Every finding on record at Springs Valley Meadows

Based on observation, interview, and record review, the facility failed to ensure infection control practices were followed for 2 of 3 residents observed for incontinence care and 3 of 7 residents observed for medication pass. The nursing staff failed to change gloves after touching multiple items in the room before starting incontinence care, touched medications with bare hands, and a washed hands with a five second lather. (Resident 61, Resident 21, Resident 24, Resident 45, Registered Nurse 32, CNA 14, CNA 21, CNA 44)Findings include: 1. On 4/27/26 at 6:35 A.M., Registered Nurse (RN) 32 was observed prepping medications for Resident 21. She pulled the card of medications up from the cart, put the following medications into her bare hand, placed them into a medication cup, and administered them to the resident: one Aspirin 81 milligrams (mg) tablet for anticoagulation one Lisinopril 5 mg tablet for high blood pressure one memantine 10 mg tablet for dementia one Zoloft 50 mg tablet for depression one Vascepa 1 gram (gm) tablet for high cholesterol one Vitamin D3 25 microgram (mcg) tablet for vitamin deficiency two Tylenol 325 mg tablets for pain 2. On 4/27/26 at 6:22 A.M., RN 32 was observed prepping medications for Resident 24. She pulled the card of medications up from the cart, put the following medications into her bare hand, placed them into a medication cup, and administered them to the resident: two Tylenol 500 mg tablets for pain one citalopram 10 mg tablet for depression one galantamine 8 mg tablet for dementia behaviors one memantine 10 mg tablet for dementia behaviors one multivitamin tablet 3. During an observation on 4/27/26 at 10:29 A.M., RN 32 washed her hands with a five second lather during medication administration. 4. During an observation on 4/29/26 at 10:48 A.M., incontinence care was performed on Resident 45 by Certified Nurse Aide (CNA) 21 and CNA 44. Both CNAs washed their hands and put on gloves. CNA 44 adjusted the bed with the controller. CNA 21 grabbed wipes from the nightstand drawer. Both lowered blankets and unfastened the resident's brief. CNA 44 grabbed a wipe from the package and wiped the resident's external female genitalia from back to front, discarded the wipe in the trash bag, grabbed another wipe, and wiped the external female genitalia from back to front. Resident 45 was rolled onto her left side and held by CNA 44 wearing the same gloves used for incontinence care. CNA 21 grabbed wipes and wiped the bowel movement from the resident's buttocks. 5. On 4/29/26 at 11:10 A.M., Certified Nurse Aide (CNA) 14 was observed doing incontinence care for Resident 61. CNA 14 put on gloves, put the head of the bed down with the remote, got wipes out of drawer, pulled the privacy curtain around Resident 61 then started perineal care without changing gloves. During an interview on 4/30/26 at 10:32 A.M., the Infection Preventionist indicated nursing staff should not touch resident medications with their bare hand and should lather their hands for at least 20 seconds during handwashing. She further indicated prior to providing incontinence care, staff should remove gloves and perform hand hygiene after touching random items. On 5/1/26 at 12:36 P.M., a current Medication Pass Procedure Policy, last revised April 2025, was provided by the Administrator and indicated, . Medications opened without contamination. On 4/30/26 at at 12:36 P.M., a current Hand Hygiene Policy, last revised December 2021, was provided by the Administrator and indicated, . Purpose of Policy: To provide a standardized approach to Hand hygiene to reduce or minimize the transmission of infection from potential microorganism on the hands of all employees.B. Indication for hand rubbing but not limited to.After each resident contact and after contact with a resident's environmental surfaces, touching items on the floor, and resident care equipment. On 4/30/26 at at 12:36 P.M., a current Perineal Care Policy, last reviewed March 2023, was provided by the Administrator and indicated, . Females: separate labia and was urethral area first. Wash between and outside labia in downward strokes. Alternate from side to side wipe from front to back and from center of perineum outward . On 4/30/26 at 12:36 P.M., the Administrator provided a Hand Hygiene policy, revised 12/21, that indicated, .B. Indication for hand rubbing but not limited to.After each resident contact and after contact with a resident's environmental surfaces, touching items on the floor, and resident care equipment. 410 IAC (Indiana Administrative Code) 16.2-3.1-18(l) 410 IAC (Indiana Administrative Code) 16.2-3.1-18b(1)

Based on observation, interview, and record review, the facility failed to ensure narcotics were double locked in the medication cart for 1 of 2 medication carts observed. Narcotic box on medication cart was not locked. (South Long Hall Medication Cart)Finding includes:On 4/27/26 at 6:15 A.M., the South Long Hall Medication Cart narcotic box was observed to be unlocked.During an interview on 4/30/26 at 9:09 A.M., Licensed Practical Nurse (LPN) 56 indicated medication carts should always be locked, and the narcotic box should always be under a double lock.On 5/2/26 at 10:25 A.M., a current Controlled Substances Policy, dated November 2024, was provided by the Administrator and indicated, . It is the policy of this facility that all controlled substances will be stored . by state regulations . All controlled substances administered by the facility should be kept under double lock . 410 Indiana Administrative Code (IAC) 16.2-3.1-25(n)

Based on observation, interview, and record review, the facility failed to accurately document in clinical records for 1 of 1 resident reviewed for hospice, and 1 of 3 residents reviewed for nutrition. A resident's clinical record contained a different resident's hospice records and snacks were documented as eaten when not consumed. (Resident 6, Resident 11)Findings include: 1. On 4/28/26 at 10:36 A.M., Resident 6's clinical record was reviewed. The diagnosis included, but was not limited to, Alzheimer's disease. The most recent significant change MDS (Minimum Data Set) assessment, dated 3/13/26, indicated hospice care.Resident documents included, but were not limited to, scanned and uploaded hospice documentation dated 4/7/26. The documentation belonged to a different resident in the facility that was also under hospice care.On 4/29/26 at 10:35 A.M., the Director of Nursing (DON) indicated hospice documentation was generally uploaded to the resident's clinical record every three months, with updates to the plan of care, and when the resident passed.2. On 4/28/26 at 10:41 A.M., Resident 11's clinical record was reviewed. The diagnosis included, but was not limited to, heart failure. An IDT (Interdisciplinary Team) note, dated 2/17/26, indicated Resident 11 had experienced an 11.3% weight loss in 30 days with a new recommendation for peanut butter and jelly sandwich and chips at 10:00 A.M.Current physician orders included, but were not limited to:Peanut butter sandwich and chips at 10:00 A.M., dated 2/17/26.The most recent MDS (Minimum Data Set) assessment, dated 3/23/26, indicated no cognitive impairment, no behaviors, setup/cleanup assistance with eating, and significant weight loss.A Dietary Administration History indicated Resident 11 had been provided and eaten a peanut butter sandwich at 10:00 A.M. on the following dates:4/25/26 100% consumed4/26/26 100% consumed4/28/26 50% consumed. On 4/28/26 at 1:06 P.M., Resident 11 was observed sitting in a recliner in her room. Two unopened peanut butter sandwiches were observed on the bedside table, and one was observed on the dresser. The dates on the sandwiches were 4/25/26, 4/26/26, and 4/28/26, and all indicated a time of 10:00 A.M. On 5/1/26 at 8:59 A.M., the Administrator provided a current Nursing job description, last updated 11/2014, that indicated Monitors delivery of care and services throughout shift to ensure needs are met, tasks are completed, including complete and accurate resident documentation, and that work of direct care staff is of acceptable quality and quantity 410 IAC (Indiana Administrative Code) 16.2-3.1-50(a)(2)

Based on observation, interview and record review, the facility failed to maintain safe and secure storage of medications for 1 of 4 medication carts observed. The narcotic box lid inside the cart was not closed completely to engage the lock. (South Long Hall Medication Cart) Finding includes: On 2/26/25 at 9:45 A.M., the South Long Hall Medication Cart was observed. The lid was not closed completely to engage the lock. Narcotics were observed stored in the box at the time. At that time, Licensed Practical Nurse (LPN) 24 indicated it was not broken and should have been closed and locked. During an interview, on 2/26/25 at 1:44 P.M., the Director of Nursing (DON) indicated all narcotics should be double locked. On 2/26/25 at 2:36 P.M., a current Medication Storage Policy, revised 6/30/23, was provided by the DON and indicated . The community should store Schedule II-V controlled substances [narcotics] and other medications deemed by the community as at-risk for abuse or diversion in a separately locked, affixed compartment in a cart . 3.1-25(n)

Based on observation, interview, and record review, the facility failed to provide meals at an acceptable temperature for 1 of 1 lunch trays sampled on 1 of 2 units. Food was served cold. (South Hall) Finding includes: During an interview on 2/24/25 at 11:33 A.M., an anonymous resident indicated the food was not served hot. During an interview on 2/26/25 at 1:35 P.M., an anonymous resident indicated the food was not served hot. During an observation on 2/26/25 at 11:46 A.M., the South Hall meal trays were being distributed to resident rooms from a meal cart. The individual meals were covered with an insulated dome with a base. At 11:52 A.M., a hall tray was sampled. The cheeseburger temperature was 113 degrees Fahrenheit. It was cold to the touch and tasted cold, and the cheese was not melted on the hamburger. During an interview on 2/26/25 at 2:11 P.M., [NAME] 25 indicated cheeseburgers should be a minimum of 145 degrees Fahrenheit when they are served to the residents. On 2/26/25 at 1:21 P.M., a current Food Temperatures policy, revised 6/2023, was provided by the Administrator and indicated, .Hot foods that are potentially hazardous will be held for service at or above 135 degrees Fahrenheit . 3.1-21(a)(2)

Based on record review and interview, the facility failed to ensure person centered interventions were implemented for dementia related behaviors for 1 of 5 residents reviewed for dementia care. (Resident 5) Findings include: The record for Resident 5 was reviewed on 3/20/24 at 6:35 a.m. The diagnoses included, but were not limited to, dementia with agitation, cognitive communication deficit, and insomnia. The physician's order, dated 5/12/22, indicated the resident may receive psychiatric services. The physician's order, dated 5/17/22, indicated staff were to apply a wanderguard to the resident's right wrist for exit seeking behavior, and to check the device for function daily. The resident was to be monitored for exit seeking behavior every shift. The Activity Assessment, dated 5/18/22, indicated the resident was interviewed by the Activities Director on her activity preferences. She documented the following were somewhat important: -Having coloring books, word searches, and puzzle books. -Listening to gospel music. -Being around animals. -Going outside. Involvement in Christian activities was documented as very important. The nurse's note, dated 3/12/23 at 8:41 a.m., indicated the resident continued to attempt to go into other resident's rooms that morning. Staff attempted to redirect, but the resident continued to attempt to go right back into the rooms. The resident hallucinated, talking to people that were not there. She was talking to a chair like it was her family member. She was in the TV (television) room and attempted to get out of her wheelchair and sit herself on the floor. She kept yelling out for the babies and wanting to feed them. The resident would not sit still or stay in one place. Snacks and activities were offered, to try to keep the resident busy, but the resident was not entertained by these. The care plan, dated 3/14/23 and last reviewed 1/24/24, indicated the resident intrusively wandered at times. The interventions, dated 3/16/23, indicated staff were to call and let the resident speak with a family member, dated 3/14/23, staff were to assess the resident for pain, offer to lay down the resident to rest, offer toileting and snacks, redirect the resident to activities of interest, and take the resident to a quiet environment. The nurse's note, dated 3/15/23 at 9:29 a.m., indicated the resident was wandering around halls attempting to go into other resident's rooms and pushing their wheelchairs up the halls. The resident thought that her family member was sitting in one of the wheelchairs and the resident was talking to her. The resident went to coffee club and went over to the therapy side and was yelling at the other residents and therapy staff. Therapy staff came to get the nurse to come and get her. The resident continued to yell out at staff and was trying to get out of the doors. The nurse's note, dated 3/15/23 at 9:34 a.m., indicated the night shift reported that the resident was asleep in bed until her family member came in and woke her up and then the resident would not stay asleep. The resident was found scooting up the hallway on her bottom and had been awake since yelling at staff and trying to get into other resident's rooms. The nurse's note, dated 3/16/23 at 5:37 p.m., indicated the night shift reported that the resident had been up all night. She was going in and out of other resident's rooms, taking other residents' items. The resident had been confused and asked for a family member. The resident was not easily redirected and crawled out of bed if she was laid down. A family member and the Social Service Director were notified. The nurse's note, dated 3/20/23 at 9:17 a.m., indicated the night shift staff reported that the resident was awake all night just like she had been all weekend. When staff took her to the bathroom in the morning, they found some items that the resident had taken a thermometer, eyeglass case with glasses, nail clippers and a fidget [NAME] all were hidden under the resident's shirt. The resident had then fallen asleep sitting in her wheelchair in the common area. The IDT (Interdisciplinary Team) behavior review note, dated 3/20/23 at 3:47 p.m., indicated the resident was not sleeping. The root cause of the behavioral expression was a BIMS (Brief Interview of Mental Status) score of 0, meaning the resident's cognition being severely impaired. The preventative intervention was for the psychiatrist, who was at the facility, to increase the melatonin, as this was all the family member allowed to be done at this time. The care plan was updated, and the current interventions were revised as applicable. The nurse's note, dated 3/26/23 at 3:51 a.m., indicated the resident was up throughout the night, screaming that the facility was on fire. The resident intrusively wandered, screaming about the facility being on fire, telling other residents to get out of bed. All interventions of one-on-one, food, snacks, and redirection, failed. The physician's order, dated 4/6/23, indicated staff were to administer 10 mg (milligrams) of melatonin at bedtime for the resident. The nurse's note, dated 4/12/23 at 9:53 a.m., indicated the night shift reported that the resident had been up since approximately 3:00 a.m. The resident had been wandering throughout the hallways and was trying to get out through the doors. Redirection continued with little to no effectiveness. The nurse's note, dated 4/18/23 at 5:47 p.m., indicated she spoke with the resident's family member about the psychiatric recommendation for the resident to start Zoloft. He did not want this to happen at this time. He said he had been monitoring the resident and would continue to do so and as long as the facility staff abided by the resident's and his wishes, she would be okay. He wanted to make sure that when the resident was in bed, that a light and her TV were left on because the resident did not do well in the dark and got scared. The Annual MDS (Minimum Data Set) assessment, dated 4/20/23, indicated the resident was severely cognitively impaired. The Social Service note, dated 4/21/23 at 11:56 a.m., indicated the psychiatric social worker was at the facility to visit the resident on 4/20/2023. No new orders were received. The Social Service note, dated 5/18/23 at 11:33 a.m., indicated the Psychiatric NP (Nurse Practitioner) was at the facility to visit the resident on 5/16/23. No new orders were received. The Social Service note, dated 6/23/23 at 3:00 p.m., indicated the Psychiatric Social Worker was at the facility to visit the resident on 6/22/23. No new orders were received. The nurse's note, dated 7/2/23 at 2:09 a.m., indicated the resident was rolling herself in her wheelchair, down the hallway, when she bumped into the housekeeping cart. The broom came down and hit the resident. The nurse came and heard the incident after the fact. The resident was mad and was yelling at the cart and rubbing her head and her arm. When she was asked if the broom hit her, she answered that it did. An assessment was performed with no abnormal findings. The Social Service note, dated 7/5/23 at 7:49 a.m., indicated the Psychiatric NP was at the facility to visit the resident on 6/29/23. The nurse's note, dated 7/12/23 at 1:52 p.m., indicated the resident had been up for the past two days. The resident was displaying manic behavior. The night shift reported that they called the family member to come sit with the resident at midnight due to the resident being continuously in and out of other resident's rooms and trying to get out the doors. The family member came in on this day and was requesting that lab work be done. The nurse's note, dated 7/19/23 at 6:33 a.m., indicated the resident had a physical altercation with another resident at 5:30 a.m. The CNA (Certified Nurse Aide) heard a noise coming from the resident's room and went to investigate. The CNA saw this resident slapping Resident 6 on the face. The CNA immediately separated this resident and redirected her to the nurse's station. Resident 6 had red marks on the right side of her face. No other injuries were observed. The on-call personnel were called and was informed of the situation. The State Incident report, dated 7/19/23, indicated that Resident 5 was observed making contact with Resident 6. The residents were immediately separated. The residents were both offered a room change. Psychiatric services were to be conducted upon the next visit. The residents were to be monitored for signs or symptoms of psychosocial distress. CNA 6, indicated she had gotten Resident 5 up to her wheelchair and went to the closet to get clothes for Resident 6. She turned around to see Resident 5 smack Resident 6 and say shut up. She immediately told QMA (Qualified Medication Aide) 5 about the incident. The IDT behavior review note, dated 7/20/23 at 10:42 a.m., indicated the resident hit her roommate, Resident 6, on the right cheek when her roommate was hollering out. The immediate intervention was to separate the resident from her roommate and Resident 5 was brought to the nurse's station. Resident 5's family member was contacted, and he took her for a drive. The root cause was that the roommate, Resident 6, was hollering out and potentially caused Resident 5 over stimulation. Resident 5's roommate was hollering out after staff got her up for the morning, and Resident 5 was possibly over stimulated. The preventative intervention was that the nurses gave Resident 6 routine morphine before staff got her up in the a.m. The room move was completed to separate the roommates. Resident 6's family members were to be called if the resident appeared agitated or over stimulated. Resident 5's family member indicated he would take her for a drive. The care plan was updated, and the current interventions were revised. The records lacked documentation of a care plan for aggressive behaviors toward staff or other residents. The nurse's note, dated 7/24/23 at 8:53 a.m., indicated there was no ill effects observed from the recent resident to resident altercation. There was also no increase in moods or behaviors. Nursing would continue to monitor the residents. The nurse's note dated 7/24/23 at 12:07 p.m., indicated the Psychiatric NP was at the facility to visit the resident on 7/20/23. No new orders were received. The Psychiatric note, dated 8/10/23, indicated the resident had symptoms of aggression during care, agitation and restlessness, anxiety, exit-seeking, delusions, functional decline, hallucinations, impulsivity, disinhibition, intrusiveness, irritability, non-adherence behaviors, paranoia, suspiciousness, ruminating thoughts, wandering, and yelling out. The psychiatrist indicated the resident would benefit from ongoing psychotherapy with behavioral health services. The Quarterly MDS assessment, dated 12/20/23, indicated the resident was severely cognitively impaired. The nurse's note, dated 1/23/24 at 10:02 p.m., indicated Resident 5 was observed to wheel herself over to Resident 2, who was sitting in her wheelchair next to the South Hall spa door. Resident 2 was drinking her coffee when Resident 5 used her right hand to slap Resident 2 across her left cheek. The residents were immediately separated, and Resident 5 was moved to safety and placed on one-on-one monitoring. The Director of Nursing was notified. The family of Resident 5 was notified and encouraged to call nursing management in the morning with further questions. The IDT behavior review note, dated 1/24/24 11:32 a.m., indicated the resident slapped another resident. The immediate intervention was to separate the residents. The root cause was environmental of over or under stimulation, the approach, positioning, or other resident behavior, the cognitive level of dementia staging, or BIMS assessment. The resident had a diagnosis of dementia with a BIMS score of 3 (severely cognitively impaired). The resident had episodes of being over stimulated. The root cause of behavioral expression was that the resident was up past her usual bedtime. The preventative intervention relating to the above root causes was for staff to attempt to put the resident to bed at 8:00 p.m. The care plan was updated with the current interventions. The care plan, dated 1/24/24 and last reviewed 3/15/24 at 1:54 p.m., indicated the resident had episodes of being aggressive with other residents. The interventions, dated 1/24/24, indicated to call the family member and ask him to visit with the resident, conduct a psychiatric consult, move the resident to a quiet environment, and offer to lay down the resident at 8:00 p.m. The Social Service's note, dated 1/30/24 at 11:41 a.m., indicated the Psychiatric NP visited the resident. The records lacked documentation of provision or attendance to activities of interest to prevent the resident from harming other residents or intrusive behaviors. During an observation of the resident on 3/21/24 at 8:16 a.m., she was sitting in her wheelchair near the nurse's station with her head leaning over and she was asleep. She had a blanket over her upper body. No music was playing. Staff were not in the area. During an observation on 3/21/24 at 9:45 a.m., the activity room was empty. The resident was asleep in bed. The TV was not on and music was not playing in her room. During an observation on 3/21/24 at 11:30 a.m., an exercise activity was going on in the Main Dining Room. There were 10 residents present. The resident was still in her room asleep and was not present for exercises. Her TV was not on and music was not playing in her room. During an observation on 3/21/24 at 1:51 p.m., the activity room had the TV on with one resident sitting on the couch. The resident was asleep in her wheelchair in the nurse's station area. No music was playing. Staff were not in the area. During an observation on 3/22/24 at 8:46 a.m., the resident was asleep in bed. The TV was not on and no music was playing. The activity room had 2 male residents in the room. One was asleep on the sofa and the other was working with a puzzle at the table. There were 5 residents sitting around the nurse's station in their wheelchairs. During an interview on 3/22/24 at 9:09 a.m., RN 7 indicated it depended on the day as to whether the resident would participate in an activity. She liked to toss balloons on her own terms. The resident napped all day and night. The resident's family would take her out to eat at a local restaurant often. The family member refused to let the facility give the resident any psychotropic medications, other than melatonin. The resident would just flip out sometimes or if another resident bumped her wheelchair. A full body mechanical lift was used to get the resident up from bed. The resident would refuse to get up in the mornings sometimes and the family would come in and ask why she wasn't up. There were times when the resident would be up all night and was manic. On July 12, 2023, the resident had an altercation with another resident. It was at 5:30 p.m. The resident had been up all night for 2 nights and the family member had to come in to sit with the resident. The DON (Director of Nursing) indicated the resident slapped was Resident 6. During the altercation, Resident, 5 had just been placed into her chair. The CNA turned to obtain clothes for Resident 6. Resident 5 slapped her roommate, Resident 6 on the face and told her to shut up. The residents were separated by taking Resident 5 out of the room. An assessment was completed. The DON indicated the incident was reported due to the red marks on Resident 6's face. She indicated the other altercation occurred on January 23, 2023. The DON indicated this incident was not reported due to Resident 2 not having any red marks or injuries. The RN indicated Resident 2 was sitting in her wheelchair next to the South Hall spa door, drinking her coffee, when Resident 5 was observed wheeling herself over to Resident 2. Resident 5 used her right hand to slap Resident 2 across her left cheek. A small red spot was observed to the upper left cheek bone on Resident 2. No bruising was observed. The residents were immediately separated, and Resident 2 was moved to safety. When the resident was wandering, she was looking for a bed to lay in. She would forget where her room was. She had a wanderguard on her right wrist and was compliant with wearing it. During an interview on 3/22/24 at 10:58 a.m., the Social Service Director indicated the resident was not interviewable, but could answer some questions. She couldn't remember her family member's name. She had talked with the family member to follow up after the altercation, but he only wanted melatonin used for the resident. He only wanted herbal or homeopathic alternatives. He refused to let her receive Remeron for an appetite stimulant, because he read about the side effects. The resident was seen by the psychiatrist, and they would evaluate her. If she was up and about, they offered her food. She liked music, so they would play it for her. It wasn't every day that they did that. The other residents were protected from her by the staff watching her. They tried to get her involved in activities. The family would be called if behaviors occurred. She didn't know if anyone had talked to the resident's family about how that didn't help other residents if an occurrence had already occurred, such as her slapping another resident. The Behavior Management policy, revised August 2022, included, but was not limited to, . Interventions provided are both individualized and non-pharmacological and part of a supportive physical and psychosocial environment that is directed toward preventing, relieving and/or accommodating the resident's behavioral expressions . 1. Care plans should be initiated for any behavioral expression that is problematic or distressing to the resident, other resident or caregivers. Care plan interventions should include individualized and nonpharmacological interventions which address both proactive and responsive interventions . 3.1-37(a)

Based on record review and interview, the facility failed to ensure Social Services followed up on residents that exhibited mood and behavior issues, and failure to consult with family members related to behaviors for 4 of 6 residents reviewed for Social Services. (Residents 8, 33, and 54) Findings include, 1. The record for Resident 8 was reviewed on 3/18/24 at 2:10 p.m. The diagnoses included, but were not limited to, vascular dementia with mood disturbance, disorder of adult personality and behavior, and seizures. The Quarterly MDS (Minimal Data Set) assessment, dated 2/13/24, indicated the resident was moderately cognitively impaired. The nurse's note, dated 6/20/23 at 9:13 a.m., indicated the resident told the nurse of his wife's passing. The resident was encouraged to talk about his concerns or feelings. The nurse was able to sit and talk with the resident. The nurse's note, dated 6/20/23 at 11:42 p.m., indicated the resident came back at the beginning of the shift. The resident was tearful at times due to his wife's passing. The resident wanted to go to bed early. The nurse's note, dated 6/26/23 at 9:00 a.m., indicated the resident was sitting at the nurse's station. He was quiet and did not speak very much. The resident was encouraged to express his thoughts and feelings. He thanked the nurse and stated he was just thinking. The nurse's note, dated 7/2/23 at 10:21 a.m., indicated the resident appeared to be more withdrawn. The nurse's note, dated 7/5/23 at 9:10 a.m., indicated the resident continued to be withdrawn. He was not as engaged as prior to his wife's passing. The nurse's note, dated 7/6/23 at 12:56 p.m., indicated the resident continued to be withdrawn from activities. He would eat his meals and then requested to lay down. The resident would get up when his family members were present, but he was not as social as before. The nurse's note, dated 7/7/23 at 10:58 a.m., indicated the resident continued to be withdrawn from activities and other residents. His appetite had been fair at best. The nurse's note, dated 7/9/23 at 9:23 p.m., indicated the resident was observed with increased lethargy, and requested to go to bed almost immediately after dinner. The nurse's note, dated 7/10/23 at 5:30 p.m., indicated the resident continued to be withdrawn from activities. The nurse's note, dated 8/31/23 at 6:44 p.m., indicated the resident continued to be withdrawn. He didn't want to get up for meals and refused breakfast and lunch today. He just wanted to stay in his room and lay down. The resident would sleep throughout the day. He did eat one half of a cheeseburger after lunch when offered. He was encouraged to get up and go to activities and meals, but the resident declined. The nurse's note, dated 9/8/23 at 1:45 p.m., indicated the resident continued to show increased signs and symptoms of depression and abnormal behaviors throughout the day. He refused to get out of bed for breakfast and to eat. His appetite was poor. The nurse's note, dated 9/11/23 at 4:42 p.m., indicated the resident continued to be withdrawn and uninvolved in activities, meals or socialization. The resident preferred to stay in bed most of the time when not eating. The Psychiatric notes, dated 8/24/23, indicated the resident had increased depressive symptoms and mood disturbance which may be a symptom of the dementia progression. Orders were placed to start Zoloft 25 mg (milligrams) daily. Psychiatric services would follow up and titrate as needed to address the behavioral and psychological symptoms associated with dementia. The physician orders were placed to start galantamine 4 mg twice daily. The facility staff were to monitor the residents verbal and non-verbal cues, communicate primarily by entering patient's reality, re-orient and re-direct as appropriate, and report acute behavioral disturbances to the provider. The clinical record lacked documentation indicating the facility's Social Services's reassessed the resident for signs and symptoms of/or increased depression or follow up with the resident. 15251 2. The record for Resident 33 was reviewed on 3/22/24 at 9:10 a.m. The diagnoses included, but were not limited to, unspecified dementia, unspecified severity, with other behavioral disturbance, unspecified depression and recurrent major depressive disorder. The Significant Change MDS assessment, dated 2/20/24, indicated the resident was alert and oriented, had occasional little interest in doing things with trouble concentrating, frequently felt down and depressed, had trouble with sleep and felt tired, and a poor appetite with weight loss. The care plan, dated 10/28/19 and last reviewed on 3/2/24, indicated the resident exhibited sexual inappropriate comments towards other female staff. The interventions included, but were not limited to, staff will leave conversation when resident was being inappropriate, education provided and will have psychiatric follow up with resident, educate resident on the inappropriateness of behavior and offer distraction. The care plan, dated 12/1/21 and last reviewed on 3/2/24, indicated the resident had a history of using foul and vulgar language. The interventions included, but were not limited to, educate resident on other people's preference on not hearing foul language and encourage resident to not use foul language. The care plan, dated 1/11/22 and last reviewed on 3/2/24, indicated the resident had a history of refusing care. The nurse's note, dated 9/2/23 at 6:10 p.m., indicated that due to the resident being in bed all shift, his clothing was visibly soiled and smelled of urine. When asked by nursing if they may assist him in changing, he told them it was none of their concern and not to worry about his clothes. Education was provided by nursing. The nurse's note, dated 9/18/23 at 11:14 a.m., indicated that while a CNA was assisting another resident in the bathroom, Resident 33 continued to verbalize inappropriate comments about that resident's genitalia and the CNA. He proceeded to laugh when the CNA told him his comments were inappropriate. The nurse's note, dated 9/25/23 at 6:12 p.m., indicated the resident was making obscene gestures at the QMA and told her he was going to grab her a*s. He was also sticking his tongue out and waved it at her. Although the resident was told that his talk and gestures were inappropriate, he did not stop them. The Behavior Communication note, dated 10/28/23 at 11:03 p.m., indicated that at 10:15 p.m. when the resident asked the QMA for some cookies, she informed him there were only graham crackers. The resident then replied he wanted to get his cookies off with her. The QMA informed him this remark was inappropriate. The Behavior Communication note, dated 10/29/23 at 1:15 a.m., indicated that on 10/28/23 at 10:20 p.m., the resident had confrontational behavior with staff when he was given directions. The interventions by nursing were ineffective and his behavior worsened. The nurse's note, dated 12/4/23 at 7:10 a.m., indicated the night shift QMA reported that when she went into resident's room to give his medication to him, he pointed at his penis and asked her if she wanted to play with it? The QMA informed the resident that was inappropriate to talk to staff that way and he knew it. The nurse's note, dated 12/9/23 at 5:03 a.m., indicated the resident was observed to have refused dinner the past few nights, had not eaten his own personal food and indicated he wasn't hungry. The resident had also refused insulin each night. He was observed with increased incontinence during the night and had refused to get up and allow staff to assist him with cleaning up. The resident had not been interacting with staff and other residents in normal ways of talking and joking mannerisms. He was also observed to remain in bed for primarily throughout the shift. The NP (Nurse Practitioner) was updated on his status. The nurse's note, dated 1/10/24 at 11:50 p.m., indicated the resident refused to let staff make his bed this night. He indicated that his bed was airing out, but then he would not let staff make the bed when asked several times. The resident then put himself to bed without sheets on it. The staff attempted to get the resident up, but the resident refused. The resident continued to be incontinent at night as well and refused most times to be checked and changed when asked. The resident had become increasingly more incontinent and required more of staff assistance throughout the day and throughout the night. The resident continued to deny the need for staff assistance. The nurse's note, dated 1/11/24 at 10:46 p.m., indicated the resident had refused medications this night. He did not eat dinner and his blood sugar was low prior to dinner. The resident refused to eat a snack or let this nurse check his blood sugar and insulin was withheld. The nurse's note, dated 1/15/24 at 1:06 p.m., indicated the resident continued to refuse to wear his tubi grip (to help with leg swelling) so far on this day. Although he was educated, he continued to not wear them. The resident was in bed at this time and refused to get up for breakfast or lunch. The nurse's note, dated 1/15/24 at 8:59 p.m., indicated the resident was observed to be laying in bed which was saturated in urine. The resident was repeatedly asked by multiple different staff members to allow them to assist him with incontinent care, but he would only yell at staff to leave him alone and to get out of the room. The nurse's note, dated 1/20/24 at 3:47 p.m., indicated the resident refused to get out bed to take his medications this shift. Despite education being given, it had no effect. The nurse had re-attempted multiple times this shift, but he was currently still laying in his soiled bed. Staff had attempted to change the linens and assist the resident out of bed to change him into clean clothes, but it had no effect. The nurse's note, dated 2/4/24 at 12:21 p.m., indicated the resident had continued to refuse neurological checks after he fell out of bed earlier. The resident was also laying in bed covered in urine and refused to allow staff to assist. Multiple staff members had attempted to help the resident with no effect. The nurse's note, dated 2/15/24 at 1:07 p.m., indicated the resident refused to get out of his urine soaked bed. Multiple staff members had tried to get him out of bed with no success and were unable to change the resident's wet bed. The nurse's note, dated 2/28/24 at 2:09 p.m., indicated the resident had been non-compliant with the staff in allowing them to change his bedding. The nurse's note, dated 2/22/24 at 12:34 p.m., indicated the resident spent most of the morning laying in his wet soiled bed and refused to get up or be changed. Multiple staff attempted to get the resident out of his soiled bed but were unsuccessful. When staff told the resident that he was making the hallway stink, he told them to go outside or spray something. The resident would laugh at the staff when they encouraged him to get cleaned up. The nurse's note, dated 3/6/24 at 1:13 p.m., indicated the resident continued to remain in bed at this time with several attempts from staff to get him up and get dry clothes on to change his bedding. The nurse's note, dated 3/12/24 at 10:47 a.m., indicated the resident was in bed at that time and refused to get up and change into clean clothes. He stated he doesn't have to get up if he didn't want to. The nurse's note, dated 3/16/24 at 11:18 a.m., indicated the resident remained in bed with a soiled brief and clothes. The nurse had encouraged the resident multiple times to assist him to get out of bed and change with no effect. Documentation was lacking of the Social Service Director having visited the resident after the behaviors and refusals of care. There was only documentation by the IDT (Interdisciplinary Team) having met to discuss the resident. 3. The record for Resident 54 was reviewed on 3/20/24 at 8:37 a.m. The diagnoses included, but were not limited to, anxiety disorder, depression, chronic post-traumatic stress disorder (PTSD) and bipolar disorder, current episode depressed, mild. The Quarterly MDS assessment, dated 3/4/24, indicated the resident was alert and oriented, had frequent little interest in doing things, felt down and depressed, had trouble with sleep and appetite issues. The care plan, dated 12/4/23 and last reviewed on 3/15/24, indicated the resident had manic episodes related to her bipolar disorder. The goal was to have no manic episodes. The interventions included, but were not limited to, medication adjustments by psychiatric services, one on one conversations with resident to allow her to voice her feelings, and to redirect her to activities. The care plan, dated 3/8/24 and last reviewed on 3/15/24, indicated the resident had experienced trauma and experienced PTSD due to a family member being abusive. The resident experienced the following expressions in response to trauma: (flashbacks, nightmares and severe anxiety, uncontrollable thoughts about the event.) No triggers were identified by the resident. The resident was also at risk for experiencing re-traumatization, feeling unsafe/untrusting, and or distressed. The goal was to eliminate or mitigate (reduce) triggers that might cause re-traumatization. The approaches included, but were not limited to, allow the resident to talk about her past if she chose to and give comfort and reassurance, Behavioral Health Services, ensure the resident had a sense of environmental and physical safety, establish and encourage open communication between resident and staff, new or worsening behaviors will be assessed to identify additional potential triggers and the need for additional support and behavioral health services, and resident specific approaches. The nurse note, dated 12/3/23 at 6:53 p.m., indicated the resident continued with manic and mania rambling talk without stopping throughout the day. She was also observed to have insomnia for the last couple days. The resident indicated they had tried to put her on seroquel at one point and time for her periods of highs and lows but she didn't want to do that. The resident was observed to be pacing at times. The nurse's note, dated 12/4/23 at 5:48 a.m., indicated the resident was again up throughout the night sitting up at the nurse's station talking with staff for the entirety of the shift non-stop. The IDT Behavior Review note, dated 12/4/23 at 11:36 a.m., indicated the resident continued with manic and mania rambling, talking without stopping throughout the day and had insomnia the last couple days. The resident was also pacing at times. The immediate intervention was to allow the resident to voice her feelings. The root cause of the behavioral expression was thought to be isolation and acute illness due to COVID-19. The nurse's note, dated 12/5/23 at 1:45 p.m., indicated the resident had diagnoses of bipolar, anxiety, and PTSD, and was expressing signs and symptoms of mania. She did sleep the prior night, but was up early, dressed, and ready for the day. The resident was very talkative, pacing back and forth in the hallway and going to each person in the hallway and talking to them. Although the resident was pleasant, her behavior was abnormal. She presented with shaking hands and voiced to this nurse that she knew she was up and down right now. The nurse's note, dated 12/6/23 at 3:28 p.m., indicated the resident has had mood swings throughout the shift. She indicated that the CNAs and residents were talking bad behind her back and that the CNAs were texting other residents about how she used to do drugs. The resident got up out of bed at 2:00 a.m. and stayed next to nurse station until 3:30 a.m. The IDT Behavior Review note, dated 12/7/23 at 10:27 a.m., indicated the resident was talking a lot and pacing. The immediate intervention was for staff to listen to the resident. The root cause of the behavioral expression was determined to be that the resident was in a manic phase of disorder as the resident indicated she did this from time to time. The nurse's note, dated 12/28/23 at 5:58 p.m., indicated the resident's mania was somewhat better this day, but was still rambling and had thoughts of people talking about her. The nurse's note, dated 2/24/24 at 10:19 p.m., indicated the resident was observed to be up and ambulating throughout north hall common area this evening. She indicated she was upset and unhappy with her roommate and stated F*** her, I don't care what she says. Staff were uncertain as to why the resident was upset and what she was referring to. The resident was unable to explain why she was upset. The IDT Behavior Review note, dated 2/27/24 at 11:37 a.m., indicated the resident had increased manic mood and behavior. The immediate intervention was to allow the resident to voice feelings and validate. The root cause of the behavioral expression was thought to be a manic episode. The nurse's note, dated 3/1/24 at 10:06 p.m., indicated that when the CNA entered the room to take in new water cups to the resident and her roommate, the resident stated Don't just stand there, if you have something to say, just come on over here and say it. When the CNA asked the resident what she was talking about, the resident indicated she thought the CNA was her roommate. The roommate was observed in bed with her eyes closed. Documentation was lacking of the Social Worker having visited the resident after the behaviors. There was only documentation by the IDT (Interdisciplinary Team) having met to discuss the resident. During an interview with the Social Services Director on 3/22/24 at 10:20 a.m., she indicated that she was not the only one who should have been documenting on the residents as the other disciplines were just as responsible. She indicated she talked to multiple residents everyday and always followed up with them after the IDT meetings on behaviors. She also indicated she did not always chart the visit. During this meeting with the Social Services Director, the DON (Director of Nursing) also indicated only new behaviors were usually documented on. If the behavior was not new, it probably would not be charted on. The Social Services Director Job Description included, but was not limited to, SUMMARY OF POSITION FUNCTIONS: The Social Services Director provides medically-related social services to attain or maintain the highest practicable, physical, mental, and psychosocial well-being of each resident; and shares a responsibility toward creating and sustaining an environment that humanizes and individualizes each resident's living area. ESSENTIAL POSITION FUNCTIONS: Assesses each resident's psychosocial needs and develops a plan for providing care. Reviews resident's needs and care plan with progress notes indicating implementation of methods to respond to identified needs .Mediates and must be able to deal tactfully and professionally with issues that arise among residents and their families and/or assigned ombudsman .Establishes a positive and socially therapeutic environment through staff training and input on policies and procedures. Collaborates with other departments, physicians, consultants, community agencies, and institutions to improve quality of services and to resolve identified problems . 3.1-34(a)

Based on observation, record review, and interview, the facility failed to ensure accurate documentation of controlled substances on the controlled drug record sheet for 2 of 27 residents reviewed for narcotic storage. (Residents 2 and 28) Findings include: 1. During an observation of the South Short Hall Medication Cart on 3/18/24 at 10:17 a.m., with QMA (Qualified Medication Aide) 3 Resident 2's acetaminophen-codeine number (#)4 medication card contained only 20 tablets of the medication. Resident 2's clonazepam 0.5 mg (milligrams) medication card contained only 22 tablets of the medication. The controlled drug storage record sheet indicated there should be 21 doses of the acetaminophen-codeine #4 and 23 tablets of the clonazepam 0.5 mg remaining. The last doses signed out on the controlled drug storage record sheet were on 3/17/24 at 5:00 p.m. The record for Resident 2 was reviewed on 3/18/24 at 10:20 a.m. The diagnoses included, but were not limited to, generalized anxiety disorder and muscle spasm. The physician's order, dated 11/19/20, indicated the resident received acetaminophen-codeine #4 three times daily for chronic pain. During an interview on 3/18/24 at 10:20 a.m., QMA 3 indicated she had given the medications to the resident that morning and had not signed them out. She did not have a reason why she had not signed it out. She tried to make sure she signed them out when she gave them. She had administered the medications to the resident on 3/18/24 at approximately 8:00 a.m. 2. During an observation of medication administration for Resident 28 on 3/18/24 at 10:32 a.m., QMA 4 indicated she was preparing medications for Resident 28. She obtained one tablet of Ativan 0.5 mg from the narcotic drawer and placed it into a medication cup. She did not have the Resident's MAR (Medication Administration Record) pulled up on her computer. She did not refer to the MAR during any point of the administration observation. She indicated the Resident's MAR would not show any medications as being due to administer. She crushed the medication and placed it into a medication cup before taking it to the resident's room. QMA 4 administered the medication to the resident on 3/18/24 at 10:46 a.m. The record for Resident 28 was reviewed on 3/18/24 at 1:30 p.m. The diagnosis included, but was not limited to, anxiety disorder. The physician's order, dated 3/9/23, indicated the resident received Ativan 0.5 mg three times daily for anxiety at 8:00 a.m., 2:00 p.m., and 8:00 p.m. The controlled substances record sheet indicated the QMA documented the medication as being administered on 3/18/24 at 8:00 a.m. During an interview on 3/18/24 at 1:59 p.m., QMA 4 indicated the resident's medications had not been showing up on the MAR because she had clicked them off earlier as administered. She had pulled the medications that morning and the resident would not wake up, so she had to dispose of them. She had already documented them as administered earlier. She needed to go back in and amend them. She had tried to wake her up and she was not having it. The resident's Ativan was supposed to be given at 8:00 a.m. She was about to get another Ativan at 2:00 p.m. During an interview on 3/20/24 at 8:16 a.m., the DON (Director of Nursing) indicated with specific timed medications, they had an hour before and an hour after the timed dose to administer them. If it could not be administered in that time frame, they would try again later. If they didn't wake up or they would refuse, staff would attempt again later. With the narcotic, they would probably waste it then. She would expect staff to document medication as administered after the medication was administered. She would expect the nurse to document the time of the narcotic after the medication was administered. She would expect them to document the actual time of the medication administration. The most current Controlled Substances policy, included, but was not limited to, . The staff at the Community must also maintain strict records of the controlled substances stored in the Community as well as the dose given to the resident . When a controlled substance is administered to a resident, it must be recorded on the resident's Medication Sheet as well as a separate Controlled Substance/Schedule II Narcotic Sheet that is created for each prescription . 3.1-25(b)(3)

Based on observation, record review, and interview, the facility failed to ensure medication errors less than 5% for 3 of 30 medication observations of medication administration. (Resident 28) Findings include: During an observation of medication administration for Resident 28 on 3/18/24 at 10:32 a.m., QMA (Qualified Medication Aide) 4 indicated she was preparing medications for Resident 28. She obtained one tablet of Ativan 0.5 mg (milligram) from the narcotic drawer and placed it into a medication cup. She then obtained two tablets of potassium 10 meq (milliequivalent) and 1 tablet of levothyroxine 150 mcg (micrograms) from the medication cart and dispensed them into the same cup. She did not have the Resident's MAR (Medication Administration Record) pulled up on her computer. She then pulled up a copy of the resident's physicians order, and prepared the rest of the resident's morning medications, which included coreg 6.25 mg, clopidogrel 75 mg, gingko biloba, hydrochlorothiazide (HCTZ) 12.5 mg, imdur 20 mg three one half tablets to equal 30 mg, lisinopril 10 mg, Namenda 10 mg, famotidine 40 mg tablet, sertraline 100 mg, and sertraline 25 mg. She did not refer to the MAR for any of the administration observation. She indicated the Resident's MAR would not show any medications as being due to administer. She crushed the medications and placed them in individual medication cups before taking them to the resident's room. QMA 4 administered the medications to the resident on 3/18/24 at 10:46 a.m. The record for Resident 28 was reviewed on 3/18/24 at 1:30 p.m. The diagnoses included, but were not limited to, dementia, hypokalemia, depressive episodes, osteoarthritis, muscle weakness,, GERD (gastroesophageal reflux disease), hypothyroidism, HTN (hypertension), insomnia, major depressive disorder, hyperlipidemia, heart disease, and dysphagia. The physician's orders indicated the following: -Ativan 0.5 mg give 0.25 mg three times daily for anxiety, which started on 3/9/23. The medication was scheduled in the mornings for 8:00 a.m., with the next dose due at 2:00 p.m. - Levothyroxine 175 mcg once daily at 7:00 a.m., which started on 3/12/24. - Famotidine 40 mg twice daily, which started on 11/12/24. The morning dose was scheduled to be given at 7:00 a.m. During an interview on 3/18/24 at 1:59 p.m., QMA 4 indicated the resident's medications had not been showing up on the MAR because she had clicked them off earlier as administered. She had pulled the medications that morning and the resident would not wake up, so she had to dispose of them. She had already documented them as administered earlier. She needed to go back in and amend them. She had tried to wake her up and she was not having it. The resident's Synthroid and famotidine were due at 7:00 a.m., and the Ativan was supposed to be given at 8:00 a.m. She was about to get another Ativan at 2:00 p.m. During an interview on 3/20/24 at 8:16 a.m., the DON (Director of Nursing) indicated with specific timed medications, they had an hour before and an hour after the timed dose to administer them. If it could not be administered in that time frame, they would try again later. If they didn't wake up or they would refuse, staff would attempt again later. With the narcotic, they would probably waste it then. She would expect staff to document medication as administered after the medication was administered. She would expect the nurse to document the time of the narcotic after the medication was administered. She would expect them to document the actual time of the medication administration. During an interview on 3/20/24 at 10:50 a.m., the RDCO (Regional Director of Clinical Operations) indicated they could not obtain a report to show the exact time of administration documentation on the MAR. The most current Medication Administration Procedure included, but was not limited to, . Medications administered within 60 minutes before and/or after time ordered . 12. Refusal of medication document as appropriate . 19. Medication administration will be recorded on the MAR/EMAR or TAR after given . 33. Administration and inventory of controlled substances were documented according to facility policy . 3.1-48(c)(1)

Based on observation, record review, and interview, the facility failed to ensure appropriate labeling and storage of medications for 3 of 27 residents reviewed for Medication Storage. (Residents 33, 61, and 273) Findings include: 1. During an observation of the South Short Hall Medication Cart on [DATE] at 10:17 a.m., with QMA (Qualified Medication Aide) 3, there was a bottle of lispro, dated [DATE], with Resident 33's first and last name written on it in black marker. The bottle was open and approximately three-quarters full. There was also a Fiasp insulin pen for Resident 33, dated [DATE]. The record for Resident 33 was reviewed on [DATE] at 1:00 p.m. The diagnosis included, but was not limited to, type 2 diabetes mellitus. The physician's order, dated [DATE], indicated the resident received Fiasp FlexTouch U-100 insulin pen per sliding scale four times daily. The order was discontinued on [DATE]. The physician's order, dated [DATE], indicated the resident received insulin lispro U-100 per sliding scale four times daily. The order was discontinued on [DATE]. During an observation on [DATE] at 11:10 a.m. of the South Short Hall with QMA 4, Resident 33's Fiasp and insulin Lispro vial remained in the top drawer of the medication cart. During an interview on [DATE] at 11:11 a.m., QMA 4 indicated Resident 33 did not have current orders for either Fiasp or insulin lispro. The insulins should have been removed when the orders were discontinued. The insulins were only good for 28 days, and they were beyond that. 2. During an observation of the South Short Hall medication cart on [DATE] at 10:17 a.m., the following concerns were observed: a. Resident 61's Breyna (budesonide-formoterol) ,d+[DATE].5 mcg/act (micrograms per actuation) inhaler and his albuterol sulfate 90 mcg/act inhalers were both in the bottom right hand drawer of the medication cart. They were both stored lying on their side. The record for Resident 61 was reviewed on [DATE] at 1:00 p.m. The diagnoses included, but were not limited to, COPD (chronic obstructive pulmonary disease), allergic rhinitis, and asthma. The physician's order, dated [DATE], indicated the resident received budesonide-formoterol ,d+[DATE].5, two puffs twice daily. The Breyna Package Insert Storage instructions indicated to store the medication with the mouthpiece down. b. Resident 273's albuterol 90 mcg/act inhaler was lying on its side in the bottom right hand drawer. The medication was opened with 240 doses remaining. The instructions on the side of the package indicated to store the inhaler with the mouthpiece down. The record for Resident 273 was reviewed on [DATE] at 1:05 p.m. The diagnosis included, but was not limited to, single pulmonary nodule. The physician's order, dated [DATE], indicated the resident received albuterol sulfate 90 mcg/act, 2 puffs four times daily as needed. During an interview on [DATE] at 8:16 a.m., the DON (Director of Nursing) indicated the insulins were good for 30 days. She was aware of the policy for some inhalers to be stored upright but wasn't sure which ones. The most current Medication Storage Guidelines included, but were not limited to, . Breyna Inhalation Aerosol (budesonide/formoterol) . store . with the mouthpiece down . Ventolin HFA (High Flow Actuation) Inhalation Aerosol . store the inhaler with the mouthpiece down . Storage Recommendations for Injectable Diabetes Medications . Fiasp . Opened . 28 days . Insulin Lispro . Opened . 28 days . Properly handle and dispose of any expired or unused product in accordance with facility policy or local, state, and federal regulations . 3XXX,d+[DATE](j)

Based on record review and interview, the facility failed to promptly obtain dental services for 1 of 2 residents reviewed for dental services. (Resident 23) Findings include, The record for Resident 23 was reviewed on 3/19/24 at 10:34 a.m. The diagnoses included, but were not limited to, functional dyspepsia, constipation, muscle weakness, chronic vascular disorders of the intestine, nausea, and vomiting. The Admission MDS (Minimal Data Set) assessment, dated 2/6/24, indicated the resident was moderately cognitively impaired. The care plan, dated 3/4/24, indicated the resident had some of his natural teeth lost. He did not have dentures or a partial plate. The interventions included, but were not limited to, obtaining dental consult as indicated, and observing chewing or eating difficulties at meals. The nurse's note, dated 7/29/23 at 9:50 a.m., indicated the resident continued to complain of oral pain due to the loss of a filling. Slight redness was observed on the gum. Resident 23 stated, it makes it difficult to chew Staff would continue to monitor the resident. The nurse's note, dated 7/30/23 at 9:37 a.m., indicated the nurse examined the area where the tooth had appeared to have broken off. The sharp part of the tooth was exposed above the gum line. Resident 23 stated, that it's getting tender and hard to chew. The nurse would pass it on to set up a dental appointment. The nurse's note, dated 8/15/23 at 9:08 a.m., indicated the resident complained of discomfort from a broken tooth. No redness or swelling was observed. No signs and symptoms of distress were observed. Nursing would continue to monitor the resident. The nurse's note, dated 8/16/23 at 8:48 a.m., indicated the nurse asked the resident about a dental appointment. The resident stated, he didn't want one at this time. Staff would continue to monitor the resident. The NP (Nurse Practitioner) note, dated 8/25/23 at 5:50 p.m., indicated the resident had some broken teeth which caused him some soreness. Orajel was ordered for dental pain. The nurse's note, dated 8/27/23 at 9:35 a.m., indicated the resident continued to complain of tooth pain when eating. No redness or swelling of the gum was observed but could see where the tooth was broken off. The nurse's note, dated 8/28/23 at 3:52 p.m., indicated the resident denied any tooth pain or discomfort this day. This nurse reported to management that the resident needed a dental appointment to look at the resident's tooth. The nurse's note, dated 8/30/23 at 9:28 a.m., indicated the resident stated his tooth was kind of sensitive when he bit down on things. No redness was observed to the gums, but staff would continue to monitor the resident. The clinical record lacked documentation indicating a dental appointment was made or the family was contacted about making a dental appointment for the resident. During an interview on 3/20/24 at 11:00 a.m., the Social Service Director (SSD) indicated the resident declined the in-house dentist. He had an outside dentist to go to. Social Services or the scheduler could make the appointment for the resident. She would also let the family know if they wanted to make the appointment and take the resident. She indicated there was no information documented that the resident had an appointment to see the dentist, or the family was contacted. During an interview on 3/21/24 at 9:00 a.m., RN 8 indicated when a resident needed to see the dentist, he would inform the scheduler, or Social Services and they would make a dental appointment for the resident or call the family to see if they wanted to make the appointment. The facility's current policy titled Dental Services/Missing Dentures, included, but was not to limited to, The facility obtains needed dental services, including routine and emergency dental services; assist in providing these services and makes prompt referrals for dental services as needed . 3.1-24(a) 3.1-24(a)(1)(2)

Based on interview and record review, the facility failed to ensure an accurate account of controlled medications dispensing and administration records were maintained. Medication administration records were not completed and/or did not match controlled substance records and controlled substance records were dated incorrectly. (Resident B, Resident C, Resident D, Resident F, Resident G, Resident H) Findings include: 1. During a review of facility reported incidents on 1/31/2 at 12:50 P.M., an incident, dated 10/9/23, included that during an audit, a concern for inaccurate documentation of PRN (as needed) narcotic administration. Medication administration date was noted to be prior to received date. During record review on 1/31/24 at 11:40 A.M., Resident B's physician orders included, but were not limited to hydrocodone-acetaminophen 5-325 mg (milligram) as needed (started on admitted [DATE]). Resident B's medication administration record indicated the first date the resident received a PRN hydrocodone-acetaminophen 5-325 mg medication was on 10/7/23. A review of Resident B's controlled substance count sheet for PRN hydrocodone-acetaminophen 5-325 mg indicated that staff was signing the medication out daily since Resident B's admitted [DATE]. During an interview on 1/31/24 at 1:15 P.M., the DON (Director of Nursing) indicated that during an audit of PRN narcotic medications, it was noticed that Resident B's PRN hydrocodone-acetaminophen 5-325 mg medication was signed out by staff on 10/4/23 prior to the medication delivery from pharmacy on 10/5/23. A shipment summary for Resident B's PRN hydrocodone-acetaminophen 5-325 mg medication included a received date of 10/5/23 at 7:32 A.M. 2. During a review of Resident C's record on 1/31/24 at 2:00 P.M., Resident C's physician orders included but were not limited to hydrocodone-acetaminophen 7.5-325 mg every 4 hours as needed (started 5/23/23). Resident C's controlled substance count sheet for PRN hydrocodone-acetaminophen 7.5-325 mg indicated that staff signed out the medication on 9/13/23. Resident C's MAR for 9/13/23 included no documentation of the resident's PRN hydrocodone-acetaminophen 7.5-325 mg medication being administered. 3. During a review of Resident D's record on 1/31/24 at 1:30 P.M., Resident D's physician orders included but were not limited to hydrocodone-acetaminophen 5-325 mg once a day as needed (started 12/19/22). Resident D's controlled substance count sheet for PRN hydrocodone-acetaminophen 5-325 mg indicated that staff signed out the medication on 9/10/23, 9/11/23, 9/13/23, and 9/14/23. Resident D's MAR for 9/2023 included no documentation of the resident's PRN hydrocodone-acetaminophen 5-325 mg medication being administered on 9/10/23, 9/11/23, and 9/14/23. 4. During a review of Resident F's record on 1/31/24 at 1:15 P.M., Resident F's physician orders included but were not limited to hydrocodone-acetaminophen 5-325 mg at bedtime (started 4/30/23). Resident F's controlled substance count sheet for hydrocodone-acetaminophen 5-325 mg indicated that LPN 9 signed the medication out on 9/14/23 with a hand-written note that Resident F had refused to take the medication due to the medication being crushed in error. Resident F's MAR for 9/14/23 included documentation from LPN 9 that indicated hydrocodone-acetaminophen 5-325 mg was administered. 5. During a review of Resident G's record on 1/31/24 at 2:45 P.M., Resident G's physician orders included but were not limited to hydrocodone-acetaminophen 5-325 mg every 4 hours as needed (started 8/24/23). Resident G's controlled substance count sheet for PRN hydrocodone-acetaminophen 5-325 mg indicated that staff signed out the medication four times on 9/9/23, four times on 9/10/23, and three times on 9/11/23. Resident G's MAR for 9/2023 included documentation of the resident's PRN hydrocodone-acetaminophen 5-325 mg medication being administered only twice on 9/9/23, three times on 9/10/23, and twice on 9/11/23. 6. During a review of Resident H's record on 1/31/24 at 3:00 P.M., Resident H's physician orders included but were not limited to hydrocodone-acetaminophen 10-325 mg every 6 hours as needed (started 8/15/23). Resident H's controlled substance count sheet for PRN hydrocodone-acetaminophen 10-325 mg indicated that staff signed out the medication twice on 9/9/23 and once on 9/10/23. Resident H's MAR for 9/2023 included documentation of the resident's PRN hydrocodone-acetaminophen 10-325 mg medication being administered three times on 9/9/23 and twice on 9/10/23. During an interview on 1/31/24 at 1:40 P.m., RN 7 indicated that when documenting a PRN narcotic medication, staff should first document any non-pharmaceutical interventions that were tried prior to administering the medication. When documenting any narcotic medication, the nurse administering the medication should sign and date the controlled substance record and count off the medication, and the nurse should document in the MAR that the narcotic medication was administered. On 1/31/24 at 3:55 P.M., the DON supplied a facility policy titled, PRN Medications, dated 11/2015. The policy included, .When administering a PRN medication, record the following information . Date medication was given . Time medication was given . Name of medication given . Doses given . Reason the medication was given. This citation relates to complaint IN00419218. 3.1-25(b)(3)

Based on interview and record review, the facility failed to ensure residents were free from verbal abuse for 1 of 1 allegations of abuse. A staff member cursed at a resident while the resident was exhibiting inappropriate behaviors. (Resident D) Finding includes: During a review of facility reported incidents on 1/31/2 at 12:45 P.M., an incident, dated 10/25/23, included that a staff member used inappropriate language while having a conversation with Resident D. During record review on 1/31/24 at 1:30 P.M., Resident D's diagnoses included but was not limited to dementia, recurrent depressive episodes, major depressive disorder, and altered mental status. Resident D's most recent Annual MDS (Minimum Data Set) Assessment, dated 11/2/23, included that the resident was cognitively intact. Resident D's care plan included but was not limited to resident exhibits bothersome behavior towards others. An approach included educate resident on the reason it is not appropriate to bother others (started 3/2/22). Resident exhibits sexual inappropriate comments toward female staff. An approach included, educate resident on the inappropriateness of behavior (started 5/24/21). During a review of the facility's investigation of the incident between Resident D and CNA 13 on 1/31/24 at 2:00 P.M., a written statement from CNA 13, dated and signed 10/25/23, included, I was sitting at desk finishing up charting (and) [Resident D] keep [sic] making kissing nosies [sic] (and) asking me to go to bed with him and that is when I said what I said. A written statement from LPN 4, dated and signed 10/25/23, included, I went to South to pass insulin (and) hang IV (intravenous) ABT (antibiotic). As I rounded the corner into the (nursing) station I heard CNA 13 state to [Resident D] 'F--- you [Resident D], F--- you.' Resident appeared unbothered as he continued making noises at staff . During an interview on 1/31/24 at 2:15 P.M., LPN 6 indicated that Resident D is aware of what he is saying during behaviors and that staff should provide education to the resident if he is being inappropriate. Staff should not engage in an inappropriate conversation. On 1/31/24 at 3:55 P.M., the DON supplied a facility policy titled, Abuse Prohibition, Reporting, and Investigating, dated 6/2023. The policy included, It is the policy of [company name] to provide each resident with an environment that is free from abuse . Definitions/Examples of abuse: .Verbal abuse - The use of oral, written, and/or gestured language that willfully includes disparaging and derogatory terms to residents . within their hearing distance . 3.1-27(b)

Based on record review and interview, the facility failed to ensure care plans were updated to reflect a resident's history of noncompliance for 1 of 20 residents reviewed for care plan revisions. (Resident 1) Findings include: The clinical record for Resident 1 was reviewed on 10/5/22 at 10:00 a.m. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The nurse's note, dated 9/10/22 at 12:53 a.m., indicated the resident was transferring himself without assistance and without calling for staff. He was refusing to wear his boot to his right lower extremity and was bearing full weight. The nurse's note, dated 9/10/22 at 11:15 a.m., indicated the resident continued to self transfer. The nurse's note, dated 9/11/22 at 9:59 a.m., indicated the resident remained noncompliant with the use of his walking boot and self transfers. The nurse's note, dated 9/12/22 at 12:57 p.m., indicated the resident remained noncompliant with transfers and not wearing his walking boot. He was also noncompliant with his isolation restriction. The nurse's note, dated 9/13/22 at 3:27 p.m., indicated the resident remained noncompliant with self transfers and his walking boot. The nurse's note, dated 9/14/22 at 9:02 p.m., indicated the resident was walking without his boot and stated he didn't want to wear it. The nurse's note, dated 9/14/22 at 9:03 p.m., indicated the resident continued to self transfer. The nurse's note, dated 9/24/22 at 1:44 p.m., indicated the nurse was making routine bed checks when the resident was observed sitting on the side of bed trying to ambulate. As the nurse entered, the resident dropped back onto the bed. The nurse requested assistance from 3 other staff members to assist the resident back into bed. The resident was educated on the use of his call light and fall prevention. The resident indicated he didn't care, and he'd do what he wanted. The nurse's note, dated 9/26/22 at 6:58 p.m., indicated the resident was walking without his walking boot and didn't want to wear it. The nurse's note, dated 9/28/22 9:28 a.m., indicated the resident refused his walking boot. The nurse's note, dated 9/30/22 at 12:58 p.m., indicated the resident was walking without his boot and didn't want to wear it. The nurse's note, dated 9/30/22 at 10:42 p.m., indicated the resident had been noncompliant with care. He was frequently removing his oxygen and bi-pap machine. He was refusing his walking boot and was transferring himself from bed to his wheelchair without assistance. The nurse's note, dated 10/1/22 at 10:17 p.m., indicated the resident continued to be noncompliant with his [CONDITION(S)] machine. The nurse's note, dated 10/2/22 at 10:17 p.m., indicated the resident continued to be noncompliant with his [CONDITION(S)] machine. The clinical record lacked documentation of any care plans related to the resident's noncompliance with transfers, wearing his walking boot, or use of his [CONDITION(S)] machine. During an interview on 10/6/22 at 2:46 p.m., the DON indicated they typically developed care plans for non-compliance. Resident 1 should definitely have had a care plan for non-compliance in place. 3.1-35 (a) 3.1-35 (e)

Based on record review and interview, the facility failed to notify a physician of a resident's refusal to be weighed and when a resident had a weight gain greater than 3 pounds in one day for 2 of 18 residents reviewed for weight related to hydration status. (Residents 20 and 1) Findings include: 1. The clinical record for Resident 20 was reviewed on 10/4/22 at 2:59 p.m. A Quarterly MDS (Minimum Data Set) assessment, dated 7/14/22, indicated the resident was cognitively intact. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An open-ended physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The September 2022 EMAR/ETAR (Electronic Medication Administration Record/Electronic Treatment Administration Record) indicated the resident refused or the the daily weight was not obtained on the following dates: - 9/1/22, refused to get up, - 9/3/22, refused to get up, - 9/5/22, refused, - 9/6/22, not obtained, - 9/7/22, refused, - 9/11/22, refused, - 9/14/22, not obtained, - 9/15/22, refused, - 9/16/22, refused, - 9/20/22, refused, - 9/21/22, refused to get out of bed, - 9/23/22, refused, - 9/24/22, refused, - 9/25/22, refused, - 9/29/22, not obtained, - 9/30/22, refused. The clinical record lacked documentation that the physician had been notified of the resident refusal of the daily weights. During an interview on 10/06/22 at 2:17 p.m., RN 4 indicated the resident could be non-compliant with some care. If the resident refused to take medications or treatments more than one time, she would ask for the reasoning as to why they were refusing. She would chart that the resident refused and if it continued then she would document the refusal in the EMAR and a progress note. The MD would be notified. If there was a blank in the EMAR then it meant the medication or treatment was not administered or obtained. 2. The clinical record for Resident 1 was reviewed on 10/5/22 at 10:00 a.m. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The September 2022 Electronic Medication Administration Record indicated the following: - On 9/11/22 the resident weighed 314.9. - On 9/12/22 the resident weighed 318.8 which was a gain of 4 lbs in one day. The physician was not notified. - On 9/25/22, 9/26/22, and 9/27/22, the resident's weight was not obtained due to the resident's condition. - On 9/28/22, the resident refused to be weighed. The Weight Summary Report, indicated a weight of 306 lbs was entered for the resident by the Dietary Manager on 9/26/22, but lacked documentation of any additional weights on 9/25/22, 9/27/22, or 9/28/22. The clinical record lacked documentation of what the resident's condition was that limited the ability to obtain his weight, or any notification to the physician of the weights not being obtained or the 4 lbs weight gain on 9/12/22. During an interview on 10/6/22 at 2:46 p.m., the DON indicated they notified the physician of any weight gain of 3 lbs in a day or 5 lbs in a week. Usually they would chart it on the EMAR. The weights taken on night shift would be called to the physician by the day shift staff. The resident was weighed with a mechanical lift. If he was refusing to be weighed, she would expect the physician to be notified. The record didn't specify when the resident's weight was not obtained, due to condition, what the condition was. If the resident was refusing she would expect them to document it and let the physician know. During an interview on 10/6/22 at 2:57 p.m., RN 10 indicated the resident was to be weighed daily, but had a right to refuse. There were a few days he did not want to get out of bed and he was weighed with a mechanical lift. He had just come back from the hospital, he was a little lethargic and he just wasn't awake or responsive enough to use a mechanical lift. During an interview on 10/6/22 at 3:04 p.m., RN 10 indicated she did not document where they notified the physician of the resident's weight not being obtained. She did not contact the physician and she did not have any documentation of it. The current facility policy titled, Resident Refusal of Mediations, Treatments, with a revised 1/2015 was provided by the DON (Director of Nursing) on 10/07/22 at 9:34 A.M. The policy indicated, .It is the policy of this facility to allow the resident the right to refuse services provided including medications, treatments, diagnostic tests or administration of ADL's .If the resident refuses administration of a medication or treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] .Documentation of the physician/family notification and any new orders/recommendations will be charted in the nursing progress notes .Repetitive non-compliance of physician orders: .A care plan conference will be scheduled with the resident and/or responsible party to discuss the continued non-compliance . 3.1-46

Based on observation, record review, and interview, the facility failed to follow physician's orders related to hold parameters for cardiac medications for 2 of 6 residents reviewed for unnecessary medications. (Residents 12 and 41) Findings include: 1. On 10/4/22 at 9:16 a.m., Resident 12 was observed sitting in her wheelchair near the nurses' station. The resident's legs were swollen and wrapped in bandages. The resident was pleasantly confused, but there were no signs or symptoms of discomfort or distress. The resident's clinical record was reviewed on 10/4/22 at 3:48 p.m. An Admission MDS (Minimum Data Set) assessment, dated 7/6/22, indicated the resident was severely cognitively impaired. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The physician's orders, with a start date of 8/19/22, indicated the resident received [MEDICATION(S)] (a cardiac medication). The staff were to administer 25 mg (milligrams) twice a day, once between 7:00 a.m. and 11:00 a.m., and once between 7:00 p.m. and 11:00 p.m. If the resident's heart rate was less than 60 bmp (beats per minute), the medication was to be held. The medication order was discontinued on 10/1/22. The resident's EMARs (Electronic Medication Administration Record) for August, September, and October 2022 were provided by the DON (Director of Nursing) on 10/6/22 at 4:04 p.m. The [MEDICATION(S)] medication was administered when the resident's heart rate was below 60 on the following dates and times: - On 8/30/22, the a.m. dose of the medication was administered when the resident's heart rate was 40, - On 8/31/22, both doses of the medication was administered when the resident's heart rate was 40 in the a.m. and 56 in the p.m., - On 9/1/22, the a.m. dose of the medication was administered when the resident's heart rate was 54, - On 9/3/22, the EMAR was blank (no hear rate documented) for the morning dose of medication, - On 9/13/22, the a.m. dose of the medication was administered when the resident's heart rate was 59, - On 9/14/22, both doses of the medication was administered when the resident's heart rate was 50 in the a.m. and 56 in the p.m., - On 9/15/22, the p.m. dose of the medication was administered when the resident's heart rate was 54, - On 9/27/22, the a.m. dose of the medication was administered when the resident's heart rate was 40, - On 9/29/22, the a.m. dose of the medication was administered when the resident's heart rate was 41, and - On 10/1/22, the a.m. dose of the medication was administered when the resident's heart rate was 50. The clinical record lacked documentation the medication was held on the above dates. During an interview on 10/6/22 at 11:08 a.m., LPN (Licensed Practical Nurse) 5 indicated if a resident's heart rate was out of range or below the ordered parameter, she would hold the medication and she would document that she held the medication in the resident's clinical record. 2. The clinical record for Resident 41 was reviewed on 10/5/22 at 12:11 p.m. A Quarterly MDS assessment, dated 8/8/22, indicated the resident was moderately cognitively impaired. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's order, dated 11/4/20 through 10/5/22, indicated the nurse was to administer [MEDICATION(S)] (a blood pressure medication) 25 mg, twice a day, and to hold the medication if the resident's systolic (top number/heart at work) blood pressure was less than 120. The August, September, and October 2022 EMAR, indicated the resident had received the medication when the systolic blood pressure was less than 120 on the following dates and times: - On 8/2/22 from 7:00 p.m. to 11:00 p.m., the resident's blood pressure was 107, - On 8/10/22 from 7:00 p.m. to 11:00 p.m., the resident's blood pressure was 96, - On 8/15/22 from 7:00 p.m. to 11:00 p.m., the resident's blood pressure was 118, - On 8/30/22 from 7:00 p.m. to 11:00 p.m., the resident's blood pressure was 95, - On 9/14/22 from 7:00 p.m. to 11:00 p.m., the resident's blood pressure was 107, - On 9/18/22 from 7:00 p.m. to 11:00 p.m., the resident's blood pressure was 106, - On 9/24/22 from 7:00 a.m. to 11:00 a.m., the resident's blood pressure was 117, - On 9/29/22 from 7:00 a.m. to 11:00 a.m., the resident's blood pressure was 109, - On 10/2/22 from 7:00 a.m. to 11:00 a.m., the resident's blood pressure was 115, - On 10/3/22 from 7:00 p.m. to 11:00 p.m., the resident's blood pressure was 113, and - On 10/4/22 from 7:00 p.m. to 11:00 p.m., the resident's blood pressure was 112. The clinical record lacked documentation the medication was held on the above dates. During an interview on 10/6/22 at 10:23 a.m., RN 3 indicated if a resident had vital hold parameters on a medication order, she would obtain the vitals before administration of the medication. The following would be documented in the EMAR: the resident's vitals, if the resident's medication was held, and the reason for holding the medication. During an interview on 10/7/22 at 10:32 a.m., the Executive Director indicated the facility did not have a specific policy related to following physician's orders, but it was standard nursing practice to follow physician's orders as they were written. 3.1-48(a)(6)

Based on observation, interview, and record review, the facility failed to implement infection control measures to prevent the spread of COVID-19 for 2 of 2 residents observed for care. Staff did not wear proper PPE while showering observed, did not properly don or doff PPE, and did not sanitize hands after touching used PPE. (Resident 7, Resident 11) Findings include: On 1/12/21 between 9:10 A.M., and 9:50 A.M., the following observations were made: 1. LPN 4 observed putting on an isolation gown in the North Hall hallway. The gown was placed over the head, with the inside of the gown rubbing LPN 4's goggles and N95 face mask, then rested on her scrub top. At that time, LPN 4 indicated the facility had plenty PPE, including disposable gowns. She indicated all of the disposable gowns were placed over the head to put on, then ripped from the back to remove. 2. CNA 9 was observed wearing a face shield and N95 face mask in the North Hall hallway. During an interview, she was observed to touch her face shield with bare hands, then place her hands in her pockets, take them out and rub them together, then touch the computer kiosk in the hall. She then was observed to open a drawer in the common area, coughed while touching her N95 face mask, then walked to the shower room. She opened the door with bare hands, and went inside. She did not wash or sanitize her hands during the observation. CNA 9 indicated at that time staff was inserviced on PPE (Personal Protective Equipment) use and Infection Control practice every couple of weeks and more frequently as needed. Short time later, CNA 9 was observed in the North Hall shower room assisting Resident 11 with a shower. CNA 9 was wearing an N95 face mask, face shield, and gloves during the shower. No gown was observed. The resident was not wearing a mask during close contact care. CNA 9 indicated at that time that Resident 11 was not on any type of precautions. She also indicated all residents, whether on precautions or not, use the same shower room, and staff only wore a gown while assisting with residents on precautions take a shower. 3. Staff 8 was observed leaving the North Hall shower room with Resident 7. Staff 8 wore an N95 face mask, goggles, a disposable gown, and gloves while wheeling the resident down to the end of the hall, and into her room. Resident 7 wore a surgical face mask. A sign was on Resident 7's door that indicated she was on droplet + isolation precautions. Staff 8 indicated at that time she did not normally give showers to residents, but was helping out. She indicated she wore the same disposable gown from the time she initially went into Resident 7's room for her shower until she brought her back from the shower, then took the gown off before exiting the resident's room. During an interview on 1/12/21 at 12:20 P.M., Staff 8 indicated training had been done related to sanitizing hands after touching worn PPE. On 1/12/21 at 12:29 P.M., an undated form titled Sequence for putting on personal protective equipment (PPE) was provided, and indicated after putting on a gown, to fasten in back of neck and waist. The form also indicated to keep hands away from the face, and limit surfaces touched. On 1/12/21 at 12:29 P.M., an undated form titled How to safely remove personal protective equipment (PPE) was provided, and indicated . Remove all PPE before exiting the patient room . On 1/12/21 at 12:29 P.M., a current Hand Hygiene Policy, revised 12/2020, was provided and indicated Healthcare personnel should use an alcohol-based hand rub or wash with soap and water for the following clinical indications: . Touching front of facemask, nose, mouth, hair, overbed table, call light . 3.1-18(b) 3.1-18(l)

Based on interview and record review, the facility failed to ensure residents were free from unnecessary medications. A laxative ordered once a day was given to a resident without constipation twice in one day, resulting in loose stools for 1 of 4 resident reviewed for unnecessary medications. (Resident 70) Finding includes: During an interview on 3/4/20 at 10:41 A.M., Resident 70 indicated he had had very loose stools for the last 5 days, had told staff, and staff did not seem concerned. On 3/9/20 at 9:30 A.M., Resident 70's clinical record was reviewed. The most recent MDS (Minimal Data Set) Assessment (admission), dated 2/18/20, indicated a moderate cognitive impairment, required extensive assistance of 2 for toileting, transfers, and bed mobility, was occasionally incontinent of bladder, frequently incontinent of bowel, and [DIAGNOSES REDACTED]. An ADL (activities of daily living) care plan, dated 2/11/20, indicated Resident 70 required assistance with ADLs including toileting. A cognitive loss care plan, dated 2/18/20, indicated Resident 70 had short and long term memory deficit with impaired decision making ability. Interventions included, but were not limited to, give resident cues and repeat directions as needed. Orders included, but were not limited to, the following: [MEDICATION NAME] suppository 10 mg (milligrams) once a day as needed for constipation, dated 2/11/20. [MEDICATION NAME] powder 17 gm (grams) once a day as needed for constipation, dated 2/11/20. Resident 70's orders lacked an order related to treatment of [REDACTED]. Resident 70's clinical record lacked any events related to loose stools or constipation. Resident 70's output sheet indicated the following bowel movements from 2/29/20 - 3/9/20: 2/29/20 9:47 A.M. large 2/29/20 10:07 A.M. large 2/29/20 8:28 P.M. medium 3/1/20 11:38 P.M. medium 3/2/20 5:02 P.M. large 3/2/20 11:41 P.M. medium 3/3/20 9:58 A.M. large 3/4/20 1:59 A.M. medium 3/4/20 2:01 A.M. medium 3/4/20 11:03 A.M. large 3/4/20 10:13 P.M. medium 3/5/20 9:11 A.M. large 3/5/20 9:45 A.M. large 3/5/20 8:35 P.M. large 3/5/20 10:03 P.M. large 3/6/20 8:07 P.M. large 3/7/20 10:01 A.M. medium 3/7/20 2:01 P.M. large 3/8/20 10:01 A.M. medium 3/8/20 3:56 P.M. medium 3/9/20 9:33 A.M. large Resident 70's MAR (medication administration record) for March 2020 indicated a [MEDICATION NAME] suppository was administered on 3/8/20 at 11:11 A.M., with a comment it was charted late. Resident 70's February and March 2020 progress notes lacked documentation of any loose stools. During an interview on 3/9/20 at 10:45 A.M., CNA 3 indicated Resident 70 did have a loose stool this morning, and was documented in the chart as large, but staff did not document consistency. She indicated if staff were to notice a trend, the nurse would be notified. She further indicated she had not been there the last few days, so there was no way for her to notice a trend. During an interview on 3/9/20 at 11:06 A.M., LPN 1 indicated a trend of loose stool had not been noticed for Resident 70, and if it had, staff would have opened an event in the clinical record, and called the physician. LPN 1 indicated Resident 70 eats prunes and sugar free candy which could lead to loose stool, but that morning was the first she had heard of any loose stool, and did not have any knowledge of loose stools in the last few days. During an interview on 3/9/20 at 11:40 A.M., LPN 1 indicated the nurse that worked the previous night had failed to document or inform her of a [MEDICATION NAME] suppository that was given to Resident 70 at about 4:00 P.M. on 3/8/20, and staff was now watching and tracking Resident 70's bowel movements. During an interview on 3/9/20 at 12:06 P.M., the DON (Director of Nursing) indicated Resident 70 had told the nurse on 3/8/20 he didn't think he had had a bowel movement for a few days, so the nurse did a bowel assessment, and because the resident was complaining of constipation, administered a laxative. The DON further indicated the facility did not have a protocol for administration of as needed laxative suppositories, and administered to residents based on nursing judgement. On 3/11/20 at 1:00 P.M., a current Medication Pass Procedure form was provided, revised 12/2016, and indicated . Medication administration will be recorded on the MAR/EMAR or TAR after given . 3.1-48(a)(3) 3.1-48(a)(4)

Based on observation, interview, and record review, the facility failed to ensure infection control practices and standards were maintained for 2 of 5 Residents observed for incontinence care. (Resident 51, Resident 22) Findings Include: 1. On 3/9/20 at 12:00 P.M., incontinence care was observed for Resident 51. Upon entering the resident's room, CNA 4 completed hand hygiene for 35 seconds and CNA 5 completed hand hygiene for 22 seconds and both donned gloves. CNA 4 then removed gloves and left the room to obtain wipes for incontinence care. Hand hygiene was not performed when leaving room. CNA 4 returned and completed hand hygiene for 25 seconds. CNA 5 removed the blanket from Resident 51 and pulled Resident 51's pants and brief down, tucking the brief under Resident 51. CNA 5 then wiped Resident 51's peri area and inner thighs using a disposable wipe. CNA 4 donned gloves, hand hygiene was not performed prior to applying gloves and applied barrier cream to Resident 51's peri area and inner thighs. CNA 5 rolled Resident 51 to her left side and removed the brief. CNA 5 wiped Resident 51's buttocks with a new disposable wipe and barrier cream was then applied by CNA 4. At that time, CNA 4 and CNA 5 removed their gloves. Hand hygiene was not performed and new gloves were not applied. A clean brief was positioned under Resident 51 per CNA 4 and Resident 51 was rolled to her back. CNA 4 then secured the brief. CNA 5 pulled up Resident 51's pants and Resident 51 was sat up onto the side of the bed. CNA 4 applied a gait belt to Resident 51 and CNA 4 and CNA 5 assisted Resident 51 into a wheelchair. CNA 4 removed the gait belt and CNA 5 obtained a comb from the dresser drawer. CNA 5 combed Resident 51's hair and returned the comb to the drawer. CNA 4 bagged up the trash containing the soiled brief and sat it on the bedside table while placing a new liner inside the trash can. CNA 4 then made Resident 51's bed. Resident 51 was pushed in the wheelchair to the doorway where CNA 5 utilized hand sanitizer. CNA 4 retrieved the bag of trash from the bedside table and utilized hand sanitizer at the doorway before exiting. The table top was not sanitized after the bag of soiled items was removed from the room. On 3/9/20 at 10:10 A.M. Resident 51's clinical record was reviewed, including the most recent Annual MDS (Minimum Data Set), dated 1/22/20. [DIAGNOSES REDACTED]. Resident 51 was identified with severely impaired cognition and required extensive assistance for bed mobility, transfers, and toileting. During an interview on 3/11/20 at 10:00 A.M., CNA 2 indicated that gloves should be changed and hands sanitized between dirty and clean tasks while performing care and that gloves should always be worn for the entire task of incontinence care. On 3/11/20 at 10:08 A.M., CNA 3 indicated that gloves are always to be worn when providing direct resident care and that gloves should be changed and hand hygiene performed between clean and dirty tasks. 2. On 3/9/20 at 10:50 A.M., CNA 3 was observed to perform pericare for Resident 22. After assisting to change Resident 22's brief, CNA 3 removed her gloves, gathered the garbage bag from the can, tied the bag, took it to the soiled linen room, then walked to the sink by the common area on the North Hall and washed her hands for 5 seconds. During an interview on 3/11/20 at 10:45 A.M., CNA 2 indicated that when performing hand hygiene, hands should be washed for a minimum of 20 seconds. On 3/11/20 at 10:35 A.M., a policy dated 3/2018 and titled Hand Hygiene Policy was provided and reviewed. The policy stated that handwashing is indicated after contact with bodily fluids or excretions and hand rubbing is indicated .when moving from a contaminated body site to a clean body site during resident care and after removing glove On 3/11/20 at 10:35 A.M. a policy dated 3/2012 and titled Gloves was reviewed. The policy states that after gloves have been removed and disposed of, one must wash hands. On 3/11/20 at 11:00 A.M. a policy dated 3/2012 and titled Perineal Care was reviewed. The policy indicated that after perineal care had been completed one must remove gloves then wash hands On 3/11/20 at 10:40 A.M. the policy dated 3/2018 and titled Hand Hygiene Policy was reviewed. The policy indicated that the duration of the handwashing procedure should be 40-60 seconds 3.1-18(b) 3.1-18(l)

Based on interview and record review, the facility failed to provide necessary documentation to ensure a resident or responsible party was issued a Notice of Medicare Non-Coverage (NOMNC) before the proposed end of services for 1 of 3 beneficiary notices reviewed. (Resident 36) Findings include: On 2/21/18, at 10:30 A.M., during review of three randomly chosen resident Medicare Part A discharge notices, the notice stated, Please sign below to indicate you received and understood this notice . I have been notified that coverage of my services will end on the effective date indicated on this notice and that I may appeal this decision by contacting my (Quality Improvement Organization) QIO. The notice had not been signed by the patient or their representative. A note had been written on the signature line indicating the patient or representative was unable to sign, and that the representative had been spoken to. The notice was dated 12/21/17. During an interview with the Social Services Director (SSD) on 2/26/18 at 8:09 A.M., the SSD indicated the resident's son had been notified over the phone of the upcoming end of coverage by the therapy department. The SSD indicated there was no documentation of the phone call, and a NOMNC was not mailed out to be signed since the representative was notified over the phone. The SSD further indicated there was no notice that had been signed by the representative. On 2/26/18 at 8:30 A.M., the Business Office Manager provided the facility policy for issuing a Notice of Medicare Non-Coverage (NOMNC)/Determination on Continued Stay. The policy stated, NOMNC form must be issued no later than two days (48 hours) before the proposed end of services. The policy further indicated that when unable to provide the NOMNC to the resident or responsible party in person and must be done via telephone, the responsible party must come in to sign the NOMNC or it needs to be sent out by mail with a return envelope. 3.1-4(i)

Based on interview and record review, the facility failed to ensure a dependent resident received the necessary supervision and care to be free of hazards to prevent a large hematoma (raised bruise) on the head, skin tears, and a left femur (hip) fracture, for 1 of 3 residents reviewed with injuries, in a sample of 7. Resident C Findings include: The closed clinical record of Resident C was reviewed on 8/1/16. The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Progress Note, dated 7/11/16 at 2:40 P.M., indicated, Pt (patient) arrived at facility .Pt alert and oriented to self and place with confusion noted at times An admission assessment, dated 7/11/16, indicated the resident weighed 92 pounds. A Care Plan, dated 7/12/16, indicated: Problem, Resident needs assistance with ADLs (activities of daily living) including bed mobility, transfers, eating and toilet use related to: weakness, pain, left clavicle fx (fracture) with sling to left arm. The Approaches included: 2 staff assist with transfers. An additional Care Plan, dated 7/12/16, indicated, Problem, Resident is at risk for fall due to: weakness, hx (history) of falls, decreased mobility, acute pain left clavicle fx with left arm sling, dementia with decreased safety awareness. The Approaches included: Assist of 2 required with all transfers. An additional Care Plan, dated 7/12/16, indicated, Pain related to: left clavicle fx, depression. The Approaches included: Assist with positioning to comfort. Notify MD if pain is unrelieved and/or worsening. Observe for non verbal signs of pain. A Care Plan regarding left hip pain was not found in the clinical record. A Progress Note, dated 7/12/16 at 9:01 A.M., indicated, .Resident noted to have pain/discomfort upon movement of L (left) extremity d/t (due to) L clavicle fx .No c/o pain at this time except when moving extremity A Fall Risk Assessment, dated 7/12/16 at 1:13 P.M., indicated the resident had a history of [REDACTED].> 13 Total Points = High Fall Risk). A Progress Note, dated 7/12/16 at 1:35 P.M., indicated, Resident alert and oriented with confusion noted .Able to make wants and needs known. Up with 2 assist with transfers and ADL's .Pain noted with movement of L extremity .no pain or discomfort voiced at this time. A Physical Therapy (PT) Plan of Care, dated 7/12/16, indicated, Reason for Referral: .due to fall and resulting of (sic) left clavicle fracture Therapy necessary for increase (sic) muscle strength in both LE (lower extremities) and stabilized pain in left shoulder .Precautions: high risk of fall due to confusion, needed all the time cuing on left shoulder not to be used due to left clavicle fracture .Patient complains of pain in left shoulder .able to follow simple commands .The PT note did not document complaints of left hip/leg pain. A Progress Note, dated 7/13/16 at 12:24 A.M., indicated, .Resident noted to have discomfort upon movement of left arm d/t left clavicle fx .Will continue to monitor. A 72 hour Admission Shift Charting, dated 7/14/16 at 1:34 A.M., indicated, Is resident currently experiencing pain? No, Mobility Uses wheelchair, Mental status Fearful, Oriented to None of the above .Lower body weakness Progress Notes continued: 7/15/16 at 4:00 P.M. (Recorded as Late Entry on 07/18/2016 at 09:45 AM) CNA came to nurse at this time to inform nurse of knot located on resident L side of head and area to L hand. When nurse CNA what happened (sic) CNA state that she walked into room to give resident bed bath at this time. CNA noticed a knot located on L side of head and skin tear located on L hand and one on L elbow. CNA checked bed alarm and it was in place and working properly. CNA then asked resident what happened. Resident stated 'I fell .' CNA replied 'You are in here because you fell but what happened to your head? Resident stated I do not know.' CNA then came to nurse with information, this nurse assessed resident and took vital signs. Vital signs WNL (within normal limits). When asked what hurts resident pointed to L hand and L side of head .Will continue to monitor. 7/15/16 at 5:15 P.M.: CNA came to nurse at this time to tell nurse that resident is c/o (complaining) of L hip pain. Nurse assessed resident. Resident moaning in pain with any movement to LLE (left lower extremity). Call made to (name of physician) at this time for N/O (new order) to send resident to ER for eval and tx (evaluation and treatment) A hospital # 1 Emergency Department note, dated 7/15/16 at 6:38 P.M., indicated, .The patient was brought in by EMS (emergency medical services) after it was reported to the nurse (name), by CNA, that patient was found in her bed with with (sic) purple lump on the left side of forehead. Staff attempted to get patient up and take her to the dinning (sic) room and pt. was yelling in pain because her left hip was hurting and she could not bear weight. Pt. also has skin tear on her left elbow and left, lateral pinky finger. There were no witnesses who reportedly were present when patient was injured. Patient had a fall earlier on July 8, one week ago, and has a left fractured clavicle .The onset was unknown. The occurrence was unknown. The location where the incident occurred was at a nursing home .The character of symptoms is pain and loss of mobility. The degree at present is severe .Skin symptoms: Abrasions, Contusion on forehead .Left, hip, acute, pain, decreased range of motion .Alert, moderate distress, emaciated, underweight, cooperative .Alert and oriented to person, place, time, and situation .Wounds: Left elbow and left lateral pinky finger .Differential Diagnosis: [REDACTED]. A hospital # 1 report, dated 7/15/16 at 7:23 P.M., indicated a Cat Scan of the head revealed findings consistent (with) evolving subacute infarct. No intracranial hemorrhage and the resident was transferred to a larger hospital with a [DIAGNOSES REDACTED]. A hospital # 2 history and physical, dated 7/16/16, indicated, Chief Complaint: Falls .(Resident C) .provides her own history. She tells me that she has fallen twice in the last week. Her first was on July 8 .fractured her left clavicle .Today she was found by the staff with a large bruise on the left side of her head and minimal skin injuries to her left hand and left elbow. After the staff tried to assist her with ambulation she was unable to bear weight secondary to her left hip pain. She had a repeat head and pelvic CTs (cat scans) as well as repeat imaging of her collarbone .Physical Exam: .Alert: Cooperative: Oriented - person, place, month; disoriented to year .Contusion - large goose egg on left side of head anterior to the ear .Pain - Spasmodic pain in the left hip. Pain present with trial of passive range of motion .Hematoma 1. On left side of head. 2. Over the left clavicle . A hospital # 2 discharge summary, dated 7/20/16, indicated, .Hospital Course: This is an unfortunate [AGE] year-old female who had an apparently unwitnessed fall at the skilled nursing facility where she resided. She was then sent to (name of hospital # 1) where she was found to have a subacute insult in the left parietooccipital region. She was transferred here for further workup .After persistent hip pain here despite a negative CT (cat scan) at (hospital # 1), a CT of her hip was repeated and identified a small periprosthetic femoral shaft fracture (hip) just distal to the trochanter On 8/1/16 at 12:05 P.M., LPN # 1 was interviewed. LPN # 1 indicated she was working on 7/15/16. She indicated CNA # 1 notified her that Resident C had a pretty big goose egg on her head, and skin tears on her arm. She indicated the resident told her that she had fallen. LPN # 1 indicated she observed a drink spilled on the floor. LPN # 1 indicated Resident C was alert, but had confusion at times. She indicated she did not think the resident would be able to get back up on her own if she had fallen. LPN # 1 indicated that later she had told staff to get Resident C up for supper, and the staff informed her that she was complaining of left leg pain. She indicated she then called the physician and sent her out to the hospital. LPN # 1 indicated she really didn't know what happened, and did not want to accuse anyone. On 8/1/16 at 2:00 P.M., CNA # 1 was interviewed. CNA # 1 indicated on 7/15/16, she went in to give Resident C a bed bath. She indicated the resident told her she had to use the bathroom, and CNA # 1 went to get CNA # 2 to assist her. CNA # 2 was giving another resident a shower, and told CNA # 1 to give her a minute, and she would assist her. CNA # 1 indicated when she went back in the room, she observed Resident C was already wet, so she went ahead and changed her. She indicated the resident's brief was wet, but her pants were not wet. She indicated she did not have to get the resident up out of bed. She indicated Resident C complained that her head hurt, and she noted a huge bruised knot on her head and a skin tear on her hand. She indicated she observed pop that was spilled under the chair next to the bed. She indicated she then went and informed the nurse. CNA # 1 indicated she was unsure how long it was from the time she spoke to CNA # 2 until she went back into the resident's room, but found the resident laying in bed. She indicated the resident had 1/4 siderails, and she wondered if the resident hit her head on one of the rails. She indicated she did not take the resident to the bathroom. On 8/1/16 at 2:20 P.M., CNA # 2 was interviewed. CNA # 2 indicated she was working on 7/15/16. She indicated she was working in a room across the hall from Resident C, and heard an alarm going off. She indicated she saw Resident C sitting on the side of the bed. She indicated she observed the resident's bed was quite wet. CNA # 2 indicated she lifted the resident's legs back up in bed, and positioned her. She indicated there was no knot or bruise on the resident's head at that time. She indicated she was in the shower room, and CNA # 1 came in and asked her to assist her in taking Resident C to the bathroom. CNA # 2 indicated she informed CNA # 1 that she was almost done, and would be able to help her. She indicated when she got back to Resident C's room, everyone was in there. She indicated she asked, What's going on? and asked CNA # 1 how she got the resident's bed dry if she didn't get her up. On 8/2/16 at 9:40 A.M., the Administrator and Director of Nursing (DON) were interviewed. The DON indicated the Unit Manager had informed her on 7/15/16 that Resident C had possibly hit her head on the grab bar. She indicated CNA # 1 had observed a hematoma on the left side temporal area, and had observed a drink spilled on the left side of the floor. The DON indicated she was also aware of a skin tear on the resident's finger, and found out later about the skin tear on the resident's elbow. She indicated the resident had said she fell in the bathroom, but she knew the resident had fallen in the bathroom at home. She indicated the resident had been confused since admission. The Administrator indicated they interviewed staff and came to the conclusion that the resident may have hit her head on the grab bar, so they rearranged the furniture. The Administrator and DON were informed at that time that a fracture had been discovered at the second hospital. They both indicated they were unaware of that. On 8/2/16 at 10:30 A.M., during an interview with the Corporate Nurse, he indicated he thought the resident had left hip pain prior to being admitted to the facility. He indicated he was unsure why there was no documentation regarding left hip pain until 7/15/16. On 8/2/16 at 12:00 P.M., during an interview with the Administrator, she indicated she had spoken to the Physical Therapist, and that the therapist had informed her that the resident had complained of bilateral lower extremity pain, and that it was possible the hospital had missed the fracture prior to admission. She indicated she had spoken to the staff, and didn't think any of them were being less than truthful. She indicated if the resident had fallen from bed, she did not think one person could get her up by themselves, even if she weighed 92 pounds. On 8/2/16 at 10:15 A.M., the DON provided the current facility Fall Management Program, revised 7/2016. The policy included: .Post fall: 1. Any resident experiencing a fall will be assessed immediately by the charge nurse for possible injuries and necessary treatment will be provided This Federal tag relates to Complaint IN 347. 3.1-45(a)(1) 3.1-45(a)(2)

Based on observation, interview, and record review, the facility failed to safely transfer a resident, resulting in a fall and fractured elbow; failed to notify the nurse to perform an assessment immediately following the fall; failed to notify the family and/or physician timely following the fall; failed to document completely and accurately the events of the fall; and failed to properly secure a resident during a hoyer transfer, resulting in a fall, for 2 of 3 residents reviewed for falls, in a sample of 4. Resident A, Resident C Findings include: 1. On 4/14/15 at 10:45 A.M., during the initial tour, the Administrator indicated Resident A had recently fallen. On 4/14/15 at 11:25 A.M., Resident A was observed sitting in a wheelchair, by the nursing station. Her left arm was observed to be in a soft cast, wrapped with an ace bandage. Her left arm was in a sling. RN # 1 indicated at that time that Resident A "fell and shattered her elbow." RN # 1 indicated the resident had [DIAGNOSES REDACTED], but could communicate with sounds and gestures. On 4/14/15 at 11:30 A.M., the Administrator provided a list of residents, highlighting those considered "interviewable." Resident A was marked as interviewable. The clinical record of Resident A was reviewed on 4/14/15 at 11:35 A.M. [DIAGNOSES REDACTED]. A physician's orders [REDACTED]." A "Resident Lifting, Transferring and Repositioning Data Collection," initially dated 2/22/14 and last dated 9/4/14, indicated, "Resident's level of assistance: Extensive Assistance, Weight Bearing Capabilities: (left blank), Bilateral Upper Extremity Strength present? No...Check all that apply when determining lifting...C.P. ([DIAGNOSES REDACTED]), poor wt. bearing. Based on data collection findings, the Interdisciplinary Team (IDT) recommendation for transferring and repositioning techniques are: Transferring: (one) assist, Repositioning: (one) assist...." Documentation, dated 9/4/14, indicated, "(No) change." Documentation following the 9/14/14 date, undated, indicated: "Quarterly, (No) (changes) noted @ this time." A quarterly Minimum Data Set (MDS) assessment, dated 3/3/15, indicated Resident A scored a 15/15 for cognition, indicating no memory impairment. The resident required extensive assistance of two+ staff for transfer, and extensive assistance of one staff for toileting. A test for "Balance During Transitions and Walking" indicated the resident was "Not steady, only able to stabilize with staff assistance" while moving on and off of the toilet and surface-to-surface transfer. The MDS assessment indicated the resident had fallen once within the last 90 days. A resident care plan, initially dated 12/5/14 and updated 3/3/15, indicated: "Problem: Potential or Actual ADL (activities of daily living)/Mobility deficit...r/t (related to) [DIAGNOSES REDACTED], Muscle spasm, profound M.R. (mental retardation), Cervical spondylosis, As evidenced by: Generalized weakness...Interventions: Provide assistive device as needed for transfer: (one) assist...." An additional resident care plan, initially dated 12/5/14 and updated 3/27/15, indicated: "Fall/Injury Risk related to: History of Falls, stiffness, unsteady, pain, shuffled gait, leaning, cervical spondylosis...[DIAGNOSES REDACTED]..3/27/15 (left) elbow bruising/edema...fall (assisted) in bathroom...Interventions: Ambulation: 2A (assist of two), Transfer: 2A, 3/27/15 Rsd (resident) prefers bear hug transfer...Rug to floor - plays on floor...2/25 Dycem to w/c (wheelchair)...." Nursing Progress Notes included the following notations: 3/25/15 at 9:00 P.M., written by RN # 2: "(CNA # 1) called for this nurse to assess resident (left) elbow. This nurse assessed did not note any warmth, redness, or swelling @ this time. Muscular pain reliever analgesic balm rubbed onto elbow @ this time. Resident tolerated well. CNA stated, 'Resident was being transferred to commode. Asked resident to give bear hug and when transferring resident twisted opposite direction of expected and CNA noticed resident was going to fall so lowered resident to floor. The incident occurred around 7:30 pm. Resident was placed into bed and around 9:00 pm Resident turned call light on and reported pain in her elbow. After initial assessment, there were (no) further complaints this evening." 3/26/15 at 10:00 A.M.: "Noted Res (resident) (with) swelling and bruising to (left) elbow. (Name of Nurse Practitioner) notified and STAT x-ray of elbow and shoulder ordered. (X-ray company) called and x-ray ordered. Elbow immobilized and ice applied @ this x (time). DON (Director of Nursing) notified of (left) elbow." A Radiology report, dated 3/26/15, indicated: "...Conclusion: Limited study due to patient positioning. Findings raise suspicion for fracture...." Nursing Notes continued: 3/26/15 at 2:00 P.M.: "X-ray results rec (received) and (Nurse Practitioner) notified. N.O. (new order) to (increase) Tylenol # 4 to TID (three times daily)...Place arm in sling until appt (appointment) (with) Ortho...." A hospital radiology report, dated 3/31/15, indicated, "Impression:...Comminuted and complex intra-articular fracture at the distal humerus...." An Orthopedic Physician's note, dated 3/31/15, indicated, "(Resident A)...apparently last week Wednesday on March 25, 2015 fell from standing height while a healthcare provider was helping her off the commode. She landed apparently onto her left upper extremity. Pain was noted. She has noted dramatic bruising over the last week...Left elbow: Appearance: Dramatic ecchymosis (bruising) and swelling noted over the elbow...Anticipate performing surgery this coming Friday at hospital...." On 4/14/15 at 2:15 P.M., CNA # 3 and CNA # 4 were observed to transfer Resident A from her wheelchair to the commode. They utilized a gait belt during the transfer. At that time, they each indicated that they always utilized a gait belt during transfers. CNA # 3 indicated prior to Resident A's fall, the resident required the assist of "1 or 2 staff." CNA # 4 indicated that she transferred the resident herself by having the resident wrap her arms around her neck, but that she "always used a gait belt." At that time, Resident A was interviewed. CNA # 3 was present during the interview. Resident A indicated "yes" or "no" by shaking and nodding her head. She nodded "Yes" when asked if (CNA # 1) was the person who transferred her when she hurt her elbow. She nodded "No" when asked if CNA # 1 was wearing a gait belt to assist her. On 4/14/15 at 3:20 P.M., the Administrator provided an incident report regarding Resident A, dated 3/26/15. The report included: "Type, Fall, Location, Bathroom - Resident, Activity, Transferring...Physician called 3/26/15 10:00, POA (power of attorney) called (Name) 3/26/15 10:15...Cognition Prior to Occ. (sic), Oriented to Person/Place/Time...Injuries Left Elbow...Nurse's Note of what happened: (CNA # 1) came to find (RN # 2) because resident reported pain in Left elbow. This nurse assessed resident's elbow. Resident was in bed when this nurse assessed elbow...Resident points to elbow. Answers with simple yes or no answers. Witness statement...Staff was assisting resident to restroom per care plan. Resident was instructed to give a big bear hug for transfer. While transferring toward commode, resident twisted opposite direction from expected direction and was lowered to floor by staff...." A "Follow up Report," dated 4/14/15 and written by the DON, indicated, "Resident was lowered to the floor by a CNA approx. 7:30 pm on 3/25/15...CNA slid resident down her leg and stated resident ended up sitting on her bottom on the bathroom floor...CNA stated around approx 9pm resident's light was on. CNA entered room to find resident on the floor next to her bed. Resident c/o (complained of) elbow pain at this time by pointing to her elbow...Staff assisted resident back to bed. Resident will often intentionally get down on the floor from her bed or wheelchair...it is believed that resident fx (fractured) her elbow while getting out of bed...Recommendation, Staff to educate resident to not get out of bed or wheelchair to go to rug on her floor alone. Staff to educate resident to ask for assistance." On 4/14/15 at 4:00 P.M., during an interview with RN # 2, she indicated she was working on the evening of 3/25/15. She indicated she was notified at 9:00 P.M. that Resident A was complaining of left elbow pain. She indicated Resident A was lying in bed at that time. She indicated CNA # 1 informed her at that time that the resident had been lowered to the floor at approximately 7:00 P.M. that night. She indicated that the resident had put on her light at 9:00 P.M., because she had to go to the bathroom, and then complained of pain. RN # 2 indicated she assessed the resident's elbow, and did not notice any warmth or redness. She indicated that CNA # 1 informed her that the resident had gotten out of bed by herself at approximately 9:00 P.M. RN # 2 indicated she did not see the resident on the floor. RN # 2 indicated she did not call the physician nor the family that night. On 4/14/15 at 4:10 P.M., CNA # 1 was interviewed. CNA # 1 indicated she was working on 3/25/15, and cared for Resident A. She indicated she was transferring Resident A to the commode, and Resident A "arched her back" so she lowered her to the floor. She indicated she did not have a gait belt around Resident A. She indicated she did not recall the resident hitting her elbow on anything. She indicated she did not inform the nurse at that time, "but now I know I should have." CNA # 1 indicated the resident did not complain of pain at that time. CNA # 1 indicated the resident put her call light on at approximately 9:00 P.M., and had "put herself on the floor." CNA # 1 indicated she assisted the resident back to bed, and then the resident complained of elbow pain, so she notified her nurse. On 4/15/15 at 10:35 A.M., during an interview with the DON and Administrator, the DON indicated that nursing staff are informed in orientation to always use gait belts during transfers. The DON indicated following this incident, all nursing staff were inserviced to report any fall to the nurse immediately. The Administrator indicated that staff were to report falls to the physician and family "in a timely manner," and that RN # 2 did not call either "because it was too late." On 4/15/15 at 9:10 A.M., the Assistant Director of Nursing provided the current facility policy on "Fall/Injury Management - Post Fall or Injury," revised November 2013. The policy included: "(The corporation) recognized proper action following a fall includes: Ascertaining if there were injuries and providing treatment as necessary...Communicating the fall to the physician and the responsible party in a timely manner...." 2. The clinical record of Resident C was reviewed on 4/14/15 at 2:40 P.M. [DIAGNOSES REDACTED]. An annual MDS assessment, dated 12/18/14, indicated the resident was unable to be assessed for cognition, and required total dependence of two+ staff for transfer. A physician's orders [REDACTED]." A Physician Communication form, dated 1/28/15 at 4:45 A.M., indicated, "The resident appears to have slid out of hoyer lift to have hard nodule/area on buttock. 0430 (4:30 A.M.) This nurse heard a scream. This nurse ran towards the scream et (and) arrived @ (room number). This nurse entered room to see 2 CNAs in room et Rsd head laying on back on floor (with) head facing bed et legs et feet laying over the legs of the hoyer lift. 0445 (4:45 A.M.) (Name of physician) notified et made aware of the situation and made aware of hard nodule/area on buttocks et asked for x-ray of pelvis/coccyx. Physician replied...Just continue to monitor...." A "Multi-Disciplinary Therapy Screening Tool," dated 1/28/15, indicated: "Fall during hoyer transfer - Nursing to provide staff education re: appropriate hoyer pad placement/securing hoyer straps." A Physician's note, dated 2/6/15, indicated: "fell off hoyer lift while transporting. Landed on buttock. Has been asymptomatic. X-ray showing questionable pelvic fx. Re-read not seen fx (sic)." On 4/14/15 at 3:45 P.M., the Medical Records staff provided an incident report. The report, dated 1/28/15, indicated: "Type: Fall...Activity: Transferring, Witnesses, CNA # 5 and CNA # 6...Cognition Prior to Occ. Comatose, Injuries, Abrasion Lower Right Back, Lower Right Back...Immediate Actions Taken, Lift taken out of use until inspection. CNAs re-educated on appropriate use of lift and safety checks while operating lift...." A "General Follow up," written by the DON and dated 2/6/15, indicated, "...Root Cause, CNA did not ensure all straps were secure before lift was used...." On 4/15/15 at 10:35 A.M., during an interview with the DON and Administrator, the DON indicated all staff were inserviced on the correct use of the hoyer lift following this incident. The DON indicated the education director observed each CNA using the lift. The Administrator indicated CNA # 5 did not work at the facility anymore. On 4/15/15 at 2:55 P.M., the Medical Records staff provided "General Guidelines" regarding the hoyer lift. The guidelines included: "...The patient should be approximately centered on the sling section...CAUTION When using either the chains or straps to connect the sling to the patient lift, the shortest of the two sections of the chains or straps MUST be attached to the back section of the sling.... This Federal tag relates to Complaint IN 851. 3.1-45(a)(2)

Based on observation, interview, and record review, the facility failed to ensure residents identified as having a history of falls/and or at fall risk received adequate supervision and/ or effective interventions and/or safe environment to prevent further falls for 3 of 5 residents reviewed for falls. This practice resulted in Resident H experiencing 14 falls in a 6 month period and Resident B receiving a hip fracture. (Resident H, Resident B, Resident O) Findings include: 1. On 8/25/14 at 9:54 A.M., Resident B was observed in bed with 2 grab bars up and her call light in reach. On 8/26/14 at 11:00 A.M., Resident B's clinical record was reviewed. Her Minimum Data Set Assessment ((MDS) dated [DATE] indicated a cognitive summary score of 12 ( moderate cognitive impairment). Resident B needed extensive assistance of 1 for bed mobility, transfers, walk in room and corridor, and toilet use. The MDS dated [DATE] indicated a cognitive score of 8 (moderate cognitive impairment). Extensive assistance of 1 staff needed for bed mobility, transfers, walk in room and corridor, and toilet use. The MDS dated [DATE], indicated a cognitive score of 3 (severe cognitive impairment). Extensive assistance of 2 staff needed for bed mobility, transfers, walk in room, and toilet use. The extensive assistance of 1 staff needed for walking in the corridor. A fall care plan initiated 3/1/14, indicated a history of falls, and cognitive impairment factors of dementia and Alzheimer's disease. Interventions included but were not limited to, ambulation with the assistance of 1, the use of a rolling walker (device), high/low bed, bilateral grab bars, and non-skid socks. A fall progress note dated 8/8/14 at 12:45 P.M., indicated, " CNA (CNA's name) stated, 'I went to make the bed, and turned around and resident was transferring self to wheelchair. when resident went to turn and sit in her wheelchair, she got caught on the little wheel of the wheelchair and that caused her to call (sic).' A physician's orders [REDACTED]. Resident B was then sent to the hospital on [DATE] due to a left hip fracture. She returned to the facility after left hip surgery on 8/14/14. On 8/26/14 at 12:00 P.M., the Director of Nursing (DON) was interviewed regarding Resident B's 8/8/14 fall. The DON indicated Resident B had fallen in the bathroom. She indicated the CNA had left the resident in the bathroom and went to start making the resident's bed when the resident transferred self and fell . The DON indicated the care plan was updated after the fall. The updated intervention dated 8/8/14, indicated " Educate staff to not leave resident." The DON indicated, Resident B should not have been left unattended on the commode. On 8/28/14 at 09:00 A.M., during interview with the DON she was made aware of the MDS dated [DATE] (before the fall) which had indicated a severe cognitive impairment and assistance needed for transfers. 2. On 8/25/14 at 11:00 A.M., Resident H was observed in bed. On 8/25/14 at 8:31 A.M., Resident H's clinical record was reviewed. [DIAGNOSES REDACTED]. She had been admitted to the facility on [DATE]. Her Minimum Data Set Assessments ((MDS) dated [DATE], 4/23/14, and 7/22/14, indicated a cognitive score of 3 (severe cognitive impairment). She needed extensive assistance of 1 staff for bed mobility, transfers, walking in room or corridor and toilet use. The MDS also indicated the resident was always continent of urine. On 8/28/14 at 7:47 A.M., the Director of Nursing (DON) was interviewed regarding Resident H's falls in regard to reviewing Resident H's fall progress notes and care plan. The fall care plan had an initiation date of 7/28/14, and addressed fall risk related to, history of falls, unsteadiness, potential for high or low blood sugar and cognitive impairment factors of dementia and Alzheimer's. Interventions included but were not limited to, ambulation with the assist of 1, use of a walker device, use of a grab bar, and 15 minute checks related to fall risk. The DON indicated before the first fall on 2/8/14 at 11:00 P.M., Resident H was to be toileted every hour while awake. The fall progress note dated 2/8/14 at 11:00 P.M., indicated, "Staff heard a bang and resident yelled out. CNA found Resident on knees by bed. CNA alerted this nurse, (nurse's name) to room. Res (resident) had bumped Left elbow on bedside table and obtained a 3 cm x 0.1 cm skin tear. Res. stated she went to bathroom and on her way back she fell into bedside table. Res did have on nonskid slippers..." The DON indicated the intervention implemented was to place signs on bedside table and bathroom door instructing the resident to use walker. The DON was made aware at this time that Resident H's cognition score was a 3 (severe cognitive impairment). The DON indicated the resident reads a lot. The 2nd fall occurred on 2/11/14 at 1:10 P.M. The fall progress note indicated, "resident found sitting in hallway on her buttocks was barefoot walker sitting beside her." The DON indicated the new intervention was to add gripper socks and that was added on the care plan on 2/11/14. The 3rd fall occurred in the resident's restroom on 3/6/14 at 9:10 P.M. The fall progress note indicated, "I heard rsd (resident) yelling help from her bathroom. When I entered bathroom I found rsd. lying on her left side on floor. Skin tear noted to left elbow..." "... Rsd. was wearing socks and shoes." The DON indicated, the new intervention was for staff to check q 30 minutes on resident and document they had checked on the resident. The 4th fall had occurred on 3/20/14. The DON indicated the fall had occurred at 3:30 P.M., in the resident's room. The intervention implemented was to adjust the resident's anti-anxiety medication (xanax) time administered from 2:00 P.M., to 4:00 P.M. The 5th fall progress note of 4/14/14 at 12:50 A.M., indicated, " I was in the hallway when I heard a resident on short hall say 'help me.' I found resident on the floor sitting on her bottom. resident stated she was going to use the bathroom. It appeared that resident had slipped on her pants that had longer bottoms. Resident was barefoot..." "... Placed shoes on resident's feet. Resident assisted to bathroom and then back to bed. Resident instructed on use of call light. Also replaced pants with shorted pj bottoms. Shoes placed next to residents bed, along with gripper socks. Resident placed on 15 min. (minute) checks on back of door instead of 30 min. checks." The DON indicated an intervention initiated was to change toileting program to staff to assist 12:00 A.M., 3:00 A.M., and 6:00 A.M. The fall progress noted dated 5/18/14 (6th fall) at 8:05 P.M., indicated, " This nurse was called to resident bathroom by CNA to find resident lying on the floor. CNA had placed pillow behind resident's head. CNA had recently been in resident room to adjust temperature. Resident unsure what she was doing or where she was trying to go. Resident barefoot. Magazines on floor near residents feet..." The DON indicated the immediate intervention was gripper socks which had already been in use. The DON indicated an intervention was implemented to assist with toileting every 2 hours from 6:00 A.M., to 10:00 P.M. The DON was made aware that before the first fall the resident had been on toileting program of every hour while awake. The DON indicated an intervention to keep resident's walker in reach had been added to the care plan on 5/19/14. A fall progress note dated 5/28/14 at 9:00 P.M., indicated, "Went to check on rsd. for her 30 min. checks and found rsd. on bathroom floor on right side. Rsd. said she was getting up from the toilet and became unsteady and fell . Rsd. was wearing shoes. Asked rsd. if she hit head. Rsd. said I think so, on the door frame..." "... Small hematoma noted on right side of forehead. Rsd. states her forehead feels sore..." The DON indicated the resident's toileting program was changed to every 2 hours from 6:00 A.M., to 4:00 P.M., and every hour from 4:00 P.M., to 10:00 P.M., due to last falls were around 8:00 P.M., and 9:00 P.M. The 8th fall progress note was dated 6/17/14 at 2:00 A.M. The note indicated, " Heard a loud crash down short hall. Found resident sitting on floor with shoes sitting on floor in front of her. Rsd. said she was trying to get to the bathroom. Rsd. had just been toileted 30 minutes prior to fall..." "...Hematoma noted on bottom of back of head. Rsd. c/o (complained) pain to back of head. Ice applied..." The DON indicated the immediate intervention was that the resident was placed on 1 on 1 monitoring at the nurse's station for neurological checks. A therapy screen was also completed and it was determined the resident was not a candidate for therapy services. The 9th fall occurred on 6/24/14 at 10:20 P.M., in the resident's restroom. The fall note indicated, "Rsd. was found sitting on bottom no (sic) BR (bathroom) floor. Rsd. had shoes on. Light is on. No clutter or spill is noted on the floor. Skin tear is noted on right elbow. Telfa applied. Rsd was trying to go to the bathroom, Rsd. had just been toileted at 10 pm and was resting in bed at 10:15 per 15 min. skin checks. No further injury is noted." The DON indicated the immediate intervention was 1 on 1 monitoring. An order was obtained for an urinalysis (urine test for possible urinary infection) which was positive and was treated. Two days later on 6/26/14 at 12:20 P.M., the 10 th fall occurred. The fall progress note indicated, "Resident was self transferring in front of nurses station when CNA said resident's name. Resident turned around and lost balance. That is when the resident stumbled and fell hitting head on wall." The DON indicated the resident had been sent to the hospital emergency room for an evaluation. The DON indicated also a meeting with the resident's family had been initiated for possible suggestions to prevent falls. The DON also indicated the family was unable to provide new suggestions. The 11th fall occurred on 7/6/14 at 10:55 A.M. The fall progress note indicated, "Heard noise and res was found lying on back states she hit head and don't know what else happened...said she was trying to straighten up room." The immediate intervention was to keep her room door open at all times unless providing care. On 7/28/14 at 9:00 A.M., the 12 th fall occurred. The fall progress note indicated, " CNA walking past res br (bathroom) door to be open (sic) when CNA entered heard res fall to floor and res was found sitting on bottom leaning with back to other br door...res was noted to have a .5 cm skin tear to r (right) elbow. The DON indicated intervention initiated was for staff to offer to toilet every 15 minutes during 15 minute checks. A fall progress note dated 8/10/14 at 11:35 A.M., indicated, "Rsd. noted to be sitting on buttocks, in floor by restroom door, walker to the right side of resident, with milk cup next to resident in floor (house keeper, (housekeeper's name) stated she seen (sic) resident fall and resident bumped back of her head on the door. Also, knocked milk cup onto floor as she fell . Abrasion noted to right second toe, no bleeding noted." The DON indicated a post void residual urine (catheterization after resident has voided) was obtained and was with in normal limits. Also a CT head scan was completed and was negative. Another intervention initiated was hipsters ( a padded clothing device) on 8/11/14. The 14th fall occurred on 8/26/14 at 11:20 P.M. The fall progress note indicated, "I heard someone's toilet flush on short hall so I went to investigate. I looked in Rsd. room just as rsd. was coming out of bathroom. As soon as rsd. opened bathroom door she fell . I was too far away from rsd. to catch her. Rsd. did not hit her head. Rsd. caught herself with her hands and the rest of her body. Rsd. was lying on the right side. Small skin tear is noted to right elbow..." "... Rsd. cont. (continues) on 15 min. checks. Rsd. will be watched for one hour one-on-one for extra monitoring." The DON indicated a new intervention would be to continue to check on resident every 15 minutes and then go back in 5 minutes in case checking the resident may be triggering resident to toilet. During an interview on 8/28/14 at 8:47 A.M., the DON was made aware the documentation lacked evidence Resident H received adequate supervision and/or effective interventions were implemented to ensure the safety of Resident H. The DON then indicated the facility was concerned about preventing major injuries for Resident H. On 8/28/14 at 10:46 A.M., the facility policy, entitled "3.3.3. Risk Reduction: Falls and Injuries Program" revision date of November 2013 was received and reviewed. The policy included but was not limited to, "...Determine appropriate interventions for identified risk factors. Interventions include, but are not limited to:..." "... b. Recognize and intervene when independent ambulation is not safe or feasible..." 3. On 8/21/14 at 11:21 A.M., Resident O was observed lying in bed. The Clinical Record for Resident O was reviewed on 8/27/14 at 10:54 A.M., [DIAGNOSES REDACTED]. Fall #1 occurred on 7/10/14 at 12:15 P.M., The nursing progress note included, "Res found on floor beside her bed, Res had shoes on". The intervention was a verbal reminder to call for staff to assist prior to getting up. Fall #2 occurred on 7/23/14 at 4:00 P.M., The nursing progress note included, " Resident was attempting to push another resident out of the center of the hall. When the resident was heading towards the back of the wheelchair, the resident caught her foot on the front wheel of the wheel chair and tripped Resident stumbled backwards and feel (sig) onto her buttocks." The intervention put into place on 7/24/14 was a verbal reminder for resident not to assist other residents and to call for staff. The MDS (Minimum Data Set assessment) dated 7/6/14 indicated Resident O had a BIM (Brief Interview for Mental Status) score of 8 with a 8-12 indicating moderate cognitive impairment. Under functional status it indicated Resident O was unable to stabilize without human assistance while ambulating and turning and required extensive physical assist of one for transfers and ambulation. The physician's orders [REDACTED]. The Care Plans included, but were not limited to, A Fall/injury assessment: prevention and management plan of care dated 3/5/14. Fall/Injury Risk related to: History of Falls, history of dizziness, history of high blood pressure. Interventions include Ambulation and transfers with assist of 1 starting 11/26/13. Activities of daily living and mobility plan of care dated 7/7/14 related to glaucoma, and retinopathy and generalized weakness included, Will transfer with one assist. A Therapist Progress and Discharge Summary dated 1/22/14 included "Pt (patient) still needs SBA (stand by assist) with care. " On 8/27/14 at 1:27 P.M., PT #1 was interviewed; he indicated stand by assist was to be in close proximity and or arms length of resident. He further indicated on 7/10/14 and 7/23/14 Resident O required assist of 1 with ambulation. On 8/27/14 at 3:15 P.M., Certified Nursing Assistant #3 was interviewed she indicated Resident O was supposed to have assistance of one with ambulation and transfers. She indicated normally she just walks around and we only help her when she gets to looking unsteady. This Federal Tag relates to Complaint IN 207. 3.1-45(a)(2)