IV care, label with date and time and initials, initiated 12/22/23. 3. During an observation on 1/4/24 at 11:55 a.m., an IV pole was observed in Resident 24's room, next to the residents bed. The resident's used tubing on the IV pole was not dated or initialed. During an observation on 1/5/24 at 10:50 a.m., the same was observed. During an observation on 1/8/24 at 9:10 a.m., the same was observed. During an interview on 1/8/24 at 9:30 a.m., LPN 2 indicated the tubing for Resident 24, Resident 139, and Resident 65 should have been initialed and dated. During an interview on 1/8/24 at 9:50 a.m., the Director of Nursing indicated the tubing for Resident 24, Resident 139, and Resident 65 should have been initialed and dated. On 1/9/24 at 8:39 a.m., the Director of Nursing provided a policy titled: Changing IV Administration Tubing, dated February 2009, and indicated it was the current policy being used by the facility. A review of the policy indicated .Labeling. Label IV tubing indicating the date and time started and nurse's initials. 3.1-47(a)(2)

Based on observation, interview, and record review, the facility failed to ensure administered medications were confirmed to have been taken for 1 of 3 randomly observed cognitively intact residents, reviewed for medication administration. (Resident 69) Findings include: On 12/13/22 at 2:43 p.m., Resident 69 was observed resting in bed. On the over the bed table, located next to the resident's bed and within reach of the resident, a white tablet (medication/pill) was observed. The tablet was approximately one-half inch in length, one-quarter inch wide, and one-eight inch thick. Printed on the tablet was the number 93. No staff were visible at that time. During an interview at that time, Resident 69 indicated the white tablet had been on the over the bed table for the past day or two. Resident 69 indicated he was unsure what the medication was or why it had been prescribed. On 12/13/22 at 3:00 p.m., RN 5 entered Resident 69's room. During an interview at that time, RN 5 indicated she was not sure what the white tablet was or why it had been prescribed. RN 5 indicated medications were not to be left in a resident's room. Staff were to administer medications and verify the medication had been consumed by the resident before leaving the resident's room. RN 5 retrieved the white tablet from the over the bed table, exited Resident 69's room and went to the medication cart. RN 5 indicated the white tablet was Resident 69's prescribed Amox-K clav (Augmentin, an antibiotic used for respiratory infections) 875/125 mg (milligram) tablet. RN 5 indicated Resident 69 was prescribed the Augmentin for seven days, starting on 12/8/22, and was to be administered every twelve hours. On 12/15/22 at 2:15 p.m., Resident 69's clinical record was reviewed. The diagnoses included, but were not limited to, pneumonia, acute and chronic respiratory failure with hypoxia (an absence of enough oxygen in the tissues to sustain bodily functions), and chronic obstructive pulmonary disease. The Quarterly MDS (Minimum Data Set) assessment, dated 11/1/22, indicated Resident 69 was cognitively intact. A Post-Acute Care Note, signed by the MD/NP (Medical Doctor/Nurse Practitioner) on 12/8/22, indicated Resident 69 had pneumonia and was prescribed Augmentin 875/125 mg. PO BID [by mouth two times per day] for 7 days. Physician Orders, as identified on the December 2022 Medication Administration Record (MAR) document indicated, Augmentin oral tablet 875-125 mg, give one tablet by mouth every morning and at bedtime for pneumonia for seven days. The MAR indicated the medication had been administered to Resident 69 at bedtime on 12/8/22; in the morning and at bedtime daily from 12/9/22 to 12/14/22; and in the morning on 12/15/22. During an interview on 12/19/22 at 3:15 p.m., the DNS (Director of Nursing Services) indicated the nursing staff were to ensure prescribed medications were administered as directed by the physician. Medications were not to be left at the resident's bedside. On 12/16/22 at 10:35 a.m., the Director of Nursing Services provided a copy of the Policies and Standard Procedures: Medication Administration policy, dated 2013, and indicated it was the current policy in use by the facility. A review of the policy indicated, .Do not leave medication at bedside . 3.1-35(g)(1)

Based on interview and record review, the facility failed to follow vaccination guidelines for the administration of the influenza vaccination for 3 of 7 residents reviewed for vaccinations. The influenza vaccine consent form was not offered at admission and the vaccinations were not administered. (Resident 8, Resident 11, and Resident 27) Findings include: 1. On 12/13/22 at 12:17 p.m., Resident 27's clinical record was reviewed. Resident 27's immunization record indicated immunization requested under the influenza section. The record lacked a current influenza vaccination. Resident 27 had an admitted [DATE]. 2. On 12/13/22 at 1:15 p.m., Resident 11's clinical record was reviewed. Resident 11's immunization record indicated immunization requested under the influenza section. The record lacked a current influenza vaccination. Resident 11 had an admitted [DATE]. 3. On 12/13/22 at 1:30 p.m., Resident 8's clinical record was reviewed. Resident 8's immunization record indicated immunization requested under the influenza section. The record lacked a current influenza vaccination. Resident 8 had an admitted [DATE]. On 12/15/22 at 2:15 p.m., the DON (Director of Nursing) provided influenza consent forms for Resident 8, Resident 11, and Resident 27. The three forms indicated that the resident or their representative had each provided verbal consent to receive the influenza vaccination and were each dated for 12/14/20. On each form, the month and day were handwritten, and the year was a part of the typed form. During an interview on 12/19/22 at 1:15 p.m., the DON indicated that the three provided influenza forms for Resident 8, Resident 11, and Resident 27 were each supposed to be dated for 12/14/22. She indicated that the forms had a typing error and that the consents were obtained on December 14 of the current year (2022). During an interview on 12/20/22 at 10:00 a.m., the DON indicated that the influenza consent forms for Resident 8, Resident 11, and Resident 27 should have been offered upon admission and that they should have received their influenza vaccinations. On 12/16/22 at 10:35 a.m., the DON provided a copy of the facility policy titled, Resident Influenza Vaccine, dated as revised for 1/14/21, and indicated it was the policy currently in use. A review of the policy indicated under the influenza season heading, The CDC [Center for Disease Control and Prevention] notes that influenza virus is with peak activity in the United States between December and March. For the purpose of this policy, the Influenza Season is considered October 1 through March 31. The policy also indicated, 1. New admission residents will be offered the education and influenza vaccine upon admission in the event admission occurs during the influenza season, October 1 through March 31. 3.1-13(a)

Based on observation, interview, and record review, the facility failed to ensure the dumpster area was kept clean for 4 of 4 dumpster area observations. Trash bags were not tied, debris was on the ground, the dumpster side panel doors were not closed, and broken furniture was left on the ground. Findings include: 1. On 12/13/22 from 11:10 a.m. to 11:15 a.m., during the initial kitchen tour with the Dietary Manager (DM), the dumpster area, located approximately 30 yards from the kitchen's rear exit door, the following was observed: a. One of the two dumpster sliding side panel doors was observed to not be closed. Inside the dumpster container were multiple filled trash bags. b. One large wooden broken piece of furniture, located on the ground behind the dumpster container, was observed. No staff were visible in the area during that time. During an interview at that time, the DM indicated the sliding side panel door was to be kept closed and the dumpster area was to be kept free from trash and debris. 2. On 12/16/22 from 9:20 a.m. to 9:25 a.m., during a follow up observation of the dumpster area with Dietary Aide 2, the following was observed: a. One large 55 gallon wheeled plastic trash can, lined with an interior plastic bag, was observed approximately 10 feet from the dumpster container. The trash can lacked a lid and the interior plastic bag was observed to not be tied. The interior plastic bag was observed to be full of garbage including, but was not limited to, corn and other un-identifiable foods. b. One of the two dumpster sliding side panel doors was observed to not be closed. Inside the dumpster container were multiple filled trash bags. c. One large wooden broken piece of furniture, located on the ground behind the dumpster container, was observed. d. Behind the dumpster and between the broken furniture, one large plastic trash bag filled with opened soda pop cans, used incontinence briefs, and other un-identifiable medical supplies were visible. No staff were visible in the area during that time. During an interview at that time, Dietary Aide 2 indicated all trash was to be put inside the dumpster container; the dumpster lids and doors were to be kept closed; and the wheeled trash can that was filled with food and other garbage the untied trash bag may have been there since the previous afternoon [12/15/22]. 3. On 12/16/22 from 4:30 p.m. to 4:35 p.m., during a follow up dumpster area observation, the following was observed: a. One large 55 gallon wheeled plastic trash can, lined with an interior plastic bag, was observed approximately 10 feet from the dumpster container. The trash can lacked a lid and the interior plastic bag was observed to not be tied. The interior plastic bag was observed to be full of garbage including, but was not limited to, corn and other un-identifiable foods. b. One large wooden broken piece of furniture, located on the ground behind the dumpster container, was observed. No staff were visible in the area during that time. 4. On 12/19/22 from 9:10 a.m. to 9:15 a.m., during a follow up observation of the dumpster area with Dietary Aide 6, the following was observed: a. One of the two the dumpster sliding side panel doors was observed to not be closed. Inside the dumpster container were multiple filled trash bags. b. One large wooden broken piece of furniture, located on the ground behind the dumpster container, was observed. c. Behind the dumpster and between the broken furniture and on two other sides of the dumpster container were multiple large plastic trash bags filled with used incontinence briefs and other un-identifiable medical supplies and foods were visible. d. Two large 55 gallon wheeled plastic trash cans were observed approximately 10 feet from the dumpster container. The trash cans lacked a lid and both cans contained multiple filled plastic bags. Both trash cans had full plastic trash bags hanging over and outside of the container. The closed plastic bags contained trash, debris and unidentifiable medical supplies and foods products. e. On the ground surrounding the dumpster container the following was observed: multiple plastic gloves, lids and utensils; a large metal lid; one cinnamon roll; an opened quart jug of milk; and noodles and other unidentifiable foods. No staff were visible in the area during that time. During an interview at that time, Dietary Aide 6 indicated the dumpster area was to be kept clean and free of trash and debris. During an interview on 12/16/22 at 3:09 p.m., the ADM indicated the facility did not have a specific trash dumpster policy. The facility followed the local, state, and federal requirements. The trash dumpster area was to be kept free of debris, trash bags were to be tied and all trash was to be placed into the dumpster container. The ADM indicated the untied trash bag that contained food and other garbage may have been at the dumpster area since earlier in the day [12/16/22]. On 12/16/22 at 3:17 p.m., a review of the Retail Food Establishment Sanitation Requirements - Title 410 IAC 7-24, effective November 13, 2004, indicated, .receptacles and waste handling units for refuse, recyclables and returnables shall be kept covered with tight-fitting lids or doors if kept outside . 3.1-21(i)(2) 3.1-21(i)(5)

Based on observation, interview, and record review, the facility failed to ensure a resident was free from Resident 27 having tried to choke her for 1 of 1 resident reviewed for abuse, which resulted in psychosocial distress with pain and redness around a resident's neck that required acute care hospital evaluation. (Resident 66) Findings include: During dining observation, on 11/15/21 at 12:21 P.M., Resident 66 was seated at a table in the dining room. Resident 27 was seated behind Resident 66. At that time, observed Resident 27, without being provoked, to wrap a cloth napkin over Resident 66's head, wrap the neck around her neck, and then pulled on the napkin. Two nurses, who were present in the dining room, immediately, responded and separated Resident 27's hands from Resident 66. The clinical record of Resident 66 was reviewed on 11/15/21 at 1:00 P.M. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A quarterly Minimum Data Set (MDS) assessment, dated 10/6/21, indicated, Resident 66 was cognitively intact. Resident 66 required limited assistance with one staff member for transfers, supervision with one staff member for eating, and limited assistance with set up only for ambulating. The clinical record of Resident 27 was reviewed, on 11/15/21 at 1:15 P.M. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A quarterly MDS assessment, dated 10/12/21, indicated, Resident 27 was not cognitively intact and had not exhibited hallucinations, delusions nor behaviors. Resident 27 used a wheelchair and required limited assistance with one staff member for transfers and required supervision with set up assistance for locomotion on unit and eating. A progress note, dated 11/14/21 at 4:44 P.M., indicated, Resident 27 had altered mental status with physical aggression and was a danger to self or others. Resident 27 was sent to the Emergency Department for evaluation. A hospital discharge summary, dated 11/15/21 at 2:44 A.M., indicated, [Resident 27] did not seem paranoid or delusional and was calm and cooperative in the emergency room .[Resident 27] continues to deny safety concerns and is agreeable to return to facility. Rationale for disposition: [Resident 27] has been made aware of several treatment options. Inpatient psychiatric hospitalization , outpatient behavioral health services, and intensive outpatient services. The treatment team, in conjunction with [Dr. name] recommends outpatient behavioral health services with current nursing home services based on strong safety plan, lack of acute risk factors, denying risk to self and others, verbalizing ability to keep self/others safe and agreeing to following up with outpatient services. On 11/15/21 at 12:35 P.M. Resident 66's neck was observed to be reddened. Interview, at that time, Resident 66 indicated, Resident 27 had put a cloth napkin over her head, then wrapped it around her neck and pulled the napkin until she couldn't breathe. She wasn't able to breathe until the nurses got Resident 27's hands loose. She was scared when that happened. She had anxiety and pain in her neck at the time of the incident. During an interview, on 11/15/21 at 1:28 P.M., Licensed Practical Nurse (LPN) 1 indicated, she heard someone yell help. When she looked in that direction, she saw a cloth napkin wrapped around Resident 66's neck and Resident 27 sitting behind her pulling the napkin. LPN 1 immediately ran to the residents and asked Resident 27 to let go of the napkin as the Unit Manager slid her fingers into Resident 27's hands in order to get Resident 27 to release her grip from the napkin. Once we separated Resident 27 from Resident 66, LPN 1 assessed Resident 66 for injuries, pain and emotional distress. Resident 66 had some redness on her neck and complained of pain in the neck area. LPN 1 thought, the incident was terrifying and caused anxiety for LPN 1. Resident 27 had never been physical with another resident. Resident 27 had been having increased hallucinations that she saw her daughter, who was murdered in 2012, working in the building and in her room. During an interview, on 11/15/21 at 2:15 P.M., the Unit Manager indicated, she was called in yesterday, on 11/14/21, because Resident 27 was being sent to the Emergency Department for having increased hallucinations that she had been seeing her daughter who was murdered in 2012, working in the building and in her room. Resident 27 had been telling staff she needed money to feed her kids and thought someone was coming after her to murder her. Today, we were in the dining room and heard someone yell help. When I looked in that direction, I saw a cloth napkin on Resident 66's neck with Resident 27's hands pulling on each side of the napkin. She immediately responded with LPN 1 and slid her fingers into Resident 27's hands in order to loosen her grip on the napkin and slid the napkin out of her hands. Once separated, Resident 27 was assessed. The Unit Manager had never experienced an incident like that before and the incident caused anxiety and emotional distress for her. Resident 27 has never been physical with another resident. Resident 27 is now on constant supervision with a staff member. During an interview, on 11/15/21 at 3:00 P.M., the Director of Nursing indicated, Resident 27 had been placed on constant supervision. Resident 27 was scheduled to leave the facility, on 11/16/21 at 11:00 A.M., to go to a hospital for treatment. On 11/19/21 at 8:40 A.M., the Director of Nursing provided a copy of a Hospital post-acute care note, dated 11/15/21. A review of the note indicated, .[Resident 27] placed a towel around [Resident 66's] neck and pulled .evaluated the neck and while it had some redness [Resident 66] was able to swallow and move air. Neck pain due to manual strangulation attempt and increased anxiety with incident. Monitor neck, [MEDICATION(S)] [a prescription medication used to treat anxiety] 0.25 mg [milligrams] orally for one dose. On 11/19/21 at 8:40 A.M., the Director of Nursing provided a copy of a pain observation tool, dated 11/15/21 at 1:30 P.M. A review of the pain observation tool indicated, Resident 66 had a pain level of 7 out of 10, in the neck. The November 2021 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] .M. On 11/16/21 at 8:45 A.M. The Director of Nursing provided a copy of a facility policy, titled Indiana Abuse and Neglect and Misappropriation of Property, dated 9/1/2017, and indicated this was the current policy used by the facility. A review of the policy indicated, It is the intent of this facility to prevent abuse . 3.1-27(a)(1)

Based on interview and record review, the facility failed to ensure monitoring for side effects of [CONDITION(S)] medications for 1 of 8 residents reviewed for unnecessary medication use. (Residents 27) Findings include: The clinical record of Resident 27 was reviewed on 11/15/21 at 1:15 P.M. Diagnoses included, but were not limited to, non-Alzheimer's dementia, anxiety, depression, [CONDITION(S)] and post-traumatic stress disorder. A quarterly Minimum Data Set (MDS) assessment, dated 10/12/21, indicated, Resident 27 was not cognitively intact and had not exhibited hallucination, delusions nor behaviors. A care plan, dated 12/15/20 and current through 1/31/22, indicated, the resident used anti-depressant medication related to depression. Interventions included, but were not limited to, Observe for side effects of anti-depressant medications, i.e., [CONDITION(S)], [CONDITION(S)], anticholinergic sx (dry mouth, blurred vision, constipation, [CONDITION(S)], [CONDITION(S)], sedation, drowsiness, increased falls, dizziness), cardiac abnormalities ([CONDITION(S)], [CONDITION(S)], irregular heart rate), anxiety, agitation, blurred vision, sweating, rashes, headache, weakness, hang over effects, appetite change, weight change, nausea, [CONDITION(S)], hallucinations, aggressive behavior, [CONDITION(S)]. A care plan, dated 2/16/21 and current through 1/31/22, indicated, The resident used anti-anxiety medication related to anxiety. Interventions included, but were not limited to, observe for side effects of anti-anxiety medications, i.e., [CONDITION(S)], [CONDITION(S)], anticholinergic sx (dry mouth, blurred vision, constipation, [CONDITION(S)], [CONDITION(S)], sedation, drowsiness, increased falls, dizziness), cardiac abnormalities ([CONDITION(S)], [CONDITION(S)], irregular heart rate), anxiety, agitation, blurred vision, sweating, rashes, headache, weakness, hang over effects, nausea, depression, hallucinations, aggressive behavior. A care plan, dated 2/16/21 and current through 1/31/22, indicated, resident has a neurologic disorder r/t [CONDITION(S)], [CONDITION(S)], [CONDITION(S)]. Interventions included, but were not limited to, Administer medications per medical providers orders. Observe for side effects and effectiveness. Report abnormal findings to medical provider, resident or resident representative. The Physician's orders, dated November 2021, indicated, phenelzine (a prescription medication used to treat depression) 15 mg (milligrams) 2 tabs orally 3 times daily (start 10/6/21), [MEDICATION(S)] (a prescription antipsychotic medication) 5 mg 2 tabs orally in the morning for hallucinations (start 11/10/21), [MEDICATION(S)] (a prescription medication used to treat anxiety) 0.5 mg 3 times daily for anxiety (start 10/6/21), [MEDICATION(S)] (a prescription medication used to treat seizures) 250 mg 3 tabs orally in the morning and at bedtime for [CONDITION(S)] (start 10/6/21). The November 2021 Medication Administration Record indicated, Resident 27 had received phenelzine 15 mg, [MEDICATION(S)] 5 mg, [MEDICATION(S)] 0.5 mg and [MEDICATION(S)] 250 mg as ordered by the Physician. The clinical record lacked documentation of monitoring for side effects of [CONDITION(S)] medications phenelzine, [MEDICATION(S)], [MEDICATION(S)] and [MEDICATION(S)]. During an interview, on 11/19/21 at 10:35 A.M., the Director of Nursing indicated, monitoring of side effects of psychotropics should have been documented. By survey exit, on 11/22/21 at 1:30 P.M., the facility was unable to provide documentation of monitoring for side effects of [CONDITION(S)] medications for Residents 27. By survey exit, on 11/22/21 at 1:30 P.M., the facility was unable to provide a policy regarding [CONDITION(S)] medication monitoring prior to exit, which had been requested from the Director of Nursing. 3.1-48(a)(3)

Based on interview and record review, the facility failed to accurately assess pressure risks and implement preventative care for a newly admitted resident and failed to promptly implement treatment, resulting in the development of an unstageable pressure ulcer and an increase in size of the pressure ulcer for 1 of 3 residents reviewed for pressure ulcers. (Resident B) Findings include: On 3/17/2021 at 10:26 a.m., the closed clinical record of Resident B was reviewed. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident B was admitted on [DATE]. An Admission Skin Evaluation, dated 12/14/2020, indicated Resident B was admitted with a surgical area on his right hip. No other skin issues were indicated. A Weekly Skin Check, dated 12/14/2020 (upon admission), indicated no skin conditions, no changes, and no ulcers, or injuries A Braden Observation Tool, dated 12/14/2020, indicated Resident B was at low risk for Pressure Ulcers. The clinical record lacked a completed Admission Observation Tool, identifying skin impairments at the time of admission. An admission Minimum Data Set (MDS) assessment, dated 12/20/20, indicated Resident B's cognitive status was moderately impaired. Resident B did not have any pressure ulcers, was at risk for developing pressure ulcers, and required extensive assistance with bed mobility. Current skin and pressure reducing treatments implemented were a pressure reducing device for a chair and a pressure reducing device for a bed. The Turning/Repositioning Program was left blank. A Care plan, (undated), indicated Resident B had a performance deficit, required assistance with activities of daily living related to femur (fracture), and dementia. The care plan lacked interventions related to wound prevention or wound care. A Physical Therapy note, dated 12/22/2020 (8 days after admission), indicated a skin check reveals approx [approximately] 1/2 dollar heel wound unstageable with 70% brown eschar (dead skin) at center and light pink wound borders. The Medical Director was notified and an order was received for offloading boots at all times. A Physicians order, dated 12/31/2020 (9 days after pressure ulcer identified), indicated Cleanse wound to left heel with NS [normal saline], apply [MEDICATION(S)], cover with ABD (abdominal gauze pad) and wrap with [MEDICATION(S)] [sic]. A Skin Grid Pressure, dated 1/4/2021 [late entry for 12/31/2020 as indicated by the Director of Nursing], indicated a new pressure area on [Resident B's] left heel, the area measured 5.0 cm x 6.0 cm x 0.1 cm, unstageable (full thickness tissue loss in which actual depth of the ulcer is completely obscured by eschar in the wound bed.) Community Acquired. Diagnosis/Additional Risk Factors: Resident admitted with a 5.0 x 6.0 x 0.1 unstageable pressure wound to left heel. However, the clinical record lacked an admission assessment for a wound on the left heel and/or documentation wound was present on admission and though 12/22/2020. A Dietary Progress Note, dated 1/6/2021 (15 days after pressure ulcer identified), indicated wound to left heel is unstageable. Medications reviewed, Registered Dietician recommended .2. add promode [sic/liquid protein] and Vitamin C to promote wound healing. A Skin Grid Pressure, dated 1/18/21, indicated .3. date area was first observed: 1/4/2021 Site: Left Heel Type: Pressure, Length 4.2 cm x 4.8 cm x 0.1 cm. Stage: unstageable. A wound care provider note, dated 2/01/2021, indicated Medical History: Positive for history of pressure wounds, left heel. A Skin Grid Pressure, dated 2/15/21, indicated .3. date area was first observed: 1/4/2021 Site: Left Heel Type: Pressure, Length 5.5 cm x 4.0 cm x 0.2 cm. Stage: unstageable. A skin/wound note, dated 3/3/2021, indicated correction noted from wound notes: Pressure area to left heel is not a new area, wound was present upon admission per wound MD [Medical Doctor]. The clinical record lacked documentation of a care plan related to the assessed unstageable pressure wound identified on 12/22/2020. During an interview, on 3/17/2021 at 1:22 p.m., the Director of Nursing, indicated Resident B was admitted with a pressure ulcer on his left heel. The DON is unsure why the wound was not observed on the day of admission. It was missed. The Director of Nursing was unable to provide documentation to indicate the wound was present upon admission nor additional documentation of a developed plan of care for the wound. During an interview, on 3/18/2021 at 8:50 a.m., the Director of Nursing, indicated, on 12/31/2021 the Physical Therapist observed no improvement to the left heel and notified the Physician. A new order for normal saline was obtained. It was New Year's Eve. The therapist did not document the skin assessment until 1/4/2021, 4 days after the assessed pressure ulcer. On 3/18/2021 at 8:45 a.m., the Director of Nursing provided a policy titled: Skin Care and Wound Management Overview, dated 4/20/2017, and indicated it was the current policy being used by the facility. A review of the policy, indicated Policy: the facility staff strives to prevent resident/patient skin impairment and to promote healing of existing wounds The interdisciplinary team evaluates and documents identified skin impairments and pre-existing signs to determine the type of impairment, underlying condition(s) contributing to it and description of impairment to determine appropriate treatment. Procedure: .2. Complete an Admission Observation Tool. Identify areas of skin impairment and pre-existing signs 6. Monitor and document progress This Federal tag relates to complaint IN 338. 3.1-40(a)(1) 3.1-40(a)(2)

A. Based on observation, interview, and record review, the facility failed to ensure dietary staff's facial hair was restrained while in the food prep area of the kitchen and while at the steam table during the meal service. This had the potential to affect 91 of 91 residents residing in the facility who received food items from the kitchen. B. Based on observation, interview, and record review, the facility failed to ensure a food item was dated when the item was placed into the refrigerator unit and labeled to identify to whom the item belonged for 1 of 2 kitchenette refrigerator units potentially affecting 49 residents who had access to the refrigerator unit of 91 who resided in the facility and the facility failed to ensure a resident's food item was dated to identify when the item was placed into the refrigerator/freezer unit for 1 of 2 resident snack refrigerator/freezer units potentially affecting 42 residents who had access to the resident snack refrigerator/freezer unit of 91 residents who resided in the facility. C. Based on observation, interview, and record review, the facility failed to ensure the resident snack refrigerator unit temperatures were recorded twice daily, as indicated by the facility practice, for 1 of 2 resident snack refrigerator/freezer units. This had the potential to affect 42 residents who had access to the resident snack refrigerator/freezer unit of 91 residents who resided in the facility. Findings include: A. On 1/30/20 from 10:10 a.m. to 10:20 a.m., during the initial kitchen tour, the DM (Dietary Manager) was in the food preparation area of the kitchen while the noon meal was being prepped. The DM's facial hair was observed to not be covered. On 1/30/20 from 12:10 p.m. to 12:15 p.m., the DM was at the steam table, in the North side kitchenette area, during the noon meal service. The DM's facial hair was observed to not be covered. On 1/30/20 from 12:10 p.m. to 12:30 p.m., Kitchen Staff 1 was at the steam table, in the North side kitchenette area, during the noon meal service. Kitchen Staff 1 was taking and recording the noon food temperatures and plating the noon meal. The Kitchen Staff 1's facial hair was observed to not be covered. Interview, on 2/3/20 at 11:30 a.m., the DM indicated all facial hair was to be covered when in the kitchen food prep area and while at the steam table serving line. Interview, on 2/5/20 at 1:45 p.m., the Administrator indicated all residents in the facility received prepared food items from the kitchen, the facility census was 91. There were 42 residents residing on the North unit who received food from the North unit's steam table serving line. On 2/3/20 at 12:45 p.m., the Administrator provided a copy of the Staff Attire-Dining Services Policy and Manual document, dated 9/2017, and indicated it was the current policy in use by the facility. A review of the document indicated, .all staff members will have their . facial hair properly restrained . On 2/5/20 at 12:45 p.m., a review of the Retail Food Establishment Sanitation Requirements Title 410 IAC 7-24, effective November 13, 2004, indicated, .food employees shall wear . beard restraints, . that are designed and worn to wear effectively keep their hair from contacting exposed food . B. On 2/4/20 at 4:10 p.m., during a facility tour with the DM (Dietary Manager), observed the South unit kitchenette refrigerator. Inside the refrigerator unit was an unopened 16.9 ounce bottle of Diet Coke. The Diet Coke bottle lacked a label to indicate to whom it belonged or when it was placed into the refrigerator. During an interview at that time, the DM indicated the refrigerator unit was for food items from the kitchen only. All items in the refrigerator were to be dated and labeled to indicate to whom it belonged. On 2/4/20 at 4:15 p.m., during a facility tour with the DM, observed the North unit resident snack refrigerator/freezer unit. Inside the freezer portion of the unit was a paper bag that contained a medium sized cup filled with a frozen milkshake. Observed ice crystals on the top of the uncovered milkshake. The milkshake lacked a label that identified when the item was placed into the freezer. During an interview at that time, the DM indicated the resident snack refrigerator/freezer unit was for resident food items only and all items were to be dated and labeled to indicate when it was placed into the unit and to indicate to whom it belonged. Interview, on 2/5/20 at 1:45 p.m., the Administrator indicated the South unit had 49 residents who had access to the kitchenette area and the North unit had 42 residents who had access to the resident snack refrigerator/freezer unit. On 2/4/20 at 4:30 p.m., the DM provided a copy of the Food Storage: Cold Foods policy, dated 4/2018, and indicated it was the current policy in use by the facility. A review of the policy indicated, .all foods will be stored, wrapped, or in covered containers, labeled and dated . On 2/4/20 at 5:10 p.m., the DM provided a copy of the Food: Safe Handling for Foods from Visitors policy, dated 7/2019, and indicated it was the current policy in use by the facility. A review of the policy indicated, .residents will be assisted in properly storing and safely consuming food brought into the facility for residents by visitors .ensure that foods are in a sealed container to prevent cross contamination .label foods with the resident name and the current date . On 2/5/20 at 1:00 p.m., a review of the Retail Food Establishment Sanitation Requirements Title 410 IAC 7-24, effective November 13, 2004, indicated .refrigerated, ready to eat, potentially hazardous food prepared and hold in a retail food establishment for more than twenty-four (24) hours shall be clearly marked to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded . C. On 2/4/20 at 4:15 p.m., during a facility tour with the DM (Dietary Manager) observed the South unit resident snack refrigerator/freezer unit. The February 2020 Refrigerator Temperature Log document was hanging on the freezer door. The document indicated the refrigerator temperatures were to be recorded in the A.M. hour and the P.M. hour. Staff were to initial the document to indicate who completed the data. A review of the document indicated no A.M. temperatures or staff initials were recorded for February 1, 2, 3, or 4, 2020. Interview, on 2/4/20 at 4:25 p.m., the DM indicated the refrigerator log lacked any recorded temperatures and staff initials for the A.M. hours on February 1, 2, 3, and 4, 2020. Staff were to record the temperatures twice a day. Interview, on 2/5/20 at 1:45 p.m., the Administrator indicated the South unit had 49 residents who had access to the South unit resident snack refrigerator/freezer unit. On 2/4/20 at 4:30 p.m., the DM provided a copy of the Food Storage: Cold Foods policy, dated 4/2018, and indicated it was the current policy in use by the facility. A review of the policy indicated, .A written record of daily temperatures will be recorded . 3.1-21(i)(2) 3.1-21(i)(3)

Based on observation, interview, and record review, the facility failed to ensure the ground surrounding the facility's dumpster area was free from rubbish. This had the potential to affect 91 of 91 residents residing in the facility. Findings include: On 1/30/20 from 10:30 a.m. to 10:35 a.m., observed the facility's trash dumpster area, which was located adjacent to the kitchen's rear door. An uncovered paper box, 17 ½ inches long by 11 ¾ inches wide by 8 ¾ deep, was filled with trash and was observed on the platform next to the dumpster. On the ground surrounding the dumpster, observed multiple pairs of used plastic gloves; multiple plastic knives, forks, and spoons; multiple empty plastic and aluminum pop cans; multiple used plastic and Styrofoam cups, lids, and straws; and an assortment of candy and snack wrappers. No staff persons were observed near the trash dumpster area. Interview, on 2/3/20 at 12:35 p.m., the Dietary Manager indicated all trash was to be bagged and placed into the dumpster. No trash was to be kept on the ground. Interview, on 2/5/20 at 1:45 p.m., the ADM (Administrator) indicated all residents residing in the facility received food from the kitchen. The current facility census was 91 residents. On 2/3/20 at 12:35 p.m., the ADM provided a copy of the Environment Policy Statement, dated 9/2017, and indicated it was the current policy in use by the facility. A review of the policy indicated, all trash will be contained in covered, leak-proof containers that prevent cross contamination .all trash will be properly disposed of in external receptacles (dumpsters) and the surrounding area will be free of debris . On 2/5/20 at 2:15 p.m., a review of the Retail Food Establishment Sanitation Requirements Title 410 IAC 7-24, effective November 13, 2004, indicated, .receptacles and waste handling units for refuse, recyclables and returnables shall be kept covered with tight-fitting lids or doors if kept outside . 3.1-21(i)(5)

Based on interview and record review, the facility failed to ensure residents were free from a significant medication error for a resident who was administered an insulin injection without a physician order [REDACTED]. Findings include: 1. During an interview, on 5/21/19 at 2:15 p.m., Resident C indicated he was not a diabetic, but a couple of weeks ago at supper, he was administered an insulin (medication for diabetics) injection by a nurse. Resident C had informed this nurse he was not a diabetic. During an interview, on 5/21/19 at 2:45 p.m., the Director of Nursing (DON) indicated Licensed Practical Nurse (LPN) 1 was asked by LPN 2 to assist her with medication pass in the evening on 5/6/19. LPN 2 asked LPN 1 to give an insulin injection to Resident F. LPN 1 walked into the wrong room and gave the insulin injection to Resident C and not to Resident F. The DON indicated LPN 1 did not perform the 5 Rights of Medication Administration in that insulin was administered to the wrong resident. During an interview, on 5/22/19 at 10:25 a.m., LPN 1 indicated on 5/6/19, she had finished her evening medication pass. She asked LPN 2 if she needed assistance with her medication pass. LPN 2 indicated she could assist with insulin injections. LPN 2 asked LPN 1 to give insulin to Resident F. LPN 1 went to Resident C and introduced herself and informed Resident C she had his insulin injection. When LPN 1 asked where did Resident C want his insulin injection, Resident C raised his shirt and indicated in his belly. LPN 1 then administered the insulin into Resident C's belly. During an interview, on 5/22/19 at 10:45 a.m., LPN 2 was finishing her medication pass, when LPN 1 offered to assist with medication pass. LPN 2 indicated she had 2 insulin injections to administer. One of the insulin injections was to Resident F. The next morning, LPN 2 was administering Resident C's medications, Resident C asked LPN 2 if there was anything in his chart about him being a diabetic. Resident C asked her because he was given a diabetic shot yesterday. Resident C described LPN 1 as the nurse who gave him the insulin injection. On 5/22/19 at 11:10 a.m., Resident C's clinical record was reviewed. The [DIAGNOSES REDACTED]. The [DIAGNOSES REDACTED]. Resident C's (MONTH) 2019 Physician order [REDACTED].>Resident C's nurses progress note, dated 5/7/19 at 10:07 a.m., indicated the nurse practitioner was notified of the insulin medication error, dated 5/6/19. On 5/22/19 at 3:00 p.m., the DON provided the Medication Administration policy, dated 8/3/10 with a revised date of 12/14/17, and indicated the policy was the one currently being used by the facility. A review of the policy indicated, a. Administer medication only as prescribed by the provider .f. Observe the (five rights) in giving each medication: i. the right resident . 2. During an interview, on 5/21/2019 at 2:45 p.m., the Director of Nursing (DON) indicated Licensed Practical Nurse (LPN) 1 was asked by LPN 2 to assist her with medication pass in the evening on 5/6/2019. LPN 2 asked LPN 1 to give an insulin injection to Resident F. LPN 1 walked into the wrong room and gave the insulin injection to Resident C and not to Resident F. The DON indicated LPN 1 did not perform the 5 Rights of Medication Administration. During an interview, on 5/22/2019 at 10:45 a.m., LPN 2 indicated Resident F did not get his insulin injection the evening of 5/6/2019, because it was administered to the wrong resident (Resident C) and they did not find out about the omission until the next day. During an interview, on 5/22/2019 at 10:49 a.m., the Unit Manager indicated she did not believe Resident F received his insulin on the evening of 5/6/2019, because the error was not caught until the next day. Resident F's clinical record was reviewed on 5/22/2019 at 11:00 a.m. [DIAGNOSES REDACTED]. Resident F's physician orders, dated (MONTH) 2019, indicated Resident F's medications included, but were not limited to Humalog Solution (insulin) 100 unit/ML (milliliter) inject 6 units subcutaneously (under the skin) with meals for diabetes mellitus. On 5/22/2019 at 3:00 p.m., the DON provided the facility's policy, Policies and Standard Procedures, with a revised date of 12/14/2017, and indicated it was the policy currently being used by the facility. A review of the policy indicated, . Procedure: 1. General Procedures: a. Administer medication only as prescribed by the provider . f. Observed the (five rights) in giving each medication . the right resident . This Federal Tag relates to Complaint IN 772. 3.1-48(c)(2)

A. Based on interview and record review, the facility failed to ensure insulin was administered to the right resident for 1 of 2 residents reviewed for medication error. (Resident C) B. Based on interview and record review, the facility failed to ensure a nurse did not administer medication drawn up by another nurse for 1 of 3 residents reviewed for insulin administration. (Resident C) Findings include: A. During an interview, on 5/21/19 at 2:15 p.m., Resident C indicated he was not a diabetic, but a couple of weeks ago at supper, he was administered an insulin (medication for diabetics) injection by a nurse. Resident C had informed this nurse he was not a diabetic. During an interview, on 5/21/19 at 2:45 p.m., the Director of Nursing (DON) indicated Licensed Practical Nurse (LPN) 1 was asked by LPN 2 to assist her with medication pass in the evening on 5/6/19. LPN 2 asked LPN 1 to give an insulin injection to Resident F. LPN 1 walked into the wrong room and gave the insulin injection to Resident C and not to Resident F. The DON indicated LPN 1 did not perform the 5 Rights of Medication Administration. During an interview, on 5/22/19 at 10:25 a.m., LPN 1 indicated on 5/6/19, she had finished her evening medication pass. She asked LPN 2 if she needed assistance with her medication pass. LPN 2 indicated she could assist with insulin injections. LPN 2 asked LPN 1 to give insulin to Resident F. LPN 1 went to Resident C and introduced herself and informed Resident C she had his insulin injection. When LPN 1 asked where did Resident C want his insulin injection, Resident C raised his shirt and indicated in his belly. LPN 1 then administered the insulin into Resident C's belly. During an interview, on 5/22/19 at 10:45 a.m., LPN 2 indicated when LPN 1 finished her medication pass, LPN 1 offered to assist LPN 2 with their medication pass. LPN 2 had 2 insulin injections to administer. One of the insulin injections was for Resident F. The next morning, LPN 2 was administering Resident C's medications, Resident C asked LPN 2 if there was anything in his chart about him being a diabetic. Resident C asked her because he was given a diabetic shot yesterday. On 5/22/19 at 11:10 a.m., Resident C's clinical record was reviewed. The [DIAGNOSES REDACTED]. The [DIAGNOSES REDACTED]. Resident C's (MONTH) 2019 Physician order [REDACTED].>Resident C's nurses progress note, dated 5/7/19 at 10:07 a.m., indicated the nurse practitioner was notified of the insulin medication error, dated 5/6/19. On 5/22/19 at 3:00 p.m., the DON provided the Medication Administration policy, dated 8/3/10 with a revised date of 12/14/17, and indicated the policy was the one currently being used by the facility. A review of the policy indicated, a. Administer medication only as prescribed by the provider .f. Observe the five rights in giving each medication: i. the right resident . B. During an interview, on 5/21/2019 at 2:15 p.m., Resident C indicated a couple of weeks ago at supper, he was administered an insulin (medication for diabetics) injection by a nurse. Resident C had informed the nurse he was not a diabetic. During an interview, on 5/21/2019 at 2:45 p.m., the Director of Nursing (DON) indicated Licensed Practical Nurse (LPN) 1 was asked by LPN 2 to assist her with medication pass in the evening on 5/6/2019. LPN 2 asked LPN 1 to give an insulin injection to Resident F. LPN 1 walked into the wrong room and gave the insulin injection to Resident C and not to Resident F. During an interview, on 5/22/19 at 10:25 a.m., LPN 1 indicated on 5/6/2019, she had finished her evening medication pass. She asked LPN 2 if she needed assistance with her medication pass. LPN 2 indicated she could assist with insulin injections. LPN 2 asked LPN 1 to give insulin to Resident F. LPN 1 went into Resident C's room and introduced her self and informed Resident C she had his insulin injection. When LPN 1 asked where did Resident C want his insulin injection, Resident C raised his shirt and indicated in his belly. The insulin injection had already been drawn up in the syringe by LPN 2. LPN 1 indicated she should not have administered an insulin injection that another nurse had drawn up. On 5/22/2019 at 3:00 p.m., the DON provided the facility's policy, Policies and Standard Procedures, with a revised date of 12/14/2017, and indicated it was the policy currently being used by the facility. A review of the policy indicated, . m. Do not administer medications prepared by others . This Federal Tag relates to Complaint IN 772. 3.1-35(g)(1)

Based on interview and record review, the facility failed to complete an Admission Observation Tool within 24 hours of admission for 1 of 3 residents reviewed for new admissions. (Resident D) Findings include: On 5/21/19 at 10:37 a.m., Resident D's clinical record was reviewed. The [DIAGNOSES REDACTED]. Resident D's admitted was 5/16/19. Resident D's Admission Observation Tool, dated 5/16/19, lacked documentation of completion. During an interview, on 5/21/19 at 11:50 a.m., Licensed Practical Nurse (LPN) 2 indicated when a resident was admitted , the facility would complete an Admission Observation Tool within 24 hours after admission. During an interview, on 5/23/19 at 2:45 p.m., the Director of Nurses (DON) indicated Resident D's Admission Observation Tool was completed late. This Federal tag relates to Complaint IN 779. 3.1-37(a)

Based on interview and record review, the facility failed to develop a baseline care plan within 48 hours of admission for 3 of 3 residents reviewed for new admission care plans. ( Resident D, Resident G, Resident H) 1. On 5/21/19 at 10:37 a.m., Resident D's clinical record was reviewed. The [DIAGNOSES REDACTED]. Resident D's admitted was 5/16/19. Resident D's 48 hour baseline care plan indicated a completion date of 5/23/2019, which was 7 days after the admitted . During an interview, on 5/21/19 at 11:50 a.m., Licensed Practical Nurse (LPN) 2 indicated when a resident was admitted , the facility would complete a baseline care plan 48 hours after admission. During an interview, on 5/23/19 at 11:45 a.m., the Director of Nursing (DON) indicated the baseline care plan must be done within 48 hours from admission. Resident D's baseline care plan was completed late. On 5/23/2019 at 2:55 p.m., the Director of Nursing (DON) provided the facility's policy, Plans of Care: General, undated, and indicated it was the policy currently being used by the facility. A review of the policy indicated, . Procedure . B. A Registered Nurse (RN) develops an initial plan of care within 24 hours after admission . 2. Resident G's clinical record was reviewed on 5/21/2019 at 11:30 a.m. [DIAGNOSES REDACTED]. limited to [MEDICAL CONDITION] and malignant neoplasm of right bronchus or lung. Resident G's admitted was 5/9/2019. Resident G's 48 hour baseline care plan indicated a completion date of 5/23/2019, which was 14 days after the admitted . During an interview, on 5/21/2019 at 11:50 a.m., Licensed Practical Nurse (LPN) 2 indicated when a resident was admitted , the facility would complete a baseline care plan 48 hours after admission. During an interview, on 5/23/2019 at 11:45 a.m., the Director of Nursing (DON) indicated the baseline care plan must be done within 48 hours from admission. Resident G's baseline care plan was completed late. On 5/23/2019 at 2:55 p.m., the Director of Nursing (DON) provided the facility's policy, Plans of Care: General, undated, and indicated it was the policy currently being used by the facility. A review of the policy indicated, . Procedure . B. A Registered Nurse (RN) develops an initial plan of care within 24 hours after admission . 3. On 5/23/19 at 10:35 a.m., Resident H's clinical record was reviewed. The [DIAGNOSES REDACTED]. Resident H's admitted was 5/11/19. Resident H's 48 Hour Baseline Care Plan, dated 5/17/19, indicated completion date of 5/23/19, which was 12 days after admission. During an interview, on 5/21/19 at 11:50 a.m., Licensed Practical Nurse (LPN) 2 indicated when a resident was admitted , the facility would complete a baseline care plan 48 hours after admission. During an interview, on 5/23/19 at 11:45 a.m., the Director of Nursing (DON) indicated the baseline care plan must be done within 48 hours from admission. Resident D's baseline care plan was completed late. On 5/23/2019 at 2:55 p.m., the Director of Nursing (DON) provided the facility's policy, Plans of Care: General, undated, and indicated it was the policy currently being used by the facility. A review of the policy indicated, . Procedure . B. A Registered Nurse (RN) develops an initial plan of care within 24 hours after admission . This Federal Tag relates to Complaint IN 779.

Based on record review and interview, the facility failed to initiate a care plan based on the comprehensive Minimum Data Set (MDS) assessment for 4 of 4 residents reviewed for care plans. (Resident 1, Resident 14, Resident 40, and Resident 52) Findings include: 1. On 1/17/19 at 1:15 p.m., the clinical record for Resident 1 was reviewed. [DIAGNOSES REDACTED]. a. The Admission Minimum Data Set assessment (MDS), dated [DATE], indicated Resident 1 had the following health condition which Included, but was not limited to, [MEDICATION NAME] (a catheter that goes directly into the ureter of the bladder to empty the bladder). The clinical record lacked a plan of care (P[NAME]) that addressed the care and maintenance of a [MEDICATION NAME] tube. b. The Admission MDS assessment, dated 12/31/18, indicated Resident 1 had the following health condition which included, but was not limited to, [MEDICAL CONDITION]. The clinical record lacked a P[NAME] that addressed the care and maintenance of a [MEDICAL CONDITION]. c. The Admission MDS assessment, dated 12/31/18, indicated Resident 1 had the following health condition which included, but was not limited to, frequent falls. The clinical record lacked a P[NAME] that addressed falls and interventions. 2. On 1/17/19 at 3:26 p.m., the clinical record for Resident 16 was reviewed. [DIAGNOSES REDACTED]. a. The Quarterly MDS assessment, dated 11/5/18, indicated Resident 16 had the following health condition which included, but was not limited to, anticoagulant therapy. The clinical record lacked a P[NAME] that addressed the anticoagulant therapy. b. The Quarterly MDS assessment, dated 11/5/18, indicated Resident 16 had the following health condition which included, but was not limited to, antipsychotic therapy. The clinical record lacked a P[NAME] that addressed the identified antipsychotic therapy and monitoring. 3. On 1/17/19 at 9:10 a.m., the clinical record for Resident 52 was reviewed. [DIAGNOSES REDACTED]. a. The significant change MDS assessment, dated 12/12/18, indicated Resident 52 had the following health condition which included, but was not limited to, post status gastrostomy (feeding tube that goes directly into the stomach). The clinical record lacked a P[NAME] that addressed the gastrostomy tube care and maintenance. b. The significant change MDS assessment, dated 12/12/18, indicated Resident 52 had the following heath condition, which included, but was not limited to, the use of a [MEDICAL CONDITION] machine to improve respiratory function (assistive breathing device that includes a full face mask over the mouth and nose). The clinical record lacked a P[NAME] that addressed the settings, care, maintenance, and monitoring of the [MEDICAL CONDITION] machine. c. The significant change MDS assessment, dated 12/12/18, indicated Resident 52 had the following health condition, which included, but was not limited to, contracture prevention care. The clinical record lacked a P[NAME] that addressed the care and interventions provided to prevent contractures. During an interview, on 1/18/19 at 10:30 a.m., the Director of Nursing (DON) indicated that these residents health conditions should have been identified through the comprehensive assessment process and documented in the plan of care. On 1/18/19 at 10:30 a.m., the DON provided an undated policy titled: Plans of Care: General. She indicated it was the current policy followed by the facility. A review of the policy indicated, 2. Assessments of resident needs provide the foundation for all care rendered in the facility. 4. The clinical record of Resident 14 was reviewed on 1/17/19 at 3:21 p.m. [DIAGNOSES REDACTED]. An admission Minimum Data Set (MDS) assessment, dated 10/12/18, indicated Resident 14 was always continent of urine. A quarterly MDS assessment, dated 11/7/18, indicated the resident was occasionally incontinent of urine. A care plan for urinary incontinence was not found in the resident's record. In an interview, on 1/22/19 at 9:21 a.m., the Director of Nursing indicated, if a resident is incontinent of urine, a care plan should be in place with personalized interventions. On 1/22/19 at 1:20 p.m., the Director of Nursing provided an undated policy, titled, Plans of Care: General, and indicated it was the policy currently used by the facility. A review of the policy indicated, 1. All resident care is designed to meet a resident's individual needs and is directed toward conservation and restoration of an optimal physical and emotion state .3. B. An initial assessment of a new resident's status and needs is conducted by each service .reassessments are made when change in condition occurs .C .In each case, the plan of care is reviewed and revised to reflect current needs of the resident. 3.1-35(a)

Base on interview and record review, the facility failed to ensure a resident received showers according to her preference for 1 of 2 residents reviewed for shower preferences. (Resident 14) Findings include: During an interview, on 1/16/19 at 9:15 a.m., Resident 14 and her daughter both indicated the resident was not always getting 2 showers a week, which was her preference. The clinical record of Resident 14 was reviewed on 1/17/19 at 3:21 p.m. [DIAGNOSES REDACTED]. An admission Minimum Data Set (MDS) assessment, dated 10/12/18, indicated the resident was moderately impaired in her ability to make decisions, was totally dependent on staff for bathing, and it was very important for the her to be able to choose between a shower, tub or bed bath, or sponge bath. A quarterly MDS assessment, dated 11/7/18, indicated the resident needed the physical assistance of 1 staff person for bathing A care plan, dated 10/22/18 and current through 1/29/19, indicated Resident 14 had an activity of daily living self care deficit related to weakness, tremors and immobility. On 1/18/19 at 1:30 p.m., the Director of Nursing (DON) provided an Assignment sheet which indicated care to be provided to residents on Resident 14's hall. The Assignment sheet indicated Resident 14 was to receive 2 showers per week, on day shift. Review of Resident 14's shower sheets, completed each time she received a shower, indicated a shower was provided on the following days: Week of 11/11/18: 1 shower (11/14) Week of 11/18/17: 1 shower (11/21) Week of 11/25/18: no showers Week of 12/2/18: 1 shower (12/5) Week of 12 9/18: 1 shower (12/12) Week of 12/16/18: 2 showers (12/16 and 12/19) Week of 12/23/18: 1 shower (12/26) Week of 12/30/18: no showers Week of 1/6/19: 2 showers (1/6 and 1/10) Week of 1/13/19: 2 showers (1/13 and 1/19) In an interview, on 1/22/19 at 9:22 a.m., the DON indicated, It is our policy to provide 2 showers a week. On 1/22/19 at 10:30 a.m., the DON provided a policy titled Personal Bathing and Shower, dated 4/25/18, and indicated it was the policy currently used by the facility. A review of the policy indicated, It is the policy of this facility to provide resident centered care that meets the psychosocial, physical and emotional needs and concerns of the residents .Residents have the right to choose their schedules including choice for personal hygiene .Bathing preferences should be care planned including type and schedule. The facility will support and accommodate the resident/representative preferences to the extent possible to reach their goals . 3.1-(v)(1)

Based on record review and interview, the facility failed to ensure staff did not leave a resident unattended in her room while in a wheelchair which resulted in a fall with diagnosed neck fracture and 3 sutures to the forehead for 1 of 3 residents reviewed for falls in a sample of 6 (Resident B). Findings include: The closed record for Resident B was reviewed on 10/31/18 at 9:51 a.m. [DIAGNOSES REDACTED]. The resident was admitted to the facility on [DATE] and discharged to the hospital on [DATE]. A Physical Therapy Plan of Care evaluation, dated 7/1/18, indicated Resident B was referred to therapy due to flaccid [MEDICAL CONDITION] affecting the right (dominant) side. Additionally, the resident showed severe overall decline in functional mobility and unable to walk at that time. The resident was also unable to maintain sitting balance without moderate to maximum support. An Occupational Therapy Daily Treatment Note, dated 7/3/18, indicated while Resident B was seated in the wheelchair with an elevated tray table, the resident almost fell out of the chair during mealtime when leaning forward to pick up something that was dropped on the floor. The therapy note also indicated the resident was impulsive and demonstrated poor safety awareness. An Occupational Therapy Daily Treatment Note, dated 7/4/18, indicated the resident's wheelchair was set up with a right-side removable, flip-over clear tray for positioning of the right arm while seated. The admission Minimum Data Set (MDS) Assessment, dated 7/7/18, indicated the resident had impaired balance ability and was only able to stabilize with staff assistance. The resident's range of motion was impaired on the right side (dominant) to the upper and lower extremities. Resident B was also severely cognitively impaired. A care plan, undated, for Resident B indicated she was a fall risk due to impaired balance with physical limitations and [DIAGNOSES REDACTED]. The goal for the resident was that she would not sustain serious injury. The record lacked documentation of a care plan for the wheelchair tray table. During an interview, on 11/5/18 at 4:25 p.m., the Nurse Consultant indicated no care plans could be found for the resident's wheelchair tray table. A progress note, dated 8/19/18, indicated the resident was found face down on the floor after she slipped out of the wheelchair. Resident B was sent to the hospital by ambulance due to a wound on the right side of the forehead. The progress note lacked documentation the positioning tray was in place at the time of the fall. An Investigative Planning Tool, dated 8/19/18 at 11:00 a.m., and provided by the Director of Nursing (DON) on 11/7/18 at 2:15 p.m., indicated the resident was found on the floor face down in her room. CNA 2 had transported resident from therapy to her room, then left to retrieve the mechanical lift and was gone approximately 1 minute when staff reported she had fallen. Further interviews with the staff indicated the tray table was in the normal position for the resident. The Therapy Program Director also reported the resident will lean forward at times, as if she is picking items up off the floor. She was able to do this because the tray does not restrict that movement. A hospital note, dated 8/19/18, indicated the resident required 3 sutures to repair the 1 cm (centimeter) laceration to the head. The results of the CT (X-ray) scan indicated a nondisplaced [MEDICAL CONDITION] (neck) vertebra. The hospital discharge summary, dated 8/23/18, gave orders for an aspen collar (neck brace) at all times. During an interview with the Therapy Manager, on 11/5/18 at 3:15 p.m., she indicated the resident was nearly dependent for everything, needed the 1/2 tray for support and could sit but would not have been left alone due to right sided weakness and poor safety awareness. During an interview with LPN 3, on 11/5/18 at 4:50 p.m., she indicated she could not remember if the resident had a tray table on her wheelchair. During an interview with CNA 4, on 11/5/18 at 4:55 p.m., she indicated she could not remember if the resident had a tray table on her wheelchair. (LPN 3 and CNA 4 worked on the 700 Unit where Resident B resided). This Federal tag relates to Complaint IN 268. 3.1-45(2)

Based on record review and interview, the facility failed to ensure staff administered [MEDICATION NAME] ([MEDICATION NAME]-narcotic pain medication) as ordered by the physician, which resulted in the resident exhibiting increased disorientation and being prescribed IV (intravenous) fluids due to medication administration errors (Resident H) for 1 of 1 resident reviewed for medication error in a sample of 11 residents reviewed. (RN 2 and RN 3) Findings include: The record for Resident H was reviewed on 5/31/18 at 2:15 p.m. [DIAGNOSES REDACTED]. An original medication order for Resident H (dated 4/2/18) for [MEDICATION NAME] HCL 4 milligrams (mg), give 2 tablets every 6 hour as needed for pain. A new medication order for Resident H (dated 4/4/18) for [MEDICATION NAME] HCL 4 mg, give 2 tablets every 5 hours. A Controlled Medication Administration Record [REDACTED]. Medications were administered as follows: 4/10/18 at 4:00 a.m., 2-8 mg tablets administered by RN 2 4/10/18 at 9:00 a.m., 2-8 mg tablets administered by RN 3 4/10/18 at 2:00 p.m., 2-8 mg tablets administered by RN 3 4/10/18 at 7:00 p.m., 2-8 mg tablets administered by RN 2 4/10/18 at 11:00 p.m., 2-8 mg tablets administered by RN 2 4/11/18 at 5:00 a.m., 2-8 mg tablets administered by RN 2 A progress note, dated 4/11/18 at 3:39 p.m., indicated the resident's family had asked for the next dose of [MEDICATION NAME] to be held due to Resident H being more disoriented since the medication was changed from as needed every 6 hours to scheduled every 5 hours. A progress note, dated 4/11/18 at 8:56 p.m., indicated a medication error ([MEDICATION NAME]) had been found. A progress note, dated 4/11/18 at 3:50 a.m., indicated Resident H had orders from the Nurse Practioner for intravenous (IV) normal saline, 1000 milliliters (ml) at 100 ml per hour due to the [MEDICATION NAME] medication error. During an interview with the Director of Nursing, on 5/31/18 at 3:45 p.m., she indicated the order was originally written for 4 mg tablets but the pharmacy sent 8 mg tablets. Resident H received 16 mg doses rather than 8 mg as ordered by the physician on 4/4/18. This Federal tag relates to Complaint IN 037. 3.1-48(c)(2)

Based on interview and record review, the facility failed to provide 1:1 supervision as was indicated by assessments to maintain resident's safety from falls which resulted in a fall with injury that required acute medical intervention for 1 of 3 residents reviewed for accidents. (Resident C) Findings include: On [DATE] at 11:15 a.m., Resident C's closed clinical record was reviewed. The [DIAGNOSES REDACTED]. A review of Resident C's Fall Risk Assessment Tool, dated [DATE], indicated a total score of 8, with a score of 4 or more being considered at risk for falling. A review of Resident C's admission Minimum Data Set (MDS) assessment, dated [DATE], indicated a Brief Interview for Mental Status (BIMS) total score of 3, with a total score of 0 to 7 being severely cognitively impaired; required extensive assistance with bed mobility, transfers, and toilet use; had history of falls in the last month prior to admission to facility; and had fallen two or more times since admission to the facility. A review of Resident C's care plan, dated [DATE], indicated (Resident's name) is at risk for falls r/t (related to) weakness and debilitated condition, s/p (status/post) ORIF (Open Reduction and Internal Fixation) of left hip, history of falling, dementia with decrease safety awareness The care plan indicated the following interventions -Be sure the call light is within reach and encourage (Resident's name) use it for assistance as needed. (Resident's name) needs prompt response to all requests for assistance -Educate/remind (Resident's name) to request assistance prior to transfer/ambulation. -Encourage common area while awake -Provide (Resident's name) non-skid footwear A review of Resident C's progress notes indicated the following: On [DATE] at 8:28 p.m., the resident was admitted from the hospital with a [DIAGNOSES REDACTED]. The resident had an incision and was pulling the dressing off. The resident was alert to self and was a high risk for falls due to confusion. On [DATE] at 10:13 p.m., the resident was found on the floor next to the bed. The resident was confused and was a new admit. The resident had no apparent injuries. The family and physician were notified. On [DATE] at 10:29 a.m., the resident was alert to self. The resident required extensive assist of one person with Activities of Daily Living (ADLs) and transfers. The resident required verbal cues for meals and to take her medications. On [DATE] at 11:27 p.m., the hospital was consulted about anchoring a Foley catheter regarding concerns the resident being a wanderer (a resident which walks or wheels wheelchair from place to place with or without known direction). On [DATE] at 12:30 a.m., the post fall investigation indicated the resident had an unwitnessed fall and was found on the floor laying on her right hand side. The resident indicated she was trying to get to the end of the bed but couldn't find the edge of it. No injuries were sustained. On [DATE] at 12:45 a.m., the resident had an unwitnessed fall in her room and was found on her right side by Certified Nurses Assistant (CNA) and nurse. The resident was alert and oriented times one. The resident frequently wandered. The resident's family and physician were notified of the fall. The resident's interventions would be: bed would remain in low position; call light education would be reinforced; and the resident would be checked frequently. The fall care plan lacked the intervention of the resident's bed to remain low. On [DATE] at 9:37 a.m., the resident was a very high fall risk and had 2 other falls in the last 2 days. On [DATE] at 9:43 a.m., the post fall investigation indicated the resident was sitting up in her wheelchair in the dining room and stood up from the wheelchair unassisted. The resident fell and her hit head on the floor and received 4.5 x 5 cm hematoma (localized collection of blood outside the blood vessels) to the back of her head. The resident's family requested she be given a sleep aide because the resident had fallen the last 2 nights. On [DATE] at 5:47 a.m., the resident was up out of bed walking without assistance two times. The second time the resident was incontinent of bowel and was stating she needed to use the bathroom. The resident was cleaned up, toileted, and returned back to bed. The resident was to be checked frequently. On [DATE] at 9:06 a.m., the resident was very lethargic. The resident was started on melatonin (sleep aide) 3 mg last night related to falls at night. The resident received a new order to decrease the melatonin from 3 mg to 1 mg every night. On [DATE] at 9:07 a.m., the plan of care note indicated Interdisciplinary Team (IDT) met to review fall from ,[DATE] and [DATE]. On [DATE], the resident was observed to be lying in a supine (lying face up) position on the floor next to the bed. The resident was confused and was a poor historian. The resident was toileted 30 minutes prior to the fall. The resident had on nonskid socks; her floor was dry/uncluttered; and the lighting was adequate. On [DATE], the resident was observed lying on her right side on the floor in her room . The resident was unable to describe the cause of the fall due to her baseline confusion. The resident had on nonskid socks; her floor was dry/uncluttered; and the lighting was adequate. On [DATE], the resident was observed to be lying in supine position in the dining room. The resident was a poor historian and was unable to describe the cause of the fall. The resident did hit her head on the floor causing a hematoma to the back of her head. The resident had on nonskid socks; her floor was dry/uncluttered; and the lighting was adequate. All falls were reported to the physician and the family. The resident's family suggested additional sleep aid medication and full side rails. The IDT educated the resident's family related to the risk of over sedation and restraints. The resident's family verbalized understanding. The physician ordered labs with abnormal results being reported to the physician and family. The resident's current interventions were nonskid footwear and call light within reach. The IDT recommended to encourage the use of common areas and activities while awake. On [DATE] at 11:04 p.m., the resident was on 1:1 supervision during the hours of 6:00 a.m. to 10:00 p.m., due to the resident was constantly getting up and wandering around without staff present. The night shift attempted to put the resident back to bed 3 times and each time the resident had gotten up out of bed on her own. The resident had to be monitored at the nursing station with on 1:1 supervision. On [DATE] at 4:59 p.m., the resident was noncompliant with using the call light and was a severe fall risk. The resident was in need of constant redirection. The resident was constantly trying to stand up even with redirection. The resident could not be left alone for even a second or she would try to stand up. The resident has been on 1:1 supervision this entire shift. On [DATE] at 4:13 p.m., the resident was on 1:1 supervision for the shift. The resident was confused and was still trying to get up out of her chair. On [DATE] at 9:15 a.m., the resident required extensive assist of one with ADLS and transfers. The resident remains on 1:1 supervision due to the high fall risk. The resident was sitting at the nurses station. On [DATE] at 6:04 a.m., the resident was trying to get out of the bed and fell . The resident was a fall risk. The resident's family was notified. On [DATE] at 6:07 a.m., the post fall investigation indicated the resident was unable to state what she was doing during the fall. The resident lost her balance and fell . On [DATE] at 9:44 a.m., the resident required extensive assistance of one assist with ADLS and transfers The resident remains on 1:1 supervision related to the high risk for falls. The resident was on fall follow-up related to the fall this am. The resident was sitting at the nurses station. On [DATE] at 5:56 a.m., the resident was attempting to stand up unassisted on several occasions this shift. On [DATE] at 3:01 a.m., the resident was found on the floor about 20 minutes after she was seen sleeping in her bed. The resident has fallen several times while at this facility. The resident has [DIAGNOSES REDACTED]. The resident's family and physician were notified. On [DATE] at 5:27 p.m., the resident remained on 1:1 supervision for this shift. The resident had to be constantly redirected. The resident was in the dining room and would continue on the 1:1 supervision. On [DATE] at 9:13 a.m., the resident required extensive assistance of one assist with ADLS and transfers. The resident remained on 1:1 supervision related to the high fall risk. On [DATE] at 11:19 a.m., the plan of care note indicated IDT met to review the falls from [DATE] and [DATE]. On [DATE], the resident was last observed to be asleep in her bed and was next to be observed lying in a supine position on the floor next to the bed. The resident was unable to describe the cause of the fall. The resident has a history of a [DIAGNOSES REDACTED]. The resident's family and physician were notified. On [DATE], the resident was last to be observed lying asleep in her bed, and then the resident was observed to be lying on floor next to the bed. The resident was unable to describe the cause of the fall. The resident has history of a [DIAGNOSES REDACTED]. The resident's family and physician were notified. The resident's current interventions were call light with in reach, nonskid socks, encourage common areas, and activities while awake. The IDT recommended to report the labs to the physician and provide 1:1 supervision. The fall care plan lacked the interventions of reporting labs to physician or providing 1:1 supervision. On [DATE] at 10:22 a.m., the resident remained on 1:1 supervision this shift. The resident had to be continually redirected; had to be with the nurse, and continued 1:1 supervision. On [DATE] at 5:20 p.m., the facility discussed with the resident's family the recommendation of a facility with a memory care placement. On [DATE] at 2:47 p.m., the resident fell on the restroom floor. The resident was bleeding from her right side of head/eye area. The resident's cognitive level was unable to to be determined due to her baseline being confused. The resident was sent to the hospital, did not return, and died on [DATE]. On [DATE] at 5:24 p.m., the plan of care note indicated IDT met to review the fall on [DATE]. The resident was observed to be lying on the bathroom floor and was bleeding from her nose. The resident was unreliable historian related to [DIAGNOSES REDACTED]. The resident had on nonskid socks; her floor was dry/uncluttered; and the lighting was adequate. The resident's family and physician were notified. The resident's current interventions were call light wight reach, nonskid footwear, encourage common areas, activities while awake, and 1:1 supervision. The IDT recommended the resident to be sent to the emergency room for evaluation and treatment. On [DATE] at 2:05 p.m., CNA 1 indicated she had been a CNA for [AGE] years and had worked at the facility for 2 years. She was familiar with Resident C's care. Resident C needed staff with her at all times and the facility had to call someone to sit with Resident C. Resident C had to sit with nurses . Resident C did not understand not to get up on her own and thought she was able to walk. On [DATE] at 10:30 a.m., the Director of Nurses (DON) indicated nursing staff would notify the DON after Resident C's falls. Resident C was impulsive. The facility was trying to set up placement in a different facility with a dementia unit. The DON indicated she found Resident C on the floor in the bathroom after the fall on [DATE] at 2:47 p.m. The CNA doing 1:1 supervision with Resident C had an emergency and had to leave Resident C unattended. The DON was on her way to relieve the CNA when the DON entered Resident C's room and found Resident C on the floor. The DON indicated Resident C was unattended for less than 3 minutes. On [DATE] at 12:05 p.m., The nursing consultant indicated Resident C was started on 1:1 supervision on [DATE]. On [DATE] at 12:16 p.m., The DON indicated the 1:1 supervision was provided on first and second shift and a few night shifts. On [DATE] at 10:31 a.m., the DON provided the policy, NCD Fall Response and Management, dated [DATE], and indicated it was the policy currently being used by the facility. The policy indicated, 3. Revise the plan of care, appropriate .c. Revise the care plan with interventions . This Federal tag relates to the complaint IN 379. 3XXX,[DATE](a)(2)