Every finding on record at Summit City Nursing and Rehabilitation

Based on interview, record review and observation, the facility failed to ensure staff were present during medication administration for 1 of 4 residents reviewed (Resident B). Findings include: During an observation on 2/23/26 at 9:42 AM, Resident B's medications were observed on the bedside table in a pill cup.In an interview, on 2/23/26 at 9:42 AM, Resident B indicated he self-administrated his medications and he often had the nurse place the medications on his bedside until he was ready to take the medications. Resident B indicated the medications on his bedside table were his morning medications and he preferred to take the medications later in the morning.In an interview, on 2/23/26 at 9:56 AM, Qualified Medication Assistant (QMA) 2 indicated Resident B self-administered his medications. QMA 2 indicated he placed the medications at bedside on 2/23/26 for Resident B to take when Resident B was ready. QMA 2 reviewed the orders and indicated he was unable to find an order for self-administration of medications for Resident B.Resident B's record review was completed on 2/23/26 at 10:41 AM, diagnoses included chronic obstructive pulmonary disease, chronic kidney disease, hepatic encephalopathy, seizures and congestive heart failure.An admission Minimum Data Set (MDS) assessment dated 12/2025, indicated Resident B had a Brief Interview of Mental Status of 15/15 (cognitively intact).Resident B's assessments were reviewed, there was no self-administration of medications assessment completed.Resident B's orders were reviewed, there were no orders for self-administration of medications. The Medication Administration Record (MAR), dated 2/2026, indicated QMA 2 administered the following medications to Resident B on 2/23/25 at 7 AM. acyclovir (antiviral) 800 mgcarvedilol (hypertensive) 6.25 mgcyanocobalamin (vitamin B12) 500 mcgfolic Acid (vitamin B9) 1 mgfurosemide (diuretic) 40 mggabapentin (anticonvulsant) 200 mgempagliflozin (antidiabetic) 10 mglevetiracetam (anticonvulsant) 500 mglinaclotide (guanylate cyclase-c agonists) 72 mcgmagnesium oxide (antacid) 400 mgmen's Daily vitamin 8 mgguaifenesin (expectorant) 600 mgomeprazole (antiacid) 20 mgranolazine (antianginal) 500 mgsenna (stool softener) 8.6 mgthiamine (vitamin B1) 100 mgvitamin D3 50 mcgDuring an interview, on 2/23/26 at 11:33 AM, the Director of Nursing (DON) indicated Resident B did not have a self-administration of medication evaluation upon admission. The DON indicated Resident B did not have an order to self-administration of medications. The DON indicated the nurse should stay with the resident until medications were consumed by the resident. A policy, last revised 1/2025, titled self-administration of medications, was provided by the DON on 2/23/26 at 11:33 AM. The policy indicated a physician provided a self-administration of medication order and the resident will be assessed to determine the ability to self-administer medicationsThis citation relates to Intake 2737108.3.1-25(b)(3)

Based on interview and record review, the facility failed to ensure a resident was informed of and able to participate in treatment decisions for 1 of 3 residents reviewed (Resident C).Findings include:A report, dated 11/6/25, alleged Resident C's medications were not being given as prescribed and the resident not informed of reason for changes in his treatment.On 12/3/25 at 2:23 P.M., Resident C's record was reviewed. Diagnoses included chronic pain syndrome and polysubstance abuse.A hospital progress note, dated 9/3/25, indicated Resident C had been hospitalized for acute/chronic respiratory failure. The note indicated the resident had chronic pain syndrome with a history of polysubstance abuse. He was prescribed Methadone and was followed by the methadone clinic near his hometown. The resident was discharged to the nursing facility with orders for Methadone 10 milligrams (mg) per 1 milliliter (ml): give 12.5 ml by mouth every day. His next dose was due on 9/5/25 at 9:00 a.m.A social services admission Minimum Data Set (MDS) documentation note, dated 9/5/25, indicated Resident C had no cognitive impairment and was able to make decisions for himself.An initial care conference form, dated 9/5/25 at 3:09 p.m., indicated staff met to discuss Resident C's Road to Recovery. The form listed attendees at the meeting, but did not include the resident. The form indicated Resident C's goal of care was to get his tracheostomy out and work through therapy. His medications were reviewed and reconciled.Care plans, dated 9/8/25, indicated the resident had a history of substance use disorder and was at risk for drug seeking behaviors, relapse and/or drug use. He had a diagnosis of chronic pain with the risk of having pain. The care plan didn't indicate Resident C's chronic pain and substance use disorder was managed with use of methadone through the methadone clinic. Methadone was retrieved from Drugs.com on 12/4/25. The article indicated methadone was a long acting opioid medication used to reduce withdrawal symptoms in people addicted to narcotics and was used for chronic pain management. When used to reduce withdrawal symptoms, methadone was only available through approved opioid treatment programs that provided regular monitoring, counseling, and routine drug testing. Withdrawal from methadone varied from person to person and could last from 2-3 weeks up to 6 months. Withdrawal symptoms included anxiety, restlessness, drug cravings, tiredness, muscle cramps, nausea, vomiting, diarrhea and depression.A physician order, dated 9/4/25, indicated to give Methadone concentrate 10mg/ml; give 12.5 ml (total dosage-125 milligrams) by mouth for chronic pain syndrome every day.A Nurse Practitioner (NP) note, dated 9/5/25 at 6:50 p.m., indicated Resident C had been hospitalized for acute/ chronic respiratory failure, was placed on a ventilator and required a tracheostomy. The note indicated the NP was asked to transition Resident C to Suboxone (used for opiate addiction but not used for pain) in place of Methadone. There was little information provided by the hospital and the NP was going to request a discharge summary.The NP note did not indicated the transition from Methadone to Suboxone had been discussed with Resident C including risks, withdrawal symptoms, benefits, and alternative treatments.An NP note, dated 9/8/25, indicated Resident C was seen for management of opioid dependency. The resident had been on methadone to wean off of opioids and had his dose decreased when admitted to the facility. His methadone would be decreased to 10 mg per day, and staff would continue to monitor for withdrawal. When he tolerated the current dose for 72 hours, the dose would continue to be decreased. When the resident was unable to tolerate the decrease, he would consider changing to Suboxone.The NP note did not indicated the transition from Methadone to Suboxone had been discussed with Resident C including risks, withdrawal symptoms, benefits, and alternative treatments.A physician order, dated 9/8/25, indicated to give methadone 10 mg/5 ml; give 5 ml one time per day.A nurse progress note, dated 9/8/25 at 1:51 p.m., indicated Resident C's methadone dose was decreased to 5 ml daily and the resident was aware.An NP note and nurse progress notes, dated 9/8/25, didn't indicate the resident understood the significant change in his methadone dosage and was agreeable to the change, nor were the risks, benefits, and alternatives to decreasing the methadone dose discussed with the resident.An NP note, dated 9/19/25, indicated Resident C was seen for management of methadone. The resident had tolerated reducing the methadone dose for at least 7 days. The methadone dose would be decreased to 2 ml per day, and staff would monitor for signs of withdrawal.The NP note did not indicate the resident was notified and understood the decrease in his methadone dose. The note didn't indicate the resident was agreeable to the change nor were the risks, benefits and alternatives discussed with Resident C.A nurse progress note, dated 9/20/25, indicated Resident C had been upset that morning because his methadone dose had been reduced. He indicated he didn't understand why there were changes due to his long-term use status and being a patient of a methadone clinic. The NP was notified and orders given to change the methadone dose back to 5 ml daily. The resident was aware of the new order and new dose administered.A nurse progress note, dated 9/21/25, at 6:55 p.m., indicated Resident C requested the methadone clinic handle his methadone dosing going forward. The NP was notified of the request.An NP progress note, dated 9/22/25, indicated the resident had been seen. During the visit, the resident indicated he preferred to have his methadone dose returned to the previous dose of 7.5 ml and have the methadone clinic provide dosing orders. The note indicated the NP would need to touch base first with the clinic.On 12/4/25 at 12:28 P.M., a healthcare provider from Resident C's methadone clinic was interviewed. The provider indicated they did not understand why the resident's methadone dosages had been decreased when he was under the methadone clinics care. The provider indicated the resident had been upset that he hadn't been receiving his usual dosage of methadone, prescribed for substance use disorder and chronic pain. Additionally, the methadone clinic was responsible for providing the methadone medication to the resident/facility to be administered but were unable to do so because they hadn't been notified of the resident's placement at the facility.On 12/4/25 at 12:54 P.M., the facility NP was interviewed. He indicated he had been told by a nurse manager, Resident C was supposed to be weaned off of methadone and changed to suboxone. At the time of admission, he had not known the resident was being seen at a methadone clinic and his methadone dosages adjusted by the clinic. When asked if the resident had been involved in the decision to decrease the methadone and risks, benefits, and alternatives discussed, the NP indicated he thought so but hadn't documented this in his progress note.On 12/4/25 at 2:17 P.M., Registered Nurse (RN) 2 was interviewed. The RN indicated the NP would document in the NP notes if a change in medication or treatment was being changed along with resident's response and approval of the changes. Staff nurses would document any adverse reactions to the change in medication and/or treatment.On 12/4/25 at 2:22 P.M., Licensed Practical Nurse (LPN) 3 was interviewed. The LPN indicated changes in medications and treatments were discussed and documented in the NP notes as well as the nurse progress notes. LPN 3 indicated their personal preference was to always re-iterate new orders with the residents prior to administration to ensure their involvement and approval of the changes as well as give an opportunity for questions. LPN 3 would document the discussion with a resident in the nurse notes.A current policy, titled Your Rights and Protections as a Nursing Home Resident was provided by the Director of Nursing Services on 12/4/25 at 3:35 P.M. which stated the following: You [resident] have the right to be informed, make your own decisions.You [resident] have the right to be informed about your medical condition, prescriptions.to participate in the decisions that affects your care.to take part in developing your care plan. By law, nursing homes must develop a care plan for each resident. You have the right to take part in this process.This Citation relates to Intake 26624083.1-3(n)(2)

Based on observation, interview, and record review, the facility failed to ensure hair and nail care was completed for 1 of 1 resident reviewed.Findings include:.During an observation, on September 23, 2025, at 1:43 PM, the following was observed: Resident 3's hair was greasy and disheveled. Resident 3's left hand had fingernails that were approximately half an inch long, and a brown substance was under her right index and pinky fingernails. Resident 3 was in a hospital gown with brown and yellow stains.During an observation, on September 25, 2025, at 10:05 AM, the following was observed: Resident 3's hair was greasy and disheveled. Resident 3's left hand had fingernails that were approximately half an inch long, and a brown substance was under her right index and pinky fingernails. Resident 3 was in a hospital gown with brown and yellow stains.During an observation, on September 26, 2025, at 10:55 AM, the following was observed: Resident 3's hair was greasy and disheveled. Resident 3's left hand had fingernails that were approximately half an inch long, and a brown substance was under her right index and pinky fingernails. Resident 3 had a blanket over her chest; her hospital gown was scrunched to her waist, and a light pink incontinence brief was exposed. Nail polish was not observed on Resident 3's fingernails. Licensed Practical Nurse (LPN) 8 asked Resident 3 if she could cut her nails. Resident 3 asked why. LPN 8 showed Resident 3 her right thumb and pointer fingernails had a brown and green substance under them. LPN 8 again asked Resident 3 if she could cut her nails. Resident 3 indicated she did not care.In an interview on, September 26, 2025 at 10:55 AM, LPN 8 indicated Resident 3 typically had long nails. LPN 8 stated she did not think Resident 3 would allow her to cut her nails, as her grandkids sometimes came in and painted her nails. LPN 8 indicated Resident 3's grandchildren were unable to paint her nails if they were short. LPN 8 indicated she was surprised Resident 3 stated she did not care if she cut her fingernails, as she typically refused to have them cut. LPN 8 indicated Resident 3 previously did want her nails cut. LPN 8 indicated she was unsure why her hair looked greasy and what was under her nails; however, she could get Resident 3 up and bathed. LPN 8 indicated Resident 3 typically refused showers and did not want to get up. LPN 8 indicated that complete bed baths should have included hair washing. LPN 8 indicated the Certified Nursing Assistants documented if a resident refused hair washing on shower sheets. LPN 8 indicated the resident's care plan should include if a resident refused care. LPN 8 indicated they should document if a resident refused care and update the care plan as needed.Resident 3's record was reviewed on September 26, 2025, at 10:00 AM. Diagnoses included depression, acquired absence of right leg above knee, and difficulty in walking.Resident 3's progress notes did not include refusal of hair or nail care.A review of Resident 3's current Preferences for Customary Routine and Activities dated August 20, 2025, indicated Resident 3 was used to bathing in the shower. The assessment indicated it was Very Important to Resident 3 to choose between tub bath, shower, bed bath, or sponge bath.A review of Resident 3's current care plan indicated the resident had a problem of requiring assistance and/or monitoring of AM/PM care, nutrition, hydration, and elimination, with a goal date of 9/18/2025. Interventions included Tasks: AM Cares including bathing, dressing, hair combing, and oral care; and Tasks: PM Cares including bathing, dressing, hair combing, and oral care. There were no interventions provided for Resident 3 regarding refusal of care.Shower sheets for Resident 3, indicated the following:Dated August 3, 2025, Resident 3 refused nail care.Dated August 14, 2025, Resident 3 refused shampoo.Dated August 21, 2025, Resident 3 refused oral and nail care, and shampoo.Dated August 28, 2025, Resident 3 refused care.Dated September 11, 2025, Resident 3 refused nail care and shampoo.Dated September 18, 2025, Resident 3 refused nail care and shampoo. Dated September 25, 2025, Resident 3 refused nail care and shampoo.There were no indications on the shower sheets Resident 3 had been offered bed baths or a reattempt at care had been tried.A current policy, dated 8/2023, provided by the Administrator, on September 29, 2025, at 12:24 PM, indicated, Create an organized resident-centered review on a routine basis to improve communication with resident, resident families and/or representative regarding the resident goals, total health status including functional status, nutritional status, rehabilitation and restorative potential, ability to participate in activities, cognitive status, psychosocial status, sensory and physical impairments as well as care and services provided to maintain or restore health and well-being.3.1-38(a)(3)

Based on observation, interview, and record review the facility failed to ensure dignity was provided for 1 of 13 residents reviewed. (Resident 22). Findings include: An observation starting on 11/12/24 at 9:18AM, in the 200 hallway, consisting of rooms 215-228, staff from several departments were observed entering resident rooms without waiting for permission or an answer after knocking softly or not knocking at all. Some of the staff did announce what department they were from, none announced their name. Certified Nursing Assistant 4 (CNA) went directly into room [ROOM NUMBER] without knocking and announced after entering, who turned the light on?. CNA 5 entered room [ROOM NUMBER] after tapping with one finger on the door and immediately entering the room. No announcement was made prior to entering. No pause was given between finger tap and entering room. In room [ROOM NUMBER], several staff were coming and going from the room. There was no knocking or asking permission to enter the resident(s) room. The Activity director, a member of laundry/housekeeping (6), and a CNA (7) were all seen entering without knocking or asking for permission to enter. One of the three did say hello upon entering. During an observation, on 11/12/24 at 10:56AM, in Resident 22's room, CNA 7, RN 3, and a member of housekeeping (8) all entered the room without knocking, clarify they did not ask for permission without asking for permission to enter, or announcing themselves by name. The CNA did state nursing upon entering the room. Each time someone entered Resident 22 stopped talking mid-sentence. In an interview on 11/12/24 at 10:57 AM, Resident 22 indicated she was embarrassed by the crusty yellow, brown and white patches on her scalp and loss of hair. Resident 22 also complained of being in a gown at near noon and expressed she did own clothing. Resident 22 indicated she did not want her husband to see her in this condition. Resident 22's record review began on 11/12/24 at 2:45PM. Resident 22 diagnoses included schizoaffective disorder, muscle weakness, major depression, and lack of coordination. Resident 22 did not have any documented diagnosis of skin conditions for her scalp or any physician orders for treatments for scalp. Resident 22's most recent comprehensive, Minimum Data Set (MDS), assessment dated [DATE] indicated the following: Section C: Cognitive Patterns. A Brief Interview of Mental Status (BIMS) score of 10, indicated moderate impairment. Section D: Mood Resident mood interview (PHQ-2 9) indicated moderate depression. Section E: Behaviors were scored as none. In an interview, on 11/13/24 at 8:01 AM, Registered Nurse 3 (RN) indicated the proper procedure to entering a resident room was to knock on door wait for an answer and announce yourself. RN 3 confirmed staff were to ask or wait for permission to enter residents' rooms. In an interview, on 11/14/24 at 10:45 AM, the Administrator asked if staff were just knocking and announcing themselves. The Administrator provided an indated policy and procedure for Abuse and Neglect. The policy did not cover resident rights to dignity. The administrator indicated he would look for a check-off in their orientation or other policies to cover entering resident rooms. No policy was made available at the time of exit. 3.1-3(p)(1)(t)

Based on observation, interview, and record review the facility failed to ensure pain was managed for 1 of 1 resident reviewed. (Resident 22) Findings include: In an interview, on 11/12/24 at 10:12 AM, Resident 22 indicated she was frequently experiencing back pain and not getting any relief from it. Resident 22 indicated she told the nurses and was at times given Tylenol and at other times given reasons she had to wait. Resident 22 indicated the nursing facility staff were aware of her pain. Resident 22 indicated she was rarely given medication for the pain and was not offered any non-pharmaceutical relief. Resident 22 indicated Tylenol was better than nothing but did not relieve the pain. During a continuous observation in Resident 22's room, on 11/12/24 between 10:12 AM and 11:03AM, Resident 22's brows were observed to be crunched, face was grimaced, and there was reddening on her forehead between her eyes. Resident 22 became tearful at times and stopped to catch her breath at other times. Registered Nurse (RN 3) came in to address Resident 22's roommate, at 10:32 AM. Resident 22 stopped her and expressed a great deal of pain. RN 3 did an assessment. Asking for her pain level. Resident 22 indicated her pain level was a 10. RN 3 asked how she was talking if her pain was a 10. Resident 22 indicated her pain was the worst pain she had ever felt, and she was having pain quite frequently as they were all aware. RN 3 asked Resident 22 to describe the pain and the location of the pain. Resident 22 explained slowly the pain was in her back, and it went from a constant throb to at times feeling like she was being stabbed. RN 3 indicated she would let Resident 22's nurse know of their discussion and request of pain medication. Resident 22 asked specifically for something more than Tylenol. Resident 22 asked for ibuprofen or tramadol and indicated Tylenol was not effective when the pain was of this level. RN 3 did not ask if there was anything else helpful in relieving the pain, offer turn or reposition, lowering the lights, a message, ice, heat, or soothing music. RN 3 did not offer any other relief. After RN 3 left the room on 11/12/24 about 10:40 AM, Resident 22 went on to explain what happened when she complained of pain. She described someone other than her nurse would come in. She felt talked down to as if she didn't know when she was in pain or not. She indicated much of the time she would not see or talk to the nurse or get any relief from the pain. She indicated she was not offered any pain relief mesures other then medications. Resident 22's record review began on 11/13/24 at 9:21AM. Resident 22's diagnoses included schizoaffective disorder, muscle weakness, diabetes, asthma, swelling, and pain. Resident 22's physician orders related to pain were limited to an order for Tylenol (acetaminophen) 325mg tablet, 650mg every 4 hours as needed. Not to exceed 4grams in 24 hours. Resident 22's most recent comprehensive, Minimum Data Set (MDS), assessment dated [DATE] indicated the following: Section C: Cognitive Patterns. A Brief Interview of Mental Status (BIMS) score of 10, indicated moderate impairment. Section D: Mood Resident mood interview (PHQ-2 9) indicated moderate depression. Section E: Behaviors were scored as none. Section J: Health Conditions Pain Assessment Interview was not completed. Resident 22's plan of care indicated the problem of at risk for pain related to impaired mobility, diabetes, and asthma, The goal was resident will be free from adverse reactions of pain. The interventions included observing nonverbal signs of pain i.e. changes in breathing, mood/behavior, eyes changing expression, sad/worried face, crying, teeth clenched, and changes in posture. An intervention was to offer non pharmalogical interventions such as a quiet environment, rest, shower, back rub, and reposition. Resident 22's progress notes, printed 11/13/24 at 11:09 AM, indicated the most recent entry of a complaint of back pain was on 11/7/24 and Tylenol was administered. The entry did not have documented non pharmacologic attempts for pain relief. The progress notes dated from 10/16/24 to 11/7/24 had no other documentation of complaints of pain. Resident 22's Medication Administration Record (MAR) dated November 2024 was reviewed through November 13. On 11/7/24 Tylenol 325mg (2) tablets were given at 2:32PM for pain, a pain level of 5, location was not indicated, and effectiveness was marked with an E. On 11/13/24 at 12:27PM Tylenol 325mg (2) tablets were given for pain, level was a 4, and location was the back. Resident 22's pain concern on 11/12/24, nor attempts for pain relief were not documented. A policy and procedure titled, Pain Management Policy dated 01/03 and last revised 7/2024, indicated .to provide the necessary care and services to attain and maintain the highest practicable physical, mental, and psychosocial wellbeing, including pain management .interviewable resident pain with be given based on intensity of the pain using the verbal descriptive, numerical scale of 0-10 .Non interviewable resident- pain medications will be given based upon nursing assessment of the following: non verbal sounds, vocal complaints of pain, facial expressions (grimaces, winces, wrinkled forehead, furrowed brows, clenched teeth), protective body movements or postures .Physician orders for pain medication will be prescribed based upon the resident's intensity of pain. For example, Tylenol for mild to moderate pain. Vicodin for severe to very severe pain . 3.1-37(a)

Based on observation and interview the facility failed to maintain the walls in 1 of 3 resident rooms reviewed. (Room 222) Findings include: During an abservation al tour with the Administrator on 10-20-21 at 9:01 AM, in Room 222, the wall by bed A had an area about 8 x 12 inches scraped into the plaster. By Bed B there was an area about 10 x 10 inches scrapped into the plaster with an area about 4 x 4 inches patched with caulking in the middle. In an interveiw with the Administrator on 10-20-21 at 9:22 AM, he indicated the faciity has been without a Maintenance Director for a while. The Facility has been moving ahead with renovations A Corporate Maintenance person comes in weekly to assist. He indicated there are persons in each room each day to notice things that needed fixing, so would reeduate on that as there were no work orders to address the areas on the wall. This citation is related to complaint IN 852. 3.1-19(e)

Based on interview, and record review, the facility failed to ensure chempotherapy medication was administered as ordered for 1 of 3 residents reviewed. (Resident B) Findings include: A review of Resident B's closed record on 3/23/2021 at 11:25 a.m., indicated [DIAGNOSES REDACTED]. A Physician Note, dated 2/20/2021, indicated the facility physician reviewed all medications, allergies [REDACTED]. The physician documented he agreed with current orders, and indicated to continue with current medications. A review of the Discharge Orders from the sending hospital, dated 2/19/2021, indicated the Medication Ibrutinib (a medication used to treat [MEDICAL CONDITION]) 35 mg(milligram)/ml(milliliter) suspension via FT (Feeding Tube) 560 mg = 16 ml daily at 10:00 a.m. was to be continued. A review of the MAR (Medication Administration Record) dated 2-2021 indicated an order for [REDACTED].=16 ml suspension at 10 a.m. On the daily administration, an X was documented in the dates of 2/19 (date of admiission), 2/20, 2/21, and 2/22/2021. On the dates of 2/23, and 2/25, initials were documented. On 2/24, documentation was blank. On the dates of 2/26, and 2/27/2021, an H was documented. Resident B had received 2 doses of the medication during her 6 day stay. During an interview on 3/23/2021 at 3:25 p.m., Nurse 1 indicated X on the MAR meant the resident was not there, initials documented meant the medication was administered, and H meant the resident had been sent out to the hospital. A Prescription Order, dated 2/22/2021 at 4:14 p.m. indicated to give Imbruvica (ibrutinib) 560 mg =16 ml suspension at 10 a.m. A Progress Note, dated 2/22/2021 at 7:08 p.m., indicated administration of the medication was to continue per order. During an interview on 3/23/2021 at 3:37 p.m., the DNS (Director of Nursing Services) indicated the pharmacy would not make the ibrutinib, it was specially made by Resident B'[MEDICAL CONDITION] doctor. The DNS further indicated the medication had been sent with Resident B and was available for administration on 2/20, 21, and 22, 2021. During an interview on 3/23/2021, at 4:23 p.m., Nurse 2 indicated she completed Resident B's Admission Assessment, including medication orders. The CNA (Certified Nurse Aide) doing the personal inventory for Resident B, gave her a bottle of medicine. The label on the bottle indicated the mediaction was Imruvica. Nurse 2 indicated there was approximately a half bottle of the suspension (about 30 ml), and she put the medication in the medication cart. She had received a report from the sending hospital and knew the resident was not due for the medication until 10 a.m. the next morning (2/20/2021). Nurse 2 indicated she did not work again until Monday 2/22/2021 on the evening shift. She indicated she called the facility pharmacy, and the pharmacy where the medication was made to follow up, because nothing had been completed over the weekend. During an interview on 3/24/2021 at 11:35 a.m., the Regional Nurse Consultant indicated the facility should have written an order to hold the medication until it was clarified. During an interview on 3/24/2021 at 1:45 p.m., the ED (Executive Director) indicated the facility did not have a policy regarding a delay in medications and or treatments. This Federal tag relates to complaint IN 504. 3.1-48(c)(2)

Based on observation, interview, and record review, the facility failed to ensure staff followed transmission based precautions to contain COVID-19 when entering a resident room in 1 of 3 random observations. Findings include: On 2/25/2021 at 8:48 p.m., LPN 2 was observed walking into an unidentified resident's room on the Covid Unit with no protective eye wear or face shield on. One resident was listed as residing in the room, with a [DIAGNOSES REDACTED]. During an interview on 2/26/2021 at 10:30 a.m., the ED (Executive Director) indicated the staff knew better. They are always to be wearing their masks, and especially on the Covid Unit. An undated form, Protective Equipment Requirements Per Zone, provided by the ED on 2/26/2021 at 11:24 a.m., indicated the following: .RED: N95 mask with eye protection (faceshield, goggles or protective eyewear). YELLOW: N95 mask with eye protection (faceshield, goggles or protective eyewear). GREEN: Surgical, KN95, N95 mask with eye protection (faceshield, goggles or protective eyewear) for those who provide services to a resident within 6 ft. This Federal citation is related to IN 256. 3.1-18(a)

Based on observation, interview, and record review the facility failed to ensure needles precautions and fall prevention interventions were maintained for 1 of 5 residents reviewed (Resident Z). This had the potential to affect 9 of the 30 residents residing on the hall. Findings include: 1. On 1/23/2020 at 11:25 a.m., the medication cart was observed on the second floor, long hall. On the side of the medication cart at approximately 3 feet high, was observed to be a sharps container in an enclosure, attached to the side of the medication cart. The door to the enclosure was observed to have a keyed locking mechanism. The sharps container was observed to have no lid covering the container and the contents of the needle box were visible when standing beside the cart. Observed inside the needlebox were trash and syringes. The interior bottom of the needle box not able to be visualized due to the level of contents of the sharps container. The door to the enclosure, was able to be opened without a key. At 11:27 a.m., RN (Registered Nurse) 1 was observed to drop a used lancet (sharp device used to puncture the skin) in the needlebox as there was no lid on the container. On 1/23/2020 at 11:35 a.m., a different medication cart on the second floor short hall was observed. The sharps container on the side of this cart was observed without a lid. When standing beside the medication cart, the contents of the sharps container were visible. The interior base of the sharps container was not visible due to the amount of trash and/or needles observed inside. On 1/23/2020 at 12:41 p.m., RN 1 was observed to have just administered an insulin injection. She was observed to dispose of the used needle in the sharps container on the side of her medication cart. She was observed to have placed it in open area on the top of the container. No lid was observed on the container. On 1/23/2020 at 1:15 p.m., RN 2 was made aware of the unsecure sharps containers on the second floor unit. On 1/23/2020 at 2:34 p.m., the DNS (Director of Nursing Service) was interviewed. She indicated they had a new nurse on the second floor unit. The DNS indicated the new nurse was the one who put the sharps container on the medication cart without a lid. On 1/27/2020 at 12:35 p.m., the DNS was interviewed. The DNS indicated the facility was unable to locate a policy and procedure regarding the sharps containers. The DNS indicated the sharps containers should have had a lid on them and the door to the enclosure on the sharps container should have been locked. On 1/27/2020 at 1:00 p.m., the sharps containers on the sides of the two medication carts were observed. The sticker on the side of the sharps container indicated Sharps Safety, Biohazard and Danger Used Needles. On 1/27/2020 at 1:31 p.m., the DNS provided a list of residents, who were identified by the facility, as being confused and independently mobile. The facility identified 9 residents on the second floor unit where the unsecured sharps containers were located to be confused and independently mobile. On 1/27/2020 at 3:11 p.m., the DNS was interviewed. She indicated the purpose of the lid on the sharps container was intended to prevent used needles and sharps in the container from being accessed. 2. A review of Resident Z's record on 1/28/2020 at 5:19 p.m., indicated the residnet had severe cognitive impairment, meaning the resident was unable to complete a BIMS (Brief Interview of Mental Status). [DIAGNOSES REDACTED]. On 1/23/2020 at 3:30 p.m., an observation of Resident Z's room indicated there was a low bed against the wall, with a raised edge mattress, and an extra mattress was leaned against a room wall. On 1/28/2020 at 4:35 p.m., Resident Z was observed sitting behind the nurses station, in his high back wheelchair beside a CNA (Certified Nurse Aide). On 1/28/2020 at 10:59 a.m., Resident Z was observed in the main lobby, in his wheelchair being pushed per the ADNS (Assistant Director of Nursing Services). On 1/28/2019 at 12:17 p.m., Resident Z was observed in the dining room eating. On 1/29/2020 at 3:54 p.m., Resident Z was observed sitting behind the nurses station, in his high back wheelchair, beside CNA 6. On 1/30/2020 at 10:10 a.m., Resident Z was observed in the dining room, sitting at a table in his high back wheelchair, participating in an activity. On 1/30/2020 at 12:15 p.m., an observation of Resident Z's room indicated there was a low bed with a parameter mattress on the bed, and the bed was made up with linens, and blankets. A flat red mat was up against the wall beside the bed that was against the wall. There were three blue mattresses that were leaned against the room mates dresser. On 1/30/2020 at 12:22 p.m., Resident Z was observed sitting in the dining room, eating lunch. During an interview on 1/27/2020 at 12:18 p.m., the ED (Executive Director) indicated the staff was using wedge pillows under Resident Z's. He decided to report, this becasue this was not a regular fall intervention, then conducted a follow up and inserviced staff. An undated statement by the MDS (Minimum Data Set) Coordinator indicated, upon morning rounding, she had found the resident's bed was elevated with wedge cushions. The wedge cushions were removed immediately, the ED and DNS were notified. There were eight interview sheets that were used for conducting interviews, but not signed by who conducted them. Four of them were staff interviews and four were resident interviews. One of the staff forms, completed by LPN 7, on 1/17/2020 indicated at the bottom of the form she did not put things under any one's bed. The nurse management team, consisting of the ADNS (Assistant Director of Nursing), the CEC (Clinical Education Coordinator), the MDS Coordinator, and the Medical Records Coordinator completed the same interview form and at the bottom of the form indicated to evaluate staff, ensure they understand protocol, inservice on proper care, and following profile sheets to ensure best practices. A Record of Facility Inservice was in an investigation file, conducted on 1/21/2020 by the CEC. The inservice consisted of the facility policy titled Abuse Prohibition , Reporting, and Investigation, dated 6/2018. During an interview on 1/29/2020 at 3:54 p.m., CNA 6 indicated they provide 1:1 when Resident Z was restless or agitated. During an interview on 1/30/2020 at 10:24 a.m., the ADNS indicated at certain times of the day Resident Z would get agitated or restless, and the CNA's would provide 1:1 observed care. During an interview on 1/30/2020 at 11:56 a.m., the MDS Coordinator indicated during her morning rounds she walked into Resident Z's room and observed 2 wedge cushions placed under his mattress, making his mattress slant toward the wall. Resident Z was in the bed at that time lying on his back. She indicated she removed the wedge cushions. She reported the findings to LPN 5, and knew the wedges were not care planned. She further indicated she had talked to the DNS about it and indicated that Resident Z was very impulsive and active. During an interview on 1/30/2020 at 12:23 p.m., LPN 5 indicated she remembered the day the wedges were found under Resident Z's mattress and that the resident was not harmed, but the wedge cushion use was not according to the care plan. A review of Resident Z's Progress Notes indicated the following: 1/17/2020 at 1:40 a.m., LPN 5 documented Resident Z was in the hallway and on his knees in front of his wheelchair. The resident was assessed and not injured. The staff assisted the resident back into his chair and was 1:1 with staff. LPN 5 had documented the resident had been agitated when staff was trying to assist him, they offered fluids and the resident accepted. 1/17/2020 at 6:17 a.m., LPN 5 documented the resident had been up all night and continued to be resistive. She further documented no psychosocial distress was noted. 1/20/2020 at 12:57 p.m., an IDT (Interdisciplinary Team) Fall Review documented by the DNS indicated the resident had an unwitnessed fall on 1/17/2020 at 1:40 a.m., and had been agitated and restless. The note indicated interventions implemented. A review of the Fall Care Plan, dated 6/4/2019 indicated no interventions that included wedge cushions. During an interview on 1/30/2020 at 2:40 p.m., the DNS indicated the state reportable was pretty vague. She indicated the ED completed the reportable and started the investigation. She indicated she made sure the staff completed the Head to Toe Assessment. She further indicated she was not in the facility on 1/17/2020. The DNS indicated she talked with LPN 5 and CNA 8, and they had indicated they put the wedge cushions there (under the mattress), because they did not want the resident to fall again. The DNS indicated she had notified the Nurse Practitioner and the residents emergency contact that morning. During an interview on 1/30/2020 at 3:08 p.m., the ED indicated he did not find out during the investigation who or how the wedges got put under the bed, he only knew they were implemented to keep the resident from falling again. The ED indicated the state reportable had not elaborated as to what the incident pertained to or any facts that indicated a root cause that was investigated by the facility. 3.1-45(a)(1)

Based on observation, interview, and record review the facility failed to ensure needles precautions and fall prevention interventions were maintained for 1 of 5 residents reviewed (Resident Z). This had the potential to affect 9 of the 30 residents residing on the hall. Findings include: 1. On 1/23/2020 at 11:25 a.m., the medication cart was observed on the second floor, long hall. On the side of the medication cart at approximately 3 feet high, was observed to be a sharps container in an enclosure, attached to the side of the medication cart. The door to the enclosure was observed to have a keyed locking mechanism. The sharps container was observed to have no lid covering the container and the contents of the needle box were visible when standing beside the cart. Observed inside the needlebox were trash and syringes. The interior bottom of the needle box not able to be visualized due to the level of contents of the sharps container. The door to the enclosure, was able to be opened without a key. At 11:27 a.m., RN (Registered Nurse) 1 was observed to drop a used lancet (sharp device used to puncture the skin) in the needlebox as there was no lid on the container. On 1/23/2020 at 11:35 a.m., a different medication cart on the second floor short hall was observed. The sharps container on the side of this cart was observed without a lid. When standing beside the medication cart, the contents of the sharps container were visible. The interior base of the sharps container was not visible due to the amount of trash and/or needles observed inside. On 1/23/2020 at 12:41 p.m., RN 1 was observed to have just administered an insulin injection. She was observed to dispose of the used needle in the sharps container on the side of her medication cart. She was observed to have placed it in open area on the top of the container. No lid was observed on the container. On 1/23/2020 at 1:15 p.m., RN 2 was made aware of the unsecure sharps containers on the second floor unit. On 1/23/2020 at 2:34 p.m., the DNS (Director of Nursing Service) was interviewed. She indicated they had a new nurse on the second floor unit. The DNS indicated the new nurse was the one who put the sharps container on the medication cart without a lid. On 1/27/2020 at 12:35 p.m., the DNS was interviewed. The DNS indicated the facility was unable to locate a policy and procedure regarding the sharps containers. The DNS indicated the sharps containers should have had a lid on them and the door to the enclosure on the sharps container should have been locked. On 1/27/2020 at 1:00 p.m., the sharps containers on the sides of the two medication carts were observed. The sticker on the side of the sharps container indicated Sharps Safety, Biohazard and Danger Used Needles. On 1/27/2020 at 1:31 p.m., the DNS provided a list of residents, who were identified by the facility, as being confused and independently mobile. The facility identified 9 residents on the second floor unit where the unsecured sharps containers were located to be confused and independently mobile. On 1/27/2020 at 3:11 p.m., the DNS was interviewed. She indicated the purpose of the lid on the sharps container was intended to prevent used needles and sharps in the container from being accessed. 2. A review of Resident Z's record on 1/28/2020 at 5:19 p.m., indicated the residnet had severe cognitive impairment, meaning the resident was unable to complete a BIMS (Brief Interview of Mental Status). [DIAGNOSES REDACTED]. On 1/23/2020 at 3:30 p.m., an observation of Resident Z's room indicated there was a low bed against the wall, with a raised edge mattress, and an extra mattress was leaned against a room wall. On 1/28/2020 at 4:35 p.m., Resident Z was observed sitting behind the nurses station, in his high back wheelchair beside a CNA (Certified Nurse Aide). On 1/28/2020 at 10:59 a.m., Resident Z was observed in the main lobby, in his wheelchair being pushed per the ADNS (Assistant Director of Nursing Services). On 1/28/2019 at 12:17 p.m., Resident Z was observed in the dining room eating. On 1/29/2020 at 3:54 p.m., Resident Z was observed sitting behind the nurses station, in his high back wheelchair, beside CNA 6. On 1/30/2020 at 10:10 a.m., Resident Z was observed in the dining room, sitting at a table in his high back wheelchair, participating in an activity. On 1/30/2020 at 12:15 p.m., an observation of Resident Z's room indicated there was a low bed with a parameter mattress on the bed, and the bed was made up with linens, and blankets. A flat red mat was up against the wall beside the bed that was against the wall. There were three blue mattresses that were leaned against the room mates dresser. On 1/30/2020 at 12:22 p.m., Resident Z was observed sitting in the dining room, eating lunch. During an interview on 1/27/2020 at 12:18 p.m., the ED (Executive Director) indicated the staff was using wedge pillows under Resident Z's. He decided to report, this becasue this was not a regular fall intervention, then conducted a follow up and inserviced staff. An undated statement by the MDS (Minimum Data Set) Coordinator indicated, upon morning rounding, she had found the resident's bed was elevated with wedge cushions. The wedge cushions were removed immediately, the ED and DNS were notified. There were eight interview sheets that were used for conducting interviews, but not signed by who conducted them. Four of them were staff interviews and four were resident interviews. One of the staff forms, completed by LPN 7, on 1/17/2020 indicated at the bottom of the form she did not put things under any one's bed. The nurse management team, consisting of the ADNS (Assistant Director of Nursing), the CEC (Clinical Education Coordinator), the MDS Coordinator, and the Medical Records Coordinator completed the same interview form and at the bottom of the form indicated to evaluate staff, ensure they understand protocol, inservice on proper care, and following profile sheets to ensure best practices. A Record of Facility Inservice was in an investigation file, conducted on 1/21/2020 by the CEC. The inservice consisted of the facility policy titled Abuse Prohibition , Reporting, and Investigation, dated 6/2018. During an interview on 1/29/2020 at 3:54 p.m., CNA 6 indicated they provide 1:1 when Resident Z was restless or agitated. During an interview on 1/30/2020 at 10:24 a.m., the ADNS indicated at certain times of the day Resident Z would get agitated or restless, and the CNA's would provide 1:1 observed care. During an interview on 1/30/2020 at 11:56 a.m., the MDS Coordinator indicated during her morning rounds she walked into Resident Z's room and observed 2 wedge cushions placed under his mattress, making his mattress slant toward the wall. Resident Z was in the bed at that time lying on his back. She indicated she removed the wedge cushions. She reported the findings to LPN 5, and knew the wedges were not care planned. She further indicated she had talked to the DNS about it and indicated that Resident Z was very impulsive and active. During an interview on 1/30/2020 at 12:23 p.m., LPN 5 indicated she remembered the day the wedges were found under Resident Z's mattress and that the resident was not harmed, but the wedge cushion use was not according to the care plan. A review of Resident Z's Progress Notes indicated the following: 1/17/2020 at 1:40 a.m., LPN 5 documented Resident Z was in the hallway and on his knees in front of his wheelchair. The resident was assessed and not injured. The staff assisted the resident back into his chair and was 1:1 with staff. LPN 5 had documented the resident had been agitated when staff was trying to assist him, they offered fluids and the resident accepted. 1/17/2020 at 6:17 a.m., LPN 5 documented the resident had been up all night and continued to be resistive. She further documented no psychosocial distress was noted. 1/20/2020 at 12:57 p.m., an IDT (Interdisciplinary Team) Fall Review documented by the DNS indicated the resident had an unwitnessed fall on 1/17/2020 at 1:40 a.m., and had been agitated and restless. The note indicated interventions implemented. A review of the Fall Care Plan, dated 6/4/2019 indicated no interventions that included wedge cushions. During an interview on 1/30/2020 at 2:40 p.m., the DNS indicated the state reportable was pretty vague. She indicated the ED completed the reportable and started the investigation. She indicated she made sure the staff completed the Head to Toe Assessment. She further indicated she was not in the facility on 1/17/2020. The DNS indicated she talked with LPN 5 and CNA 8, and they had indicated they put the wedge cushions there (under the mattress), because they did not want the resident to fall again. The DNS indicated she had notified the Nurse Practitioner and the residents emergency contact that morning. During an interview on 1/30/2020 at 3:08 p.m., the ED indicated he did not find out during the investigation who or how the wedges got put under the bed, he only knew they were implemented to keep the resident from falling again. The ED indicated the state reportable had not elaborated as to what the incident pertained to or any facts that indicated a root cause that was investigated by the facility. 3.1-45(a)(1)

Based on observation, interview and record review, the facility failed to ensure a resident with a gastrostomy tube (g tube) (tube inserted into the stomach to provide nutrition for resident who has difficulty eating) was maintained in the recommended manner for 1 of 10 residents observed during medication administration. (Resident 7) Findings include: On 1/23/2020 at 2:30 p.m., the record of Resident 7 was reviewed. [DIAGNOSES REDACTED]. The significant change MDS (minimum data set) assessment dated [DATE], included the following: resident never or rarely understood; had a feeding tube while a resident and received 51 % or more calories through the tube feeding. On 1/23/2020 at 12:00 p.m., RN 1 was interviewed. She indicated Resident 7 had her tube feeding turned off at approximately 11:00 a.m. today. RN 1 indicated Resident 7 had a [DEVICE]. On 1/23/2020 at 12:10 p.m., RN 1 was observed to remove a 60 ml (milliliter) syringe from a bag, which had been hanging at the bedside. The interior, flat portion of the syringe, was observed to have a clump of light orange residue, about 1/4 inch long by 1/8 inch wide. RN 1 was observed to attach this syringe to the resident's [DEVICE]. RN 1 was observed to pick up the canister which contained the medication and water and poured it into the syringe. RN 1 was not observed to check placement of the [DEVICE]. Before RN 1 poured the medication into the syringe, she was interviewed regarding checking placement of a [DEVICE] prior to administering medications. RN 1 indicated she was new to the facility and was not familiar with the policy for [DEVICE]s. RN 1 was then observed to pour the liquid with the 3 mixed medications into the syringe. She then pushed the plunger into the syringe, pushing the medication contents through the [DEVICE]. RN 1 repeated this process of putting the remainder of the liquid with the medication into the syringe, pushed the plunger, and pushed the contents through the [DEVICE]. RN 1 was not observed to flush the [DEVICE] with water after the medication administration. RN 1 was then observed to remove the syringe from the [DEVICE]. The clump of orange residue remained in the interior base of the syringe after the medication administration. RN 1 was observed to go into the bathroom with the syringe and rinse it out. RN 1 was interviewed at this time. She indicated the clump of orange in the base of the syringe was residue from previous medicaiton administrations. She was observed to rinse the residue out of the base of the syringe and place the syringe back in the bag. On 1/27/2020 at 12:35 p.m., the Director of Nursing Service (DNS) was interviewed. She indicated RN 1 should have checked placement of the [DEVICE] prior to administering the medications. She indicated medications administered through a [DEVICE] were to have been given separately. They indicated each medication should have been dissolved separately in 10-30 ml (milliliters) of water and flushed with 5 cc water between each medication. She indicated the medications should not have been administered mixed together. The DNS was made aware of the orange residue observed in the syringe prior to administration of the medications. She indicated the syringe should have been flushed after each administration to ensure all the medication had been administered. The DNS was made aware RN 1 administered the medications by pushing the plunger into the syringe until all the liquid had been pushed into the [DEVICE]. The DNS indicated RN 1 should not have pushed the liquid into the tube with the syringe but instead should have let the fluid flow into the [DEVICE] by gravity. She indicated the staff was to check for placement and residual prior to each time medication was administred. On 1/23/2020 at 2:33 p.m., the DNS provided a current copy of the facility policy and procedure for Enteral Tube - Medication Administration dated 3/2013. The policy and procedure included, but was not limited to, the following: check enteral tube or patency and gastric contents, remove plunger from syringe and attach barrel to feeding tube, flush tubing with 30 ml of water, administer each medication, upon competition, flush tubing with 30 ml water and rinse syringe with water, dry and place in dated plastic bag. On 1/27/2020 at 1:10 p.m., the DNS provided a current copy of the facility policy and procedure for Enteral Tube Procedure dated 9/2019. The policy and procedure included, but was not limited to, the following: Enteral Tube - Gastric Content and Patency Procedure: Attach a 30-60 ml syringe to feeding tube and aspirate for stomach contents. Rinse equipment in water, dry or air dry and return to plastic bag when completely dry. 3.1-44(a)(2)

Based on interview, and record review, the facility failed to ensure a PASRR (Preadmission Screening and Resident Review) Level II evaluation was completed for 1 of 3 residents reviewed. (Resident 16) Findings include: A review of Resident 16's record on 1/29/2020 at 10:51 a.m., indicated the resident had a BIMS (Brief Interview of Mental Status) score of 3 out of 15, meaning the resident had severe cognitive impairment. The score was obtained from the MDS (Minimum Data Set) Quarterly Assessment, dated 10/14/2019. [DIAGNOSES REDACTED]. The demographic sheet indicated Resident 16 was admitted with [DIAGNOSES REDACTED]. The MDS Annual Assessment, dated 5/7/2019 indicated no to severe mental illness in Section A 1500/1510, and an active [DIAGNOSES REDACTED]. The Care Plan for mental illness, dated 1/27/2018 indicated the residnet had a [DIAGNOSES REDACTED]. The interventions included the following, but were not limited to: a yearly RR (Resident Review) was required. A Level II evaluation was completed on 9/4/2017, indicated the resident was mentally ill, did not require specialized services, but a yearly Resident Review was required. A review of Resident 16's Level I evaluations, dated 8/21/2017 and 12/15/2017 indicated the resident was required to have Level II evaluations completed. A review of the form, State of Indiana Certification of PASARR/MI, PreAdmission Screening Determination, dated 9/4/2017 indicated the following: Under the section of Services of Less Intensity Than Specialized Services a yearly RR(Resident Review )was required. There were no other current Level II evaluations completed. During an interview on 1/30/2020 at 9:49 a.m., the ED (Executive Director) indicated the corporate SSD (Social Service Director) had informed him that yearly Level II's were no longer required, unless there was a significant change with the resident. A review of the policy, ASCEND Management Innovations, dated 6/28/2013, provided by the ED on 1/30/2020 at 10:32 a.m., under sections regarding outcomes or decisions; did not indicate that required yearly Resident Reviews were no longer required. A review of a current facility policy, PASRR Policy, dated 11/2017, provided by the ED on 1/30/2020 at 11:12 a.m., indicated the following: .It is the policy of this facility to ensure that any Pre-admission Screening and Resident Review (PASRR) recommendations which impact those with an Intellectual, Mental Disability or related conditions are completed as prescribed and PASRR assessments are updated with significant changes in mental or physical status. 2. Residents who admit to the facility with a Level 2 assessment due to an Intellectual, Mental Disability or related condition will have Level 2 recommendations incorporated into the resident's plan of care. These recommendations will be completed as described in the Level 2 assessment .

Based on observation, interview, and record review, the facility failed to ensure Activities of Daily Living (ADL) were completed per the preferences of 1 of 3 residents reviewed. (Resident 7) Findings include: On 1/23/2020 at 3:26 p.m., Resident 7 was observed in her room, lying in her bed, slightly turned on her right side, her eyes were closed, and she was dressed in a facility gown. On 1/28/2020 at 11 a.m., Resident 7 was observed in her room, lying in her bed, her eyes were closed, and she was dressed in a facility gown. On 1/28/2020 at 5:05 p.m., Resident 7 was observed in her room, lying in her bed, and slightly turned on her left side. The residents eyes were closed, and she was dressed in a facility gown. On 1/29/2020 at 4:10 p.m., Resident 7 was observed in her room, lying in her bed, and the resident was dressed in a facility gown. On 1/30/2020 at 10:07 a.m., Resident 7 was observed in her room, lying in her bed, positioned slightly to her right side, and her eyes were closed. The resident was dressed in a facility gown. On 1/30/2020 at 12:18 p.m., Resident 7 was observed in her room, lying in her bed, and was positioned on her back. The resident was dressed in pants and a top. A review of Resident 7's record indicated a BIMS (Brief Interview of Mental Status) was unable to be completed due to severe cognitive impairment. The cognitive status was obtained from the MDS (Minimum Data Set) Quarterly Assessment, dated 12/27/2019. [DIAGNOSES REDACTED]. During an interview on 1/24/2020 at 11:43 a.m., the family member indicated the resident was wearing a facility gown everyday instead of the staff getting her up and dressed in clothes. During an interview on 1/24/2020 at 12:20 p.m., the family member indicated the resident was to be assisted up in the chair at least every other day, and further indicated for several months the resident had not been out of bed. The family member indicated the staff had informed them they did not have time to get the resident up, or have time to put the resident back to bed. The family member indicated when they asked about getting the resident up, the facility indicated they would work on it. During an interview on 1/30/2020 at 10:09 a.m., CNA (Certified Nursing Aide) indicated she was new to day shift, but she was sure Resident 7 was getting up in the chair and dressed daily. During an interview on 1/30/2020 at 10:11 a.m., Employee 4 indicated they had never seen Resident 7 up in the chair parked in the residents room. Employee 4 further indicated the resident was rarely ever dressed in clothing and mainly wore the facility gown. During an interview on 1/30/2020 at 10:17 a.m., LPN (Licensed Practical Nurse) 5 indicated they had only seen Resident 7 up once since she had started several months ago. They further indicated the resident was always wearing a facility gown, and they had not seen her dressed in clothes. A review of Physician order [REDACTED]. Activity Level: Up ad lib (as much as can or wants) in wheel chair with assist, dated 2/28/2019. Positioning /Devices: Pressure reducing cushion in wheel chair every shift, dated 2/28/2019. A review of forms, Activities--Preferences for Customary Routine and Activities, dated 3/8/2019 and 10/29/2019 indicated it was important for the resident to choose clothing and preferred time to get out of bed. The information on the form was obtained from a family member interview. A Care Plan, dated 2/28/2019, Resident required assistance with ADL's, and interventions included, but were not limited to the following: Assist with ambulation as needed, resident uses a broad {sic} (Broda) chair, dated 2/28/2019. Assist with transfers as needed with a Hoyer (mechanical) lift with 2 assists, dated 2/28/2019. Assist with dressing/grooming/hygiene as needed, requires assistance with ADL's, dated 2/28/2019. A Skills Validation for CNA, [NAME]M. Care, dated 4/2012, provided by the ED (Executive Director) on 1/30/2020 at 11:33 a.m., indicated the following: assist resident with dressing as requested, and assist resident out of bed if applicable. During an interview on 1/30/2020 at 11:55 a.m., the DNS (Director of Nursing Services) indicated the facility did not have a policy directed at only ADL care. 3.1-38(a)(2)

Based on observation, interview, and record review, the facility failed to ensure it was free of a medication error rate of greater than 5 percent (%) for 2 of 10 residents observed during the medication pass. Five medication errors were observed during 28 opportunities for error in medication administration. This resulted in a medication error rate of 17.86%. (Resident 3, and Resident 7) Findings include: 1. During observation on 1/28/2020 at 12:35 P.M., RN 2 was observed to prepare and crush [MEDICATION NAME] 2 mg and [MEDICATION NAME] 25 mg for Resident 3, placed them both together in the medicine cup and mixed them with water to dissolve for [DEVICE] administration. She then proceeded to administer both medications together through the [DEVICE]. RN 2 failed to administer each medication separately through the [DEVICE]. During an interview on 1/28/2020 at 3:26 P.M., the assistant director of nursing indicated the policy is that each medication should be administered by itself, with 5 mL (milliliters) of water after each, and then followed by 30 mL water. The procedure titled Medication Pass Procedure, reviewed 12/2016 stated, Procedure Steps: . 20. Flush [DEVICE] with 30cc (sic) of water, administered each med as ordered. Flush tubing with 5cc (sic) water between each medication, followed by 30 ccwater (sic). 2. On 1/23/2020 at 12:10 p.m., RN 1 was observed to prepare medication for Resident 7. RN 1 indicated resident 7 had a gastrostomy (g) tube(tube inserted through the abdominal wall through which nutrition was provided) . RN 1 was observed to prepare 3 medications. She was observed to crush a tablet of [MEDICATION NAME], 0.2 mg (milligrams), open a capsule of [MEDICATION NAME] 100 mg, empty the contents into a cup, then pour 15 milliliters (ml) of [MEDICATION NAME] liquid 250 mg/5 ml into a separate medication cup. RN 1 obtained a measuring cup and added 100 ml of water. She was observed to add the crushed [MEDICATION NAME] tablet, the contents of the [MEDICATION NAME] capsule and the [MEDICATION NAME] liquid, into the 100 ml of water. RN 1 was observed to pour part of the water with the 3 dissolved medications in it, into a 60 ml syringe attached to the resident's [DEVICE]. RN 1 was then observed to push the contents of the syringe by inserting the plunger and pushing the contents through the syringe. RN 1 was interviewed and she indicated she was new to the facility. She indicated she was not familiar with the policy regarding g tubes. RN 1 repeated this process of putting the remainder of the liquid with the 3 medications into the syringe and using the plunger, pushed the contents through the [DEVICE]. On 1/23/2020 at 2:33 p.m., the Director of Nursing Service (DNS) provided a current copy of the facility policy and procedure for Enteral Tube - Medication Administration dated 3/2013. The policy and procedure included, but was not limited to, the following: Prepare medications: [REDACTED]. On 1/27/2020 at 12:35 p.m., the DNS was interviewed. She said the medications should have been dissolved separately in 10-30 ml of fluid each. She indicated medications administered through a [DEVICE] were to be given separately and flushed with 5 cc water between each medication. Current physician orders [REDACTED]. 3.1-25(b)(9)

Based on interview and record review the facility failed to ensure collaboration between the facility nurse practitioner and the Infectious Disease Clinic for 1 of 1 residents reviewed. (Resident B) Findings Include: Review of the clinical record for Resident B on 8/7/19 at 2:00 p.m. indicated the resident was admitted to the facility with [DIAGNOSES REDACTED]. On 7/25/19, Resident B was admitted to the hospital from an appointment with the Nurse Practitioner who works for Infectious Disease. Resident B had noted worsening absecess which the Infectious Disease Nurse Practitioner was following. On 8/7/19 at 12:00 p.m., interview with the Nurse Practitioner who works for Infectious Disease and who was following Resident B, indicated the resident's abscess was being treated for [REDACTED]. She further indicated she noted the abscess to be worse and found out the facility Nurse Practitioner had changed the Micafungin to [MEDICATION NAME] (an antifungal medication) which she indicated would not effectively treat the infection. Interview with the facilty Nurse Practitioner on 8/8/19 at 11:45 a.m., indicated Resident B had admitted to the facility with the antibiotic and antifungal orders. She indicated insurance would not cover the antifungal [MEDICATION NAME] and the pharmacy had faxed the facility with the Therapeutic Interchange form for [MEDICATION NAME]. The nurse practitioner indicated she filled out the form and went by the pharmacy recommendations on the therapeutic interchange form. She indicated she did not call the infectious Disease practitioner. On 8/8/19 at 3:00 p.m., interview with the Director of Pharmacy for the facility corporation indicated when insurance will not cover a medication, the subscriber is notified and an alternative is given through the Therapeutic Interchange form. On 8/9/19 at 12:15 p.m., interview with the Diretor of Nursing indicated Resident B had been receiving the original ordered antifungal [MEDICATION NAME] from 7/13/19 through 7/20/19 at which time the the pharmacy sent the Therapeutic Interchange and sent [MEDICATION NAME] in its place. The [MEDICATION NAME] was started on 7/20/19. This federal tag is related to complaint IN 124. No State tag.

Based on record review and interview the facility failed to ensure the Notice of Transfer or Discharge form was completed accurately for 3 of 3 records reviewed. (Resident B, Resident C & Resident D) Findings include: 1. Review of the clinical record for Resident B on 6/10/19 at 10:00 a.m. indicated the resident was transferred to another facility on 4/9/19. Review of the Notice of Transfer or Discharge form indicated the address, city state and zip code had not been completed on the form for the facility they were transferring to. Further review of the form also indicated the information for the Local Ombudsman also had not been filled out on the form. 2. Review of the clinical record for Resident C on 6/10/19 at 11:00 a.m. indicated the resident was admitted to the hospital from the facility on 6/8/19. Review of the Notice of Transfer or Discharge form indicated the information for the local Ombudsman die not have the address, city, state or zip code information. 3. Review of the clinical record for Resident D on 6/11/19 at 11:15 a.m. indicate the resident was transferred to the hospital for admission on 5/15/19. Review of the Notice of Transfer or Discharge form indicated no information had been filled out for the local Ombudsman. The name, address, city , state, phone number and zip code were missing. In an interview on 6/11/19 at 11:30 a.m. Employee 1 and 2 indicated the forms should have been filled out completely, but had not been. On 6/11/19 at 11:45 a.m., review of the facility policy and procedure for Discharge/Transfer, with a revision date of 11/17/19 indicated the following: It is the policy of this facility to make the transition for residents transferring from one facility to another safe and to provide for continuity of care and services in a manner that minimizes resident anxiety as much as possible. This federal tag is related to complaint IN 339 3.1-12 (a)(6)(A)

Based on observation, interview, and record review, the facility failed to develop a comprehensive care plan for a resident with recurrent pressure ulcers and failed to ensure weekly pressure ulcer measurements were completed for 1 of 3 residents reviewed with pressure ulcers (Resident V). Findings include: On 3/25/19 at 11:25 A.M., Resident V's record was reviewed. [DIAGNOSES REDACTED]. The resident was always NPO (Nothing by Mouth) and received nutrition via a gastric feeding tube. A quarterly MDS (Minimum Data Set) assessment, dated 1/22/19, indicated the resident was non-verbal therefore, her cognition could not be determined. During the assessment, she had no rejection of care and was dependent on staff for personal hygiene (which included oral care). The MDS indicated the resident had a stage 4 pressure ulcer (full thickness tissue loss with exposed bone, tendon, muscle; slough or eschar may be present on some parts of the wound bed; often includes undermining and tunneling) and an unstageable deep tissue injury (DTI- purple or maroon area of discolored, intact skin due to damage of underlying soft tissue). On 3/26/19 at 10:14 A.M., the resident's pressure ulcers were observed with the nurse. The resident's legs had contractures and were pulled up in a fetal position (knees to chest). Her left lateral (outside) heel was observed with a purple/maroon dark area that was slightly bigger than a dime. The skin surrounding the dark area was dry with thick scales. The entire bottom of the foot had thickened scales and her toenails were thick, brittle, and long. A Care Plan, with a start date of 10/23/18 and revised on 3/14/19, indicated the resident had impaired skin integrity. The resident had been admitted with multiple pressure ulcers which had healed and re-opened in addition to development of new pressure ulcers. The goal was her wounds would heal without complications. Interventions included, but were not limited to, assess her wounds weekly and document measurements and a description of the wounds. The care plan did not indicate the resident had a [DIAGNOSES REDACTED]. The care plan did not indicate how the resident's care would be provided without the recommended treatment, her expected outcomes, consequences of treatment refusal, or relevant alternatives to the current recommendation. A Wound NP progress note, dated 1/2/19 at 11:47 a.m., indicated the resident was seen for multiple wounds to her heels and feet. Assessment: Pressure injury of deep tissue of left heel and pressure injury to left foot, stage 4. The resident had contractures of her legs which put her at high risk for pressure to her feet. Resident V was followed by the Infectious Disease Specialist who ordered a CAT scan to be done on her foot 2 weeks ago. Staff will work on obtaining records. A Physician order, dated 1/8/19 at 1:10 p.m., was from the ID (Infectious Disease) Specialist. The order was to refer the resident to (name) orthopedics for a [MEDICAL CONDITION] due to osteo[DIAGNOSES REDACTED] in the left foot which had not resolved with IV (Intravenous) antibiotic therapy. A Nurse Progress Note, dated 1/8/19 at 2:22 p.m., indicated the facility had received a new order from the ID Specialist to refer to (name) for [MEDICAL CONDITION]. The family was notified by voice message regarding the new order. At 3:38 p.m., the Wound NP was notified of the resident's new order. A Wound NP progress note, dated 1/15/19 at unknown time, indicated the resident was seen for follow up to multiple wounds to her heel and foot. The resident currently had a stage 4 wound to the left lateral foot which measured 0.7 x 0.9 x 0.3 cm (centimeters). The left unstageable pressure ulcer measured 0.1 x 0.1 x <0.1 cm. The resident had recently been referred to ortho (orthopedics) due to continued osteo[DIAGNOSES REDACTED] in her foot. This referral was initiated by the ID who had recently ordered a CAT scan. The plan included, but was not limited to, continue with ordered dressings to her foot wounds and continue with referral to orthopedic surgery by ID for continued osteo[DIAGNOSES REDACTED] to the left foot. A Wound NP progress note, dated 2/1/19 at unknown time, indicated the resident was seen for continued follow up to multiple wounds to her heels and feet. The resident currently had a stage 4 wound to the left lateral foot which measured 0.7 x 0.3 x <0.1 cm. The left unstageable pressure ulcer was resolved. The plan included, but was not limited to, continue with ordered dressings to her foot wounds and continue with referral to orthopedic surgery by ID for continued osteo[DIAGNOSES REDACTED] to the left foot-but wound has improved. A Nurse progress note, dated 2/6/19 at 3:14 a.m., indicated the resident had a black scab to the plantar portion of her left foot and her left heel had a red scab. Facility Wound Management documentation forms, dated 2/6/19 at 12:34 p.m., indicated the stage 4 pressure ulcer on the resident's left lateral foot was healed. There was no further wound documentation completed by the facility from 2/6/19 to 3/6/19. A Wound NP progress note, dated 2/13/19 at unknown time, indicated the resident was seen for continued follow up to multiple wounds to her heels and feet. She had osteo[DIAGNOSES REDACTED] in her left lateral foot wound. The resident's left unstageable pressure ulcer remained resolved. Resident V's stage 4 wound to the left lateral foot measured 0.5 x 0.1 cm. One hundred percent of the wound was covered with a dry eschar (dead tissue). The plan included, but was not limited to, continue with ordered dressings to her foot wounds and continue with referral to orthopedic surgery by ID for continued osteo[DIAGNOSES REDACTED] to the left foot-but wound has improved. A Wound NP progress note, dated 2/27/19 at unknown time, indicated the resident was seen for continued follow up to multiple wounds to her heels and feet. She had osteo[DIAGNOSES REDACTED] in her left lateral foot wound. The resident had a newly developed left heel suspected DTI in the area where she'd had a prior wound that had resolved. The suspected DTI measured 1.5 x 2 cm. The resident's stage 4 wound to the left lateral foot measured 0.5 x 0.2 cm. One hundred percent of the wound was covered with a dry eschar. The plan included, but was not limited to, continue with ordered dressings to her foot wounds and continue with referral to orthopedic surgery by ID for continued osteo[DIAGNOSES REDACTED] to the left foot. A Nurse Progress note, dated 3/5/19 at 8:58 p.m., indicated the resident's left heel wound re-opened and measured 2.5 x 1.5 cm. An IDT (Interdisciplinary Team) note dated 3/6/19 at 3:38 p.m., indicated a left lateral heel wound, stage 2 (partial thickness skin loss). A Wound NP progress note, dated 3/13/19 at unknown time, indicated the resident was seen for continued follow up to multiple wounds to her heels and feet. She had osteo[DIAGNOSES REDACTED] in her left lateral foot wound. The resident had 2 pressure ulcers that merged together and formed 1 wound which measured 1.5 x 0.7 x<0.1 cm. The stage 4 wound to her left lateral foot was closed at this time. The plan included, but was not limited to, continue with ordered dressings to her foot wounds and continue with referral to orthopedic surgery by ID for continued osteo[DIAGNOSES REDACTED] to the left foot. Resident Progress Notes from 1/9/19 through 3/25/19 did not indicate there had been any referral made or follow up completed regarding the resident's referral to the orthopedic specialist for below knee amputation. The resident had continued to have pressure ulcers to the left foot/heel. On 3/25/19 at 4:23 P.M., the DON and ADON (Assistant Director of Nursing/Wound nurse) were interviewed. During the interview, both indicated the resident's guardian did not wish to have the resident referred to orthopedics for consideration of a below knee amputation. The DON and ADON were unable to locate any documentation to indicate the resident's guardian had been notified of the recommendation or that she had decided not to follow the recommendation. There was no documentation from the Wound NP or Medical physician/NP that they had discussed the risks/benefits of treatment, consequences of not pursuing treatment or the expected prognosis and progression of the disease. The ADON indicated she completed weekly measurements on all wounds. She indicated she was alerted to new wounds or re-opened wounds via a New Skin Event form triggered by the nurses in the electronic medical record. The ADON did not have weekly documentation completed on the resident's wounds between 2/6/19 until 3/6/19. On 3/26/19 at 11:50 A.M., the DON indicated she had spoken with the Wound NP and an addendum was made to her progress note on 3/13/19 which stated I have been notified that resident's family has refused referral to ortho for osteo[DIAGNOSES REDACTED] by DON, (name). Wound care orders will continue as currently ordered, there is a high risk of re-occurrence of foot wound and failure to heal due to osteo[DIAGNOSES REDACTED]. At this time, resident shows no s/s (signs/symptoms) [MEDICAL CONDITION] or worsening of foot woods. At this time, it may be wise to discuss future options for care with resident's family (such as do they want to see Infectious disease if wound worsens or symptoms worsen), but at this time, the patient is stable from her wound standpoint-dated 3/25/19 at 9:02 p.m. On 3/26/19 at 1:58 P.M., the DON provided a current copy of the facility policy, titled Skin Management Program which stated the following: Wound Nurse: The facility will designate a licensed nurse responsible for oversight and coordination of the skin management program. The wound nurse and/or IDT will review, assess and document on any new skin alterations in skin integrity the following business day to determine root cause and implement wound/skin integrity healing interventions and then on a weekly basis .Procedure for Alteration in Skin Integrity .4. All newly identified area after admission will be documented on the New Skin Event. The wound nurse is responsible for communicating to IDT on a weekly basis .A plan of care will be initiated to include resident specific risk factors and contributing factors with appropriate interventions implemented .When a Resident Declines Treatments or Interventions: For a resident who declines treatment the IDT or designee must discuss with the resident and/or resident representative, the resident's condition, treatment options, expected outcomes, and consequences of refusing treatment. The facility is expected to address the resident's concerns and offer relevant alternatives if the resident has declined the specific treatments This Federal tag relates to Complaint IN 795. 3.1-40(a)(1)

Based on observation and record review, the facility failed to provide oral care to 2 of 2 dependent residents reviewed for personal hygiene (Resident U and Resident V). Finding include: On 3/25/19 at 2:30 P.M., Resident U's record was reviewed. [DIAGNOSES REDACTED]. The resident was NPO (nothing by mouth) and received all of his nutrition through continuous gastric tube feeding. A quarterly MDS (Minimum Data Set) assessment, dated 1/2/19, indicated the resident's speech was not understood therefore his cognition could not be determined. The assessment indicated he was dependent on staff for personal hygiene which included oral care. He had no behaviors or rejection of care. On 3/25/19 at 10:54 A.M., Resident U was observed lying in bed. He had no gown or top on. He smiled and attempted to talk but his speech was garbled and unable to be understood. His lips were very dry and there was thick white debris observed along his gumline and upper teeth. His tongue was dry and cracked. Tubing was observed attached to a gastric tube in his stomach and extended to a pole with a tube feeding pump attached. On 3/26/19 at 9:50 A.M. and again at 11:57 A.M., the resident was observed lying in bed. He had removed his gown and top sheet which was lying on the floor mat next to his bed. His lips and tongue were dry and scaly. A white coating was observed over his top and bottom teeth. A Physician order, dated 4/23/18 at unknown time, stated Enteral Feeding: Oral care every shift. A Care Plan, initiated on 6/15/18 and revised on 1/12/19, indicated the resident received hospice services. The goal was the resident would experience death with dignity and physical comfort including maintaining optimal nutritional status and skin integrity as the disease process allowed. Interventions included, but were not limited to, provide oral care as needed due to NPO status and provide ADL assistance, including oral care to maintain the resident's comfort and dignity. A Care Plan, initiated on 12/5/18 and revised on 1/12/19, indicated Resident U required assistance and/or monitoring of morning and evening care, nutrition, hydration, and elimination. The goal was that the resident would have his ADL (Activities of Daily Living) needs met. Interventions included, but were not limited to, morning and evening care to include oral care. 2. On 3/25/19 at 11:25 A.M., Resident V's record was reviewed. [DIAGNOSES REDACTED]. The resident was always NPO (Nothing by Mouth) and received nutrition via a gastric feeding tube. A quarterly MDS (Minimum Data Set) assessment, dated 1/22/19, indicated the resident was non-verbal therefore, her cognition could not be determined. During the assessment, she had no rejection of care and was dependent on staff for personal hygiene (which included oral care). On 3/25/19 at 11:00 A.M., Resident V was observed lying in bed, on her back. She was non-verbal but made eye contact and tracked with her eyes. The mucous membranes of her mouth were extremely dry with large thick scales on her tongue. There was thick, cream colored debris attached to the roof of her mouth and upper gum line. On 3/26/19 at 9:59 A.M., the resident was observed lying in bed on her back with her head and face towards the window. An oxygen nasal cannula was observed with one prong in her nose and the other out and next to her nose. She was breathing out of her mouth. She had a congested cough and appeared to struggle to remove thick secretions that were coughed up. Her lips were dry and she had large thick scales on the front half of her tongue. There was a yellow, thickened collection of debris pocketed in her right cheek. A Physician order, dated 10/22/18 at unknown time, stated Enteral Feeding: Oral care every shift. A Care Plan, initiated on 10/23/18 and revised on 12/28/18, indicated Resident V required assistance and/or monitoring of morning and evening care, nutrition, hydration, and elimination. The goal was that the resident would have his ADL (Activities of Daily Living) needs met. Interventions included, but were not limited to, morning and evening care to include oral care. This Federal tag relates to Complaint IN 795. 3.1-38(a)(3)(C)

Based on observation, interview, and record review, the facility failed to follow physician orders [REDACTED]. Findings include: On 3/25/19 at 11:25 A.M., Resident V's record was reviewed. [DIAGNOSES REDACTED]. The resident was always NPO (Nothing by Mouth) and received nutrition via a gastric feeding tube. A quarterly MDS (Minimum Data Set) assessment, dated 1/22/19, indicated the resident was non-verbal therefore, her cognition could not be determined. During the assessment, she had no rejection of care and was dependent on staff for personal hygiene (which included oral care). The MDS indicated the resident had a stage 4 pressure ulcer (full thickness tissue loss with exposed bone, tendon, muscle; slough or eschar may be present on some parts of the wound bed; often includes undermining and tunneling) and an unstageable deep tissue injury (purple or maroon area of discolored, intact skin due to damage of underlying soft tissue). On 3/25/19 at 11:00 A.M., Resident V was observed lying in bed, on her back. She was non-verbal but made eye contact and tracked with her eyes. On 3/26/19 at 10:14 A.M., the resident's pressure ulcers were observed with the nurse. The resident's legs had contractures and were pulled up in a fetal position (knees to chest). Her left lateral (outside) heel was observed with a purple/maroon dark area that was slightly bigger than a dime. The skin surrounding the dark area was dry with thick scales. The entire bottom of the foot had thickened scales and her toenails were thick, brittle, and long. A Physician order, dated 12/11/18 at unknown time, was for [MEDICATION NAME] (water pill) 40 mg (milligram)-take 1 tablet by gastric tube 1 time a day for pleural effusion. A MAR (Medication Administration Record) dated (MONTH) 2019, indicated on 3/22/19 and 3/23/19 at 5:00 a.m., the resident was not given her [MEDICATION NAME] as ordered because the medication was unavailable. The MAR indicated [REDACTED]. Resident Progress notes on 3/22/19 and 3/23/19 did not indicate the physician or NP were notified of the medication not being available and that the resident did not receive the ordered doses of [MEDICATION NAME]. A Prescription request and confirmation of medication refill form indicated the pharmacy filled the order for [MEDICATION NAME] 40 mg tablets to be given 1 time a day per gastric tube on 3/25/19 at 12:30 p.m. On 3/26/19 at 9:55 A.M., LPN 2 (Licensed Practical Nurse) was interviewed. During the interview, she indicated if a resident did not have their medication available for administration, staff could obtain the medication from the facility EDK (Emergency Drug Kit). If the medication was not stocked in the EDK, the pharmacy would be notified to send out the medication STAT (As soon as possible). If the pharmacy didn't have the medication or wasn't able to bring it right away, the facility NP (Nurse Practitioner) would be notified and further orders obtained. She indicated the EDK did contain diuretics (water pill). On 3/26/19 at 1:58 P.M., the DON (Director of Nursing) was interviewed. During the interview, she indicated she was just made aware Resident V had been out of her [MEDICATION NAME] and did not receive it as ordered. The medication was re-ordered on [DATE] and was received by the facility on this day. She could not confirm if the medication had been given on 3/24/19 or 3/25/19 as initialed. On 3/26/19 at 12:11 P.M., the DON provided a current copy of the facility's policy titled Medication Shortages/Unavailable Medications which stated the following: 1. Upon discovery that facility has an inadequate supply of a medication to administer to a resident, facility staff should immediately initiate action to obtain the medication from pharmacy. If the medication shortage is discovered at the time of medication administration, facility staff should immediately take the action .Facility nurse should call pharmacy to determine the status of the order. If the the medication has not been ordered, the licensed facility nurse should place the order or reorder for the next scheduled delivery. If the next available delivery causes delay or a missed dose in the resident's medication schedule, facility nurse should obtain the medication from the Emergency Medication Supply to administer the dose. If the medication is not available in the Emergency Medication Supply, facility staff should notify pharmacy and arrange for an emergency delivery .If an emergency delivery is unavailable, facility nurse should contact the attending physician to obtain orders or directions 2. A Physician order, dated 1/8/19 at 1:10 p.m., was from the ID (Infectious Disease) Specialist. The order was to refer to (name) orthopedics for a [MEDICAL CONDITION] for Resident V due to osteo[DIAGNOSES REDACTED] in the left foot which had not resolved with IV (Intravenous) antibiotic therapy. A Nurse Progress Note, dated 1/8/19 at 2:22 p.m., indicated the facility had received a new order from the ID Specialist to refer to (name) for [MEDICAL CONDITION]. The family was notified by voice message regarding the new order. At 3:38 p.m., the Wound NP was notified of the resident's new order. Review of Wound NP progress notes indicated the following: 1/15/19 at unknown time, Resident seen for follow up to multiple wounds to her heel and foot. The resident had recently been referred to ortho (orthopedics) due to continued osteo[DIAGNOSES REDACTED] in her foot. This referral was initiated by the ID who had recently ordered a CAT scan. The plan included, but was not limited to, continue with ordered dressings to her foot wounds and continue with referral to orthopedic surgery by ID for continued osteo[DIAGNOSES REDACTED] to the left foot. 2/1/19 at unknown time, the resident was seen for continued follow up to multiple wounds to her heels and feet. The plan included, but was not limited to, continue with ordered dressings to her foot wounds and continue with referral to orthopedic surgery by ID for continued osteo[DIAGNOSES REDACTED] to the left foot-but wound has improved. 2/13/19 at unknown time, the resident was seen for continued follow up to multiple wounds to her heels and feet. She had osteo[DIAGNOSES REDACTED] in her left lateral foot wound. The plan included, but was not limited to, continue with ordered dressings to her foot wounds and continue with referral to orthopedic surgery by ID for continued osteo[DIAGNOSES REDACTED] to the left foot-but wound has improved. 2/27/19 at unknown time, the resident was seen for continued follow up to multiple wounds to her heels and feet. She had osteo[DIAGNOSES REDACTED] in her left lateral foot wound. The plan included, but was not limited to, continue with ordered dressings to her foot wounds and continue with referral to orthopedic surgery by ID for continued osteo[DIAGNOSES REDACTED] to the left foot. 3/13/19 at unknown time, the resident was seen for continued follow up to multiple wounds to her heels and feet. She had osteo[DIAGNOSES REDACTED] in her left lateral foot wound. The plan included, but was not limited to, continue with ordered dressings to her foot wounds and continue with referral to orthopedic surgery by ID for continued osteo[DIAGNOSES REDACTED] to the left foot. Resident Progress Notes from 1/9/19 through 3/25/19 did not indicate there had been any referral made or follow up completed regarding the resident's referral to the orthopedic specialist for below knee amputation. The resident had continued to have pressure ulcers to the left foot/heel. On 3/25/19 at 4:23 P.M., the DON and ADON (Assistant Director of Nursing/Wound nurse) were interviewed. During the interview, both indicated the resident's guardian did not wish to have the resident referred to orthopedics for consideration of a below knee amputation. The DON and ADON were unable to locate any documentation to indicate the resident's guardian had been notified of the recommendation or that she had decided not to follow the recommendation. There was no documentation from the Wound NP or Medical physician/NP that they had discussed the risks/benefits of treatment, consequences of not pursuing treatment or the expected prognosis and progression of the disease. On 3/26/19 at 11:50 A.M., the DON indicated she had spoken with the Wound NP and an addendum was made to her progress note on 3/13/19 which stated I have been notified that resident's family has refused referral to ortho for osteo[DIAGNOSES REDACTED] by DON, (name). Wound care orders will continue as currently ordered, there is a high risk of re-occurrence of foot wound and failure to heal due to osteo[DIAGNOSES REDACTED]. At this time, resident shows no s/s (signs/symptoms) [MEDICAL CONDITION] or worsening of foot woods. At this time, it may be wise to discuss future options for care with resident's family (such as do they want to see Infectious disease if wound worsens or symptoms worsen), but at this time, the patient is stable from her wound standpoint-dated 3/25/19 at 9:02 p.m. This Federal tag relates to Complaint IN 795. 3.1-35(g)(2)

Based observation and interview the facility failed to ensure the memory care unit was free of unpleasant odors. This deficiency had the potential to affect 21 of 21 resident that resided in the memory care unit. Findings include: During an observation on the memory care unit on 1/15/19 at 1:39 P.M., an unpleasant odor of urine was smelled near the entrance door and in the hallway. During and observation on the memory care unit on 1/16/19 at 9:48 A.M., an unpleasant odor of urine was smelled near entrance the door and in the hallway. During an observation on the memory care unit on 1/16/19 at 2:10 P.M., an unpleasant odor of urine was smelled near the entrance door and in the hallway. During an observation on the memory care unit on 1/17/19 at 10:18 A.M., an unpleasant odor of urine was smelled near the entrance door and in the hallway. During an observation on the memory care unit on 1/18/19 at 10:34 A.M., an unpleasant odor of urine was smelled near the entrance door and in the hallway. During an observation on the memory care unit on 1/23/19 at 9:23 A.M., an unpleasant odor of urine was smelled near the entrance door and in the hallway. A confidential interview was conducted with a family member of a resident that resided on the memory care unit. During the interview the family member indicated there was an unpleasant odor of urine on the unit in the hallway and near the entry door. The Administrator was interviewed on 1/23/19 at 3:40 P.M. During the interview the Administrator indicated there was an unpleasant odor on the memory care unit, he was not sure where the odor was coming from, but it could have been from the flooring or vents. An undated policy was provided by the Administrator on 1/24/19 at 2:00 P.M., titled Controlling Odors Within Your Community and he indicated it was the policy currently used by the facility. The policy indicated .Flooring: In resident or public restrooms, odor causing bacteria can be absorbed into unsealed floor grouting or get under the tile if grouting is missing or tiles are cracked. VCT tiled floors should have wax applied over the tile to reduce absorption, loose, cracked or missing tiles should be repaired or replaced as well. Anywhere that water can penetrate the flooring; the bacteria that can cause odors can also go. Treating these areas routinely with an approved Odor Eliminator should be part of the odor removal process .Air freshener: Odors should always be treated and removed at the source where they are generated, the use of air fresheners, glade aerosols; plug-ins etc should not be used to mask odors. 3.1-19(e)

Based on record review and interview the facility failed to ensure a safe transfer for 1 of 3 residents reviewed for transfer which resulted in the fracture of the resident's humerus (upper arm). Findings include: Review of the clinical record for Resident B on 6/29/17 at 9:00 a.m. indicated the resident had [DIAGNOSES REDACTED]. Review of the quarterly MDS (minimum data set assessment) dated 3/5/17 indicated the resident was non ambulatory and required the assistance of 2 staff for transfers. Interview with staff and review of the plan of care for Resident B indicated she was to be transferred with the use of a hoyer lift and 2 staff. Interview with the Director of Nursing on 6-29-2017 at 10:20 a.m. and review of the investigation of the fracture indicated on 6/14/17 at 4:42 p.m. the resident was complaining of pain and crying. A call was placed to the physician and an order was obtained for an x-ray. The x-ray was obtained at 10:30 p.m. and the results were received at 11:00 p.m. regarding fracture of Resident B's left humerus. The physician and POA (power of Attorney) were notified and the resident was transferred to the hospital on [DATE] at 3:00 a.m. Resident (B) returned from the hospital at 9:00 a.m. the same day with an order to wear a sling to her left arm. Review of the emergency room record dated 6-15-2017 indicated the resident had a fractured left humerus. The facility initiated an investigation of the fracture on 6/15/17 with all staff interviewed, an in-service was conducted on abuse and staff were educated on reporting incidents. The facility found the original investigation to be inconclusive, felt there were inconsistencies in staff stories and the investigation was continued and staff were re-approached. On 6/18/17 a CNA (certified nursing assistant) told another CNA that the resident fell at midnight. On 6/19/17 the DON was notified and the CNA's were re-interviewed. It was determined the resident had been dropped by 2 CNA'S while transferring her from her wheelchair to her bed. The CNAs were not using the oyer lift. The 2 CNA's involved in the incident were terminated and 2 other CNA's received written warnings. On 6/19/17 the facility re-inserviced all staff regarding reporting unusual occurrences and proper transferring. This federal tag is related to complaint IN 878 3.1-45(a)(2)

Based on observation, record review and interviews, the facility failed to ensure adequate supervision was provided and fall interventions consistently implemented on the secured dementia unit to prevent falls and accidents for 3 of 3 residents reviewed for falls. This resulted in Resident C sustaining a laceration to his head, a concussion and a fractured hip. (Residents B, C, and D) Findings include: 1. The clinical record for Resident #C was reviewed on 09/28/16 at 3:00 P.M. Resident #C was admitted to the facility on [DATE] with diagnoses, including but not limited to: dementia with behavioral disturbances, schizophreniform disorder and depressive episodes. The discharge instructions from the acute care facility, dated 06/16/16, indicated the following: .up with assist, Fall Risk very unsteady The initial MDS (Minimum Data Set) assessment, completed on 06/23/16, indicated Resident C scored 3 of 15 on a BIMS (Brief Interview for Mental Status) assessment and was severely cognitively impaired. Resident C exhibited verbally abusive behavior and rejected care, required extensive staff assistance of one staff for transfers, wheelchair locomotion, dressing and hygiene needs and was frequently incontinent of his bowels and bladder. The care plan related to the risk for falls was initiated on 06/16/16, with the following interventions: anti-rollbacks and anti-tippers on wheelchair, call light in reach, non skid footwear, personal items in reach, and therapy screen, therapy as ordered. The fall event/investigation documentation and nursing progress note, dated 07/04/16 at 10:30 P.M., indicated Resident C was behind the nurse and medication cart, stood up from his wheelchair, lost his balance and fell . The IDT (Interdisciplinary Team) meeting notes regarding the fall, completed on 07/05/16 at 8:54 A.M., indicated the root cause of Resident C's fall was his wheel rolled back when he stood up. The intervention put into place was to put anti-rollback brakes on his wheelchair. During an interview on 09/29/16 at 8:30 A.M., the DIrector of Nursing indicated unless the nurse completing the progress note regarding the resident's falls, there was no place on the Fall event/investigation form to indicate if preventative interventions already care planned were in place and functioning properly. There were no updates added to the careplan after the 07/04/16, fall as the intervention was already care planned and should have been in place. The fall event/investigation documentation and nursing progress notes, dated 07/17/16 at 8:45 P.M., indicated the resident was found lying on the floor, fully dressed and wearing shoes. The fall event/investigation documentation and nursing progress notes, dated 07/18/16 at 2:00 A.M., indicated the resident was found lying face down on the floor in his room beside his bed. He suffered a hematoma to his right forehead. The IDT meeting notes for both falls, completed on 07/18/16 at 10:51 A.M., indicated the root cause of the resident's falls was thought to be decreased safety awareness and bed boundary issues. The interventions were to check a urinalysis and to add a mattress with bolstered sides. The care plan was updated with the mattress with bolsters intervention, labs as ordered and an intervention to toilet the resident between 1-2 (there was no indication if A.M. or P.M. was intended). The fall event/investigation documentation and nursing progress notes, dated 08/01/16 at 8:49 P.M., indicated the resident, who was seated in his wheelchair by the nurses station was observed to lean forward and fall out of his wheelchair. Staff were too far away to prevent the resident's fall. An IDT note, on 08/02/16, indicated the resident was immediately assisted back into his wheelchair and placed in the activity lounge at a table and given an activity of choice. The resident was also screened by therapy for wheelchair safety. There were no safety updates added to the care plan. The fall event/investigation documentation and nursing progress notes, dated 09/03/16 at 1:40 P.M., indicated the resident was found fully dressed with his clothes and shoes on, lying on the floor in the dining room. The resident's fall was not witnessed by staff. An IDT team note, dated 08/06/16 at 11:16 A.M., indicated the root cause was unassisted ambulation attempted by the resident. The immediate intervention was to provide the resident with an activity. This was the same immediate intervention as the resident's previous fall. There was no documentation to indicate why the residnet was in the dementia unit common area during the daytime hours was not being supervised and/or provided with an activity prior to his fall. The care plan was undated with an intervention to provide the resident with activities. The fall event/investigation documentation and nursing progress notes, dated 09/08/16 at 6:55 A.M., indicated the resident was found on the floor beside his wheelchair in the dining room. Direct supervision was immediately provided to ensure the resident did not fall again. The IDT team note, dated 09/02/16 at 11:52 A.M., indicated the root cause was once again the resident attempting to transfer himself and a therapy screen was again recommended. A therapy screen was added to the care plan interventions. There was no documentation to indicate why the resident was in the dining room at 6:55 A.M. without any staff supervision prior to his fall. The fall event/investigation documentation and nursing progress notes, dated 09/17/16 at 2:38 A.M., indicated the resident was found on the floor in his room beside his bed wearing pajamas and slipper socks. The resident suffered a 3.3 centimeter laceration to his right eyebrow and complained of left hip pain. A sensory pad alarm was added to the resident's bed. The resident was transferred to an acute care facility where he was diagnosed with [REDACTED]. He returned to the facility, on 09/17/16 at 10:00 A.M., and the sensory alarm, body pillows and visual observation were put into place as interventions. The care plan was updated with bed in lowest position, bed alarm and body pillow. There was no IDT team documentation attached to the fall event/investigation report. During an interview on 09/29/16 at 3:55 A.M., CNA (Certified Nursing Assistant) #4 indicated she was working the night that Resident C fell . She indicated she was on the dementia unit by herself and was in another resident's room when she heard a crash. She indicated Resident C was already on the floor in his room bleeding from the head and complaining of back pain when she got to him. During an interview on 09/29/16 at 9:00 A.M., the Director of Nursing indicated the IDT team meetings did not follow any facility policy. She indicated the IDT team, which consisted of the Director of Nursing, the Rehab Manager, and possible the Maintenance Supervisor, a Customer Care staff member assigned to the resident being reviewed, the Medical Records staff member and the SSD (Social Service Director) as needed would meet to discuss falls usually on the next day after a fall had occurred. The team would analyze the nursing progress notes and fall events report. In addition the team would look at the location and any equipment involved in the fall to try and determine the cause of the fall. An intervention was to be put into place immediately by the nursing staff and then sometimes the IDT team would add an intervention as necessary. The DON indicated previous interventions and their effectiveness or presence at the time of the fall was not always documented or analyzed when the IDT team looked at falls. 2. The clinical record for Resident B was reviewed on 09/28/16 at 2:23 P.M. Resident #B was admitted to the facility on [DATE] with diagnosis, including but not limited to Alzheimer's disease, insomnia, restlessness and agitation. A quarterly Minimum Data Set (MDS) assessment, completed on 07/16/16, indicated the resident required extensive staff assistance of two staff for transfer needs, required extensive staff assistance for wheelchair locomotion needs and ambulation needs, had exhibited both verbal abusive behaviors and wandering behavior and had not experienced any falls prior to admission and/or in the past 2 to 6 months. A care plan, initiated on 10/24/15, related to the resident risk for falls included interventions for therapy screens as needed, personal items in reach, staff assistance of one for transfers as needed, encourage non skid footwear and call light in reach. An intervention to redirect as accepted when wandering was added on 07/15/16, and interventions to obtain a urinalysis and review his medications was added on 09/21/16. An intervention added on 09/26/16 was to decrease the resident's Klonopin (an antianxiety medication) and administer an antibiotic medication. The event charting related to falls for Resident #B indicated he had fallen on 07/15/16 while ambulating in the hallway and the intervention to redirect him when wandering was added to his care plan. The resident did not fall again until September 2016. In September 2016, the resident was documented as having fallen on 09/19/16 at 3:58 P.M., 09/20/16 at 8:55 A.M., 09/21/16 at 3:45 P.M., 09/24/16 at 6:40 A.M. and at 1:15 P.M., and on 09/28/16 at 1:10 P.M. and 10:15 P.M. The nursing progress note, dated 09/20/16 at 8:56 A.M., indicated the resident was heard yelling in his room and was found lying on the floor. The intervention was to review his medications as he had experienced two falls in 24 hours. A urinalysis was ordered and his Klonopin medication was decreased. The nursing progress notes, dated 09/21/16 at 10:02 P.M., indicated the resident was found flying on the floor in his room wrapped in a blanket. The note indicated the resident was immediately given a snack and his urinalysis test was still pending. The nursing progress notes, dated 09/24/16 at 6:40 A.M., indicated a crashing noise was heard and Resident B was found lying on the floor in front of the refrigerator. The note indicated the resident had no injures but did need assistance to ambulate due to unsteadiness. The resident was visually observed as an immediate intervention. The nursing progress notes, dated 09/24/16 at 1:28 P.M., indicated the resident was found on the floor of his room at 1:16 P.M. His fall was not witnessed. The immediate intervention was to bring him to the lounge for direct supervision. Nursing progress notes, dated 09/28/16 at 1:15 P.M. indicated the resident attempted to get up from his chair, became unsteady and fell to the floor. The resident suffered abrasions to his back. The immediate intervention was to help him back into his chair and offer him the normally scheduled activities. Nursing progress notes, dated 09/28/16 at 10:15 P.M., indicated the nurse was called to Resident B's room by CNAs (Certified Nursing Assistants) who were doing shift change rounds. The resident was found on the floor by the closet and his roommate's dresser. The intervention of putting resident back to bed and visual observation was put into place. On 09/29/16 at 3:52 A.M., CNA #5 was noted to be sleeping in a recliner next to Resident B's bed. Resident B was awake but lying on his back in his bed. CNA #5 did not awaken until 3:55 A.M., when LPN #3 entered Resident B's room to take his vital signs and complete a post fall assessment. During an interview with the DON, on 09/29/16 at 8:30 A.M. she indicated Resident B had been suffering from a Urinary Tract Infection and had been really restless and was noted to be falling frequently. She indicated after he fell the previous evening, she instituted the sitter CNA #5 to watch him to prevent falls. She indicated the CNA was not to be sleeping while providing the supervision. The fall event/investigation forms and nursing progress notes did not indicate why immediate interventions of placing the resident in direct observation, put in place after his falls on 09/24/16 was not continued until he fell twice on 09/28/16. 3. The clinical record for Resident #D was reviewed on 09/29/16 at 4:50 A.M. Resident #D was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent quarterly MDS assessment for Resident D, completed on 08/16/16, indicated the resident required the extensive assistance of one staff for transfer, ambulation needs, dressing and personal hygiene needs. Resident D required supervision and limited staff assistance for wheelchair locomotion. Resident D had experienced two or more falls since the previous MDS assessment. The care plan related to falls for Resident D, initiated on 08/01/14, had interventions to ensure personal items were within reach, non skid footwear was worn, the call light was in reach, and therapy screens were completed as ordered. Interventions were added as follows: *03/30/15: provide the resident with snacks in the afternoon. *10/28/15: utilize a large remote control. *06/16/16: utilize a toilet seat riser and non skid strips in the bathroom in front of the sink. *07/01/16: use a grab bar on the wall in the bathroom. *07/04/16: offer and assist with bedrest after the evening snack. *07/07/16: use non skid strips next to the bed for the entire length. *07/19/16: chair and bed alarm. *08/08/16: threshold alarm in the bathroom. *08/19/16: therapy screen. *09/06/16: remove shoes absent of nonskid bottoms. *09/07/16: occupational therapy evaluation and treatment. *09/26/16: readjust the non skid strips. The fall events/investigation forms and nursing progress notes for Resident D indicated he fell on the following dates and times: 07/04/16 at 9:49 P.M. while attempted to transfer himself from his wheelchair into bed. 07/05/16 at 9:46 A.M. resident fell while attempting to transfer himself from the wheelchair to a dining room chair. 07/06/16 at 9:36 A.M. resident slid off the side of his bed. 07/08/16 at 3:30 P.M. resident slid off of either wheelchair or bed in his room when trying to put his shoes on. 07/18/16 at 1:55 P.M. resident tried to get himself out of bed and fell on to the floor. 08/05/16 at 5:00 P.M. resident tried to transfer himself from his bed into his wheelchair to go to the bathroom. Resident complained of pain to his right hand. X-ray obtained did revealed a nondisplaced fracture of his 5th finger on the right hand. 08/17/16 at 9:00 A.M. resident found in his room on hands and knees by his closet. Resident had gotten himself up out of bed. Bed alarm did not function and was subsequently replaced. 08/19/16 at 2:15 P.M. resident noted attempted to ambulate from wheelchair in the dining room and lost balance and fell 09/02/16 at 5:25 P.M. resident was attempting to stand and retrieve a snack basket off of a counter in the dining area kitchenette when he lost his balance and fell . He sustained a skin tear to his right forearm. 09/07/16 at 9:40 A.M. resident ambulating behind wheelchair to the bathroom when he lost his balance and fell . Bed alarm was sounding and staff attempted to help resident but he initially refused help and when falling his waistband was grabbed by staff and resident was lowered to the floor. 09/26/16 at 6:23 P.M. resident was found without his shoes on in the doorway to his bedroom on the floor. There was no documentation regarding any alarms or previous interventions. Resident complained of left shoulder pain. The IDT (Inter-Disciplinary Team) notes included in the nursing progress notes indicated the following interventions were to be put in place for each fall: 07/04/16 - resident to be offered and assisted into bed following the evening snacks and a psychiatric medication review 07/05/16 - unclear as all of the attached nursing notes and IDT team meeting notes are dated 07/06/16 and refer to the 07/06/16 fall. 07/06/16 the root cause was resident slipped out of his bed. The intervention was to place more gripper strips extending the whole length of his bed. 07/08/16 intervention for the resident to wear gripper socks at all times. 07/18/16 intervention to place a chair and bed alarm 08/05/16 - Tylenol was given for pain, a snack was given. In addition, a threshold alarm was placed in the bathroom and staff were instructed to assist the resident with all hygiene and toileting needs. 08/17/16 - Sensor alarm mat to be placed at the bedside when available. Bed alarm not functioning and was replaced. 08/19/16 - coffee and snacks were immediately offered and a therapy screen was ordered by the IDT team. 09/02/16 - resident was given a snack, his skin tear was treated and IDT discovered his shoes did not have a non skid sole so his shoes were replaced. Resident already had an intervention to have nonskid footwear at all times in place. 09/07/16 - an intervention to use 2 - 3 person assistance with transfers as resident would allow was immediately put into place 09/25/16 - an immediate intervention to x-ray his left shoulder was implemented. IDT team reimplemented an intervention to adjust the nonskid strips next to his bed. Non skid strips were to have been put into place along his bed on 07/06//16. During an observation of Resident D's room, conducted on 09/29/16 at 5:33 A.M. with the Director of Nursing, the bathroom threshold alarm, noted on the wall above the toilet, was not functioning. The DON adjusted the alarm and put in a code and the alarm worked. The censored matt was not noted to be utilized. The DON indicated it was not being utilized currently. When Resident #D requested to be transferred back to his wheelchair on 09/29/16 at 5:35 A.M., CNA #4 attempted x 3 to transfer the resident into bed by herself. She was unable to lift the resident and the resident was unable to assist with the transfer. CNA #4 then did go get CNA #5 to assist with the transfer. 4. During the initial tour of the facility, conducted on 09/28/16 between 9:00 A.M. to 10:08 A.M., there were two male residents observed wandering up and down the dementia unit hallways. One of the residents was noted to go into resident rooms and back into the hallway, muttering alphabetical letters repeatedly. There were several residents on the dementia unit noted seated around tables in the dining/activity lounge. The unit was L-shaped and the dining/activity lounge area did not provide visual access to the hallway. There was a round mirror which did show the hallway from the nurse's station area, which was located the end of the hallway. During an observation of the dementia unit, conducted on 09/29/16 from 3:50 A.M. to 6:00 A.M., the following was noted: At 3:45 A.M., upon entrance to the facility, LPN (Licensed Practical Nurse) #3 was noted at the nurses's station for the Moving Forward nursing unit. During an interview with LPN #3, on 09/29/16 at 3:45 A.M. she indicated she was responsible for both the Moving Forward rehabilitation unit and the Auguste's Cottage dementia unit. She indicated she split her time between the nursing units. LPN #3 indicated the staffing for he dementia unit was usually 1 CNA for third shift as well as herself going back and forth. She indicated because Resident B had been falling so much, there was a sitter, CNA #5 watching him tonight. At 3:50 A.M., upon entering the dementia unit, CNA #4 was observed coming out of a resident room with a back of soiled linens. During an interview with CNA #4, on 09/29/16 at 3:50 A.M., she indicated there was usually just one CNA and then the nurse, who was assigned to two units for the third shift. CNA #4 indicated the nurse usually spent most of the shift off of the dementia unit. CNA #4 indicated sometimes she could not provide the supervision needed for the unit because some residents would stand up and if she was in a different resident room providing care, she could not always get to the resident who had gotten up before they fell . At 3:52 A.M., CNA #5 was noted to be sleeping in a recliner next to Resident B's bed. Resident B was awake but lying on his back in his bed. CNA #5 did not awaken until 3:55 A.M., when LPN #3 entered Resident B's room to take his vital signs and complete a post fall assessment. At 4:00 A.M., LPN #3 left the dementia care unit. The call light was on for Resident room #128, CNA #4 was in a different resident room completing incontinence care and CNA #5 was in Resident B's room. At 4:06, CNA #4 exited Room #132 and answered the cal light for Room #128. At 4:10 A.M., a male resident in Room 124 was noted by CNA #4 up ambulating near the doorway to his room. CNA #4 entered room #124 and directed the resident back to his bed and covered him up with blankets. At 4:11 A.M., CNA #4 took over for CNA #5 who requested a break. At 4:12 A.M., LPN #3 entered the unit and was noted to be charting at the nurse's station. At 4:15 A.M., CNA #4 had assisted Resident B into his wheelchair. CNA #4 was noted to be providing incontinence care to Resident B's roommate. A 4:18 A.M., the DON entered the dementia unit, spoke briefly with LPN #3 and then left the unit. At 4:27 A.M., CNA #5 came back onto the unit from her break, got a cup of coffee from the nurse's station, and went back to Resident B's room. At 4:37 A.M., CNA #4 left the dementia unit, LPN #3 was still charting at the nurse's station, and CNA #5 was in Resident B's room. At 4:50 A.M., CNA #4 reentered the unit and proceeded to provide incontinence care for several different resident. At 5:07 A.M., the bed alarm for Resident D went off and LPN #3 went into his room to talk with him. CNA #4 was noted to exit Resident Room #127 with a male ambulatory resident. At 5:09 A.M., CNA #4 entered Room #124 and LPN #3 exited room #124. At 5:15 A.M. CNA #4 exited Room #124 with Resident D who was dressed and in his wheelchair. Resident D was noted to propel his wheelchair into the hallway around the corner towards the activity/dining lounge area. At 5:18 A.M., CNA #4 gave the ambulatory, male resident from room #127 and Resident D a cup of coffee. LPN #3 had entered Resident B's room to do vital signs and a post fall assessment. At 5:20 A.M. CNA #4 entered Resident room #127 and shut the room door. At 5:25 A.M., CNA #4 exited Resident room #127 with another male, ambulatory resident and soiled linens and trash. After washing her hands, CNA #4 gave the resident a bowl of cereal and some beverages and assisted him to sit at a table in the activity/dining lounge. At 5:30 A.M., DON entered the unit. She entered Room #124 and then left the unit at 5:33 A.M. At 5:34 A.M., CNA #4 was in Room #124 and three residents were unsupervised, all drinking coffee and one eating breakfast in the dining/activity lounge. From 5:35 A.M. - 5:42 A.M., CNA #4 was attempting to transfer Resident D, who had propelled himself back to his room because he was tired, back into bed. The resident was unable to hear instructions and/or unable to follow instructions and CNA #4 could not provide enough assistance to get the resident out of his wheelchair. At 5:42 A.M., CNA #4 went down to Resident B's room and got CNA #5 to assist her. CNA #5 then left Resident B's room and assisted CNA #4 to transfer Resident D back into his bed. While the CNAs were in Resident D's room, a Transportation Employee #6 entered the unit and directed the male resident who had been eating his breakfast out of the unit. Employee #6 indicated she was taking the resident to dialysis. At 5:43 A.M., the DON reentered the unit and then left again at 5:48 A.M. At 5:55 A.M., a housekeeper entered the unit, looked in the linen closet and left the unit. At 5:57 A.M., LPN #3 reentered the nursing unit. There were still brief periods of time where there was no visual supervision for residents in the hall and activity/dinting lounge area and there was no immediate assistance available for residents when CNA #4 was providing incontinence care to other residents in other resident rooms. Documentation provided by the Corporate RN (Registered Nurse), Employee #2 on 09/29/16 at 8:40 A.M., indicated the usual staffing for third shift included one CNA assigned to the secured dementia unit, and one licensed nurse assigned to both the secured dementia unit and the rehabilitation unit. Documentation provided by the DON (Director of Nursing), on 09/29/16 at 9:00 A.M., indicated there were 15 residents on the secured dementia unit. Of the 15 residents, 4 required the assistance of one staff for transfer needs and 2 residents required the assistance of two staff for transfer needs. Eight of the 15 residents exhibited behaviors and 2 were noted to have wandering behaviors. There had been 36 resident falls in the past 3 months. This Federal tag relates to Complaint IN 526. 3.1-45(a)(2)

Based on observation, interview and record review, the facility failed to comprehensively assess distressed behaviors for 1 of 3 residents reviewed for behaviors (Resident T). The facility further failed to develop and implement effective preventive interventions to prevent an initial fall and subsequent falls for 2 of 3 residents reviewed for falls (Resident T and Resident P). This resulted in a laceration and fracture to Resident T's jaw and head injury with laceration. Findings include: 1. On 5/18/16 the following observations were made: At 1:15 p.m., Resident T was observed sitting in the dining room on a couch. He was unshaven and had dirty fingernails. He had a frown shaped wound on his chin and an open reddened area on his right kneecap. He was wearing non-skid socks which were partially falling off his left foot. His meal tray was sitting across the room from the couch. The tray contained several full bowls of pureed food. At 1:20 p.m., he was pacing in the glassed in computer room across from the nurses station. At 1:30 p.m., he was seated back in the dining room on the couch. At 2:50 p.m., Resident T was observed standing in the hallway next to the nurse ' s desk. Another resident seated in a wheelchair, was holding on to the resident ' s right arm, cursed and pulled him towards the wheelchair. The DON, transportation manager, and LPN #3 intervened and separated the two residents. On 5/18/16 at 3:45 p.m., during an interview, The Director of Social Services indicated that Resident T ' s behaviors had increased and he was aggressive with staff and residents. He was transferred to an acute hospital for evaluation of behaviors and aggression on 5/6/16 and 5/15/16. She further indicated attempts had been made to transfer him to a behavioral facility and two other nursing facilities that specialized in care of his disease however he was not accepted due to his age and aggression. On 5/19/16 from 12:10 p.m. to 3:45 p.m., Resident T was observed in his room lying in bed. He was lying on his right side and was curled up in a fetal position. His hands were clasped together and his eyes closed. Between his eyebrows, was a swollen area surrounded by purple discoloration. There was a wound with stitches located in the middle of the swollen area. He had dried blood around the stitches and several spots of dried blood on the bed sheet and pillow case. He was unshaven with dried dark substances at the corners of his mouth and was wearing the same shirt and sweatpants from 5/18/16. On 5/18/16 at 1:45 p.m., record review for Resident T indicated [DIAGNOSES REDACTED]. A quarterly MDS (Minimum Data Set) assessment dated [DATE] indicated a BIMS (Brief Interview Mental Status) score of 3 which indicated the resident had severely impaired cognition. Nurse and IDT (Interdisciplinary Team) notes for Resident T indicated the following: 5/3/16 at (unknown time) an order was received to increase Haldol (psychotropic) medication dosage due to increase in aggressive behaviors. 5/15/16 at 12:12 p.m., Resident T became aggressive in the dining room with RN #4. He refused lunch and pursued staff when they were carrying his lunch tray. He was re-directed to his room. An incident report dated 5/15/16 at 12:55 p.m., indicated Resident T had struck a female resident in the face. The residents were separated immediately. Preventative measures taken were to place the resident on a 15 minute monitoring schedule and keep residents separated from each other during meal times and activities to ensure safety. On 5/15/16 at 4:45 p.m., Resident T was aggressive, throwing objects in the dining room, grabbed staff, and threatened to hit another resident. An order was received for Haldol per injection. The injection was given but had no effect on his behaviors. Emergency transport was called. The police arrived to the facility at 4:25 p.m. and restrained the resident. EMT ' s arrived at 4:35 p.m. and transferred resident to the hospital. At 10:50 p.m., resident returned from the hospital. Resident T had bruises to his face, arms, and legs. He continued to ambulate. An incident report dated 5/16/16 at 3:50 p.m., indicated Resident T made threatening remarks to a female resident. The residents were separated and Resident T was placed on 15 minute monitoring schedule. Staff directed to keep the residents separated during meal times and activities. On 5/16/16 at 8:19 p.m., Resident T was walking back and forth from his room to the dining room. He was aggressive towards staff and chased staff around the nurse ' s desk with intent to harm . He cursed at staff, left the area and returned to his room. On 5/16/16 at 10:08 p.m., Resident T was given Haldol per injection. He was chasing staff and attempted to hit them. On 5/17/16 at 2:35 a.m., Resident T was jogging and pacing up and down the hall. He was banging on a computer monitor and fax machine. Resident T was given new dose of Haldol 50 mg IM (long acting) at 1:20 a.m. The resident continued to pace and jog down the hall but then became unstable . He fell asleep in the computer room for approximately 25 minutes. On 5/19/16 at 1:45 p.m., Resident T ' s plan of care and physician orders [REDACTED]. A problem start date of 11/24/15 and update 4/12/16, indicated Resident T had potential for psychosocial distress related to his young age and nursing home placement. Approaches included .encourage and allow expression of feelings; offer support and validation and observe for any signs of depression, isolation, distress, etc. A Physician order [REDACTED]. On 5/12/16, Resident T ' s Haldol (psychotropic) medication was discontinued and Zyprexa (psychotropic) medication started. On 5/15/16, Zyprexa was discontinued and Haldol restarted at 50 mg per injection every two weeks and Haldol 5 mg per injection every 6 hours as needed. On 5/18/16 an order for [REDACTED]. A problem start date of 8/15/14 and update 4/12/16, indicated the resident was at risk for side effects due to psychotropic medication. Interventions included to observe for .dizziness .drowsiness . impaired balance tremors . A problem start date of 9/8/14 indicated the resident had verbal and physical aggression toward staff during care and meals. An intervention updated on 5/4/16 indicated the resident should be offered extra food throughout the day related to agitation at meal time due to wanting food. A problem start date of 5/18/16 indicated the resident had episodes of aggression and threatening gestures. The goal was that the resident would cause no harm to self or others. Interventions included provide assistance when walking as resident will allow, provide extra food and beverages when observed agitated, psych and medication reviews, and re-direct other peers away from resident when in common areas. An activities plan of care updated on 5/18/16 indicated the resident would benefit from socialization and activities. An intervention was to provide resident with 1:1 activities such as music, readings, looking at magazines, computer tablet to keep him from being agitated. A problem start date of 8/15/14 and updated on 5/18/16, indicated the resident had difficulty making himself understood due to dementia. Interventions included give resident time to complete his thoughts, provide a quiet non-hurried environment free of background noises and distractions and remind resident to speak slowly and clearly. On 5/18/16 at 3:45 p.m., during an interview, the Director of Nursing (DON) indicated the resident was at risk for falls due to unsteady gait, uncontrolled body movements and progression of his disease. She indicated Resident T had multiple falls recently. She further indicated that when the resident was aggressive and pacing in the hallways, staff would provide 1:1 attention to prevent falls and maintain safety of Resident T and other residents around him. During an interview on 5/19/16 at 2:15 p.m., LPN #6 indicated Resident T had fallen on 5/18/16 at 10:40 p.m. He had been sent to the hospital for treatment of [REDACTED]. She indicated the resident had been asleep all day. He was difficult to wake up and had not eaten lunch. During an interview on 5/19/16 at 2:20 p.m., RN #4 indicated there was no record of what medications were administered to Resident T while at the hospital on [DATE]. He further indicated that the facility ' s medical records staff would need to contact the hospital to obtain that information. During an interview on 5/19/16 at 2:25 p.m., CNA #7 indicated the following: Resident T gets agitated and aggressive and won ' t allow staff to care for him. He indicated this has gotten worse the last few weeks. The resident ' s agitation was worse when he was in the dining room. Orderlies usually provided the resident ' s care because the resident doesn ' t ' t like females . The resident spits out his food and tries to hit female CNA ' s when they assist him to eat. CNA #7 indicated when Resident T is agitated and aggressive, the staff will try and isolate him to his room. If he won ' t go to his room, staff will try and keep other resident ' s away from him. CNA #7 further indicated he has had to grab Resident T and hold his arms down by his side or hold him down to separate him from other residents. CNA #7 indicated staff are not always able to provide 1:1 care when the resident is aggressive and pacing because other residents need care. During an interview on 5/19/16 at 2:35 p.m., CNA #5 indicated there are usually two staff on the floor in the evenings and they are not able to provide 1:1 care when Resident T is aggressive, pacing, and falling. She further indicated when male CNA ' s are not working, female CNA ' s try and do his care . She indicated that female CNA ' s are afraid of the resident. Nurse and IDT (Interdisciplinary Team) notes for Resident T indicated the following: On 5/5/16 at 12:13 p.m., Resident T had a witnessed fall onto his knees in the hallway. There was no new intervention on care plan. On 5/16/16 at 3:15 a.m., resident was walking around a corner, lost his balance, and fell on to his face. He had a cut to his chin. He was transported to the hospital for evaluation and treatment. A fall event report dated 5/16/16 at 3:15 a.m., indicated preventative measures to prevent another fall was for resident to have someone with him at all times. An incident report dated 5/16/16 at 3:15 a.m., indicated preventative measures taken to prevent further falls was update the plan of care with recommendations from the hospital. There was no update made to the care plan. On 5/16/16 at 10:13 a.m., Resident T returned from the hospital with a [DIAGNOSES REDACTED]. On 5/16/16 at 6:42 p.m., Resident T was walking towards his room and fell . A fall event reported dated 5/16/16 at 6:48 p.m., indicated intervention to prevent another fall was to feed the resident more often. On 5/18/16 at 10:23 a.m., Resident T had a witnessed fall in the hallway. He was walking when went down on his knees. The intervention to prevent further falls was offer assistance when the resident turns a corner on the hallway, when he allows. 5/18/16 at 10:40 p.m., Resident T had a fall resulting in a head injury. He required emergency treatment and stitches to his forehead. A care plan dated 4/12/16 indicated Resident T was at risk for falls due to (diagnosis) and dementia. The goal was to keep the resident from having a fall related injury. The care plan indicated the resident was at risk for side effects due to psychotropic medication. Interventions included to observe for dizziness .drowsiness . impaired balance The last fall intervention entered on the care plan was dated 3/7/16 and indicated a chair to be replaced with a bigger more stable one. 2. On 5/18/16 at 12:40 p.m., Resident P was observed lying in her bed. There were half side rails on both sides of the bed. She had fading yellow to green colored bruises on both hands. The left side of her chest, near the clavicle bone, had purple, yellow to green colored bruises. During an interview on 5/18/16 at 12:40 p.m., Resident P wanted to know why State doesn ' t ' t allow side rails . She indicated she had requested them but staff kept saying the State won ' t allow . She had a fall from bed on 4/30/16. She did not have half side rails at the time. She indicated she was being bathed by two CNA ' s. She was lying on her left side with one CNA behind and one CNA in front of her. Both CNA ' s moved away from her at the same time. She rolled out of the bed onto the floor. The EMS was called and she was transported to the hospital. She returned to the facility later that day. She had no serious injuries. On 5/19/16 at 2:45 p.m., during an interview with CNA #5, she indicated Resident P needed assistance of 3 persons for bed mobility. She further indicated there were usually two CNA ' s to assist resident with bed mobility. Resident P ' s record was reviewed on 5/19/16 at 2:30 p.m. The resident ' s [DIAGNOSES REDACTED]. An admission MDS (Minimum Data Set) assessment dated [DATE] indicated a BIMS (Brief Interview Mental Status) score of 15 which indicated no cognitive impairment. The MDS further indicated she required extensive to dependent assistance of two plus persons with bed mobility and bathing. She was bedbound. A pre-admission Resident Assessment form dated 4/26/16 requested the facility ' s input on their ability to care for the resident due to her weight and need for three person assist with care. Review of nursing notes for Resident P indicated the following: 4/27/16 at 3:30 p.m., resident needed assistance of 5 persons to transfer into bed. 4/28/16 at 10:13 a.m., 3 person assist with ADL ' s (Activities of Daily Living). 4/28/16 at 10:03 p.m., 3 plus assist with repositioning resident. 4/29/16 at 12:11 p.m., patient is a 3 plus assist with ADL ' s and repositioning in bed. 4/30/16 at 10:15 a.m., resident observed rolling out of bed on left side of bed. Large purple bruising to left side of chest near clavicle, left hand, and left upper arm . 4/30/15 at 10:30 a.m., resident was transported to the hospital per EMS. She returned to the facility on [DATE] at 7:42 p.m. 5/2/16 at 10:08 a.m., an IDT (Interdisciplinary Team) note indicated that staff had given care with two CNA ' s. The resident rolled out of bed when she turned too far while lying on her side. The immediate intervention was to place side rails to her bed for bed mobility and positioning and care plan updated. 5/3/16 at 7:54 p.m., a nursing note indicated the resident is a three to four assist with bed mobility . 5/4/16 at 12:28 p.m., a nursing note indicated she is a three to 4 assist with repositioning in the bed . On 5/19/16 at 3:44 p.m., the DON (Director of Nursing) provided a copy of Resident P ' s most current care plan. Resident P ' s care plan dated 4/28/16, indicated she required assistance with ADL ' s with goal of having ADL needs met. Interventions did not include the amount of assistance and staff needed to provide care. Resident P ' s care plan dated 4/29/16, indicated she was at risk for falls with goal of reducing fall risk factors and avoid a fall related injury. There was no intervention for use of side rails to prevent further falls. 3.1-45(a)(2)

Based on record review and interview, the facility failed to ensure staff provided supervision during care for a totally dependent resident to prevent an accident with injury for 1 resident (A) in a sample of 3 residents reviewed for accidents. Findings include: On 11/4/13 at 9:45 a.m. review of the clinical record for resident (A) indicated she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of resident (A's) admission Minimum Data Set Assessment ((MDS) dated [DATE] indicated the resident was severely cognitively impaired, and required extensive assistance of 2 staff for bed mobility and transfers, and was non-ambulatory. Review of the resident's written plan of care dated 9/13/13 indicated the resident was to have her bed in a low position when occupied . On 11/4/13 at 2:00 p.m. review of an incident report dated 10/21/13 at 9:30 a.m. indicated the resident was left unattended on her side and was found laying on the floor on her back. The resident was assessed and a lump was found on the back of her head. The physician and family were notified and the family requested the resident be sent to the hospital for further evaluation. Interview on 11/4/13 at 10:35 a.m. with nurse #7, who was working when the resident had fallen, indicated the CNA (certified nursing assistant) had been providing care for the resident and had her on her side. The CNA stepped out into the hall to call for assistance, leaving the resident on her side in the bed and when she and the CNA went back into the room the resident was on the floor. The nurse indicated the resident's bed was not in the low position. On 11/5/13 at 11:00 a.m. review of the incident report indicated the resident was assessed by the nurse and had a lump to the back of her head with a minimal amount of bleeding. Review of the hospital notes indicated the resident returned to the facility on [DATE] with a new medication order for "Keppra", an anti-seizure medication. This Federal tag is related to complaint IN 055 3.1-45(a)(2)

Based on observation, interview, and record review, the facility failed to prevent the development of a pressure ulcer, resulting in a painful open area in the palm of the hand for 1 of 1 randomly observed residents in a stage 2 sample of 27 residents (Resident #2). Findings include: 1. Resident #2 was interviewed, at 11:00 a.m., on 2/13/12, and indicated she was having pain in her hands, stomach, and buttocks, and was receiving pain medication every 4 hours, which helped "a little." Both of the resident's hands were observed to be contracted. The left hand was worse and observed balled into a fist. There were no splints noted in place. On 2/13/12, at 3:30 p.m., the resident was heard calling out for the nurse. The resident was lying in her bed, with the call light noted lying on the bed beside her left hand. The resident indicated she was not able to turn on the call light due to the contractures in her hands, and indicated her hands "hurt real bad" and she wanted to go to the hospital. At this time, LPN #40 came into the resident's room and the resident requested pain medication . During medication pass, at 9:10 a.m., on 2/15/12, with LPN#1, the LPN was observed passing medications to Resident #2. The resident indicated her left hand hurt. Both the resident's hands were noted to be in fists with the left worse then the right. An odor was noted to both of the resident's hands. LPN #1 confirmed there was an odor to the resident's hands and the nurse attempted to open the resident's hands slightly, but could not open them. The LPN indicated she had not taken care of the resident for awhile, as the resident had been on a different floor, and moved recently, but indicated the resident used to get occupational therapy and wore splints on her hands. The nurse indicated she didn't know how the CNAS washed the resident's hands. The resident was questioned at this time, and indicated they didn't wash her hands. CNA #3 was interviewed at 10:30 a.m., on 2/15/12, and indicated he was taking care of Resident #2 and she was scheduled for a bath today. The CNA indicated it was difficult to wash the resident's hands because they were so contracted and the resident couldn't open her hands. He indicated the resident used to wear a splint of some kind, but he hadn't seen her wear it lately. While talking with the CNA, the resident called out, "nurse, nurse" and indicated she was having pain. At 10:40 a.m., on 2/15/12, the CNA indicated the resident refused to bathe at this time because she was having too much pain. RN #4 was interviewed at 2:25 p.m., on 2/15/12, and indicated the physician had been called on the first shift regarding the resident's complaints of pain. The RN indicated she didn't know how the resident's hands were washed, but the Restorative Aide was going to talk to the occupational therapist today about the resident's hands. Restorative CNA #5 was Interviewed at 2:45 p.m., on 2/15/12, and indicated she was placing splints on the resident's hands everyday, and placed them on in the morning and left them on for 4 to 6 hours. She indicated she had tried to open the resident's hands this morning, but the resident indicated she was having pain. She indicated she had checked "a little bit ago" and tried to clean the resident's hands with a cloth, but as soon as she touched the resident, she indicated she was having hand pain. Restorative CNA #5 indicated the resident's hands had an odor and when she tried to open her hands, the resident indicated they hurt and started crying. Restorative CNA #5 indicated before she would apply the splints to the resident's hands, she would relax them by soaking the resident's hands in warm water with soap, try to stretch her fingers and open her hands, then apply the splints. She indicated the resident was supposed to have this done 6 days a week, but she hadn't done this treatment for 2 days because the resident had been refusing. She indicated she talked to the therapist today and asked her if she could do anything. The restorative aide indicated she told the therapist the resident's hands had an odor and needed to be cleaned, but the resident was in a lot of pain. She indicated the nurse had just given the resident pain medication. Review of the restorative documentation, provided by the restorative aide, and reviewed with her in attendance, indicated there was no documentation indicating the treatment or splints were completed on 2/7/12, 2/11/12, and a "R" indicating the resident had refused treatment on 2/14/12 and 2/15/12. The restorative aide indicated she had washed the resident's hands on 2/13/12, and applied the splints, but the resident had refused treatment on 2/14/12 and 2/15/12 because the resident was in too much pain. She indicated she had just talked to the therapist and the nurse today about the resident's refusal. Physical Therapist #6 was observed in the resident's room, at 3:10 p.m., on 2/15/12, working with the resident. He indicated he was trying to open her left hand and the reason there was an odor to the hand was because it was contractured, and hard to clean. He indicated the resident complained of pain in the palm of the hand, and it could be due to a nail pressing on the palm of the hand. He indicated he had started working with the resident last week with his goal including transfers, and mobility. He indicated the resident previously was able to transfer with 1 assist, but now required a 1-2 person transfer assist, mostly two now. The resident record was reviewed, on the afternoon of 2/15/12. [DIAGNOSES REDACTED]., [MEDICAL CONDITION], dysphagia, and [MEDICAL CONDITION]. The Minimum Data Set (MDS) assessment, dated 1/16/12, indicated the resident scored 12/15 on the Brief interview for mental status (BIMS), and indicated the resident required extensive to total assist of 1-2 persons for bed mobility, transfer, dressing, eating, and personal hygiene, had upper extremity impairment bilaterally, was incontinent of urine, and was on a scheduled pain management program. Review of the February, 2012, Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. In addition, the same pain medication was ordered to be given every 4 hours as needed (PRN) for moderate to severe pain. The MAR for February, 2012, indicated the PRN medication had been given at 2:00 p.m., on 2/15/12 for hand pain, and twice on 2/16/12, for hand pain, and hand and hip pain. Review of nursing progress notes indicated the following: 1/10/12 thumbnails were trimmed due to cutting into resident's palms; (there was no further documentation in the nursing notes of further nail care) 2/1/12 denies pain and discomfort to bilateral hands; 2/15/12 resident complained of general pain to the left arm and chronic pain to bilateral hands, and resident claimed only slight effectiveness as a result of routine pain medication; physician notified of above; 2/16/12 at 6:44 a.m., complained of hands hurting, pain pill given , effective after one hour; 2/16/12 at 8:00 a.m., resident complained of pain in bilateral hands, routine pain medication given at this time; 2/16/12 at 9:00 a.m., resident indicated pain medication did not help pain in hands. Resident would not allow nurse to assess hand; 2/16/12 at 10:15 a.m., notified by therapy of open area to resident's left palm. Observed open area to center of left palm, pink in color with white moist periwound. Resident required coaxing and encouragement to allow the therapist to open her hand; 2/16/12 at 10:15 a.m., went to resident to assess and trim fingernails, resident would not open hand for assessment; 2/16/12 at 10:30 a.m., physician notified of open area to left hand. Resident still refusing assessment, but stated pain was less now; 2/16/12 at 2:00 p.m., Resident allowed nurse to wash and dress area on left hand. Dry sterile gauze placed to prevent thumb from irritating area. Review of a pressure sore risk assessment, completed on 1/16/12, indicated the resident did not refuse care, the resident was confused or had memory problems, no history of pressure sores, and the resident had impaired or decreased mobility, Review of weekly skin assessment reports indicated skin assessments were completed most recently on 2/3/12 and 2/10/12, with no open areas noted. Review of a therapy screening, dated 10/13/11, indicated the resident required extensive assist for activities of daily living, including feeding and hygiene, the bilateral hands were contractured and range of motion(ROM) impaired, and the resident was at high risk for hand hygiene. Occupational therapy documentation indicated service was discontinued on 2/1/12, and restorative staff educated on current splint and ROM program. The discharge summary indicated the resident responded to therapy and tolerated the bilateral static hand splints and restorative ROM program. Care plans were reviewed and indicated the following: Self care deficit related to dementia and [MEDICAL CONDITION] (problem start date of 5/16/11); approaches included, but not limited to: Restorative nursing as indicated for maintenance of functional status; Chronic back and hand pain (problem start date of 5/16/11) Approaches included, but not limited to: observe for changes in day to day activities; Resident required passive range of motion to bilateral hands, wrists due to contractures (problem start date of 2/1/12). Approaches included, but not limited to: resident would tolerate 20 repetitions of passive range of motion to bilateral hands and wrists 6 days weekly after warm hand soaks; Resident required splint/brace program (problem start date of 2/1/2012) Approaches included, but not limited to: notify nurse if resident had signs of pain or had skin irritation under splint; observe skin for redness or irritation under splint; resident would tolerate wearing bilateral static hand splints for 4 hours 6 days weekly; Resident at risk for skin breakdown due to incontinence and decreased mobility (problem start date of 5/16/11). Approaches included, but not limited to: assess and document skin condition weekly and as needed. The Certified Occupational Therapy Assistant (COTA) #2 was Interviewed at 9:24 a.m., on 2/16/12. She indicated she had been treating the resident for months for hand contractures, and she was discharged from therapy as of 2/2/12 because she had reached the goals with splints, tolerating 4-6 hours a day. She indicated the resident had severe [MEDICAL CONDITION] arthritis. She indicated the restorative aide talked to her yesterday and informed her the resident had refused to wear the splints. The COTA indicated while the resident was in therapy, she was able to open her hands actively enough to wear the splints and she had never refused to wear them before. She indicated she saw the resident on 2/15/12 after talking to the restorative aide, and the resident told her she was in too much pain to wear the splints. She indicated the resident's hands had an odor and If necessary she would put her back on the caseload. She indicated this was completely a new thing with the resident refusing to wear the splints. She indicated she offered to soak the resident's hands, but the resident refused. She indicated the hands would smell after one day if the hands were not soaked. The COTA was observed in the resident's room, at 9:55 a.m., on 2/16/12, cleaning the resident's hands. The resident was noted to attempt to open her hands when requested by the COTA. When she was cleaning the resident's left hand, the resident indicated her hand hurt, and when the COTA opened her left hand, she indicated there was an open sore in the mid palm of the left hand. The COTA indicated the resident's left thumb was contracted all the way in to the palm. At this time, the open area was observed in the middle of palm of hand where the thumb nail had been pressing. The thumb nail was also long and needed to be trimmed. The COTA indicated the area was moist and odorous. Review on the morning of 2/17/12, of the therapy screening, dated 2/16/12, and completed by COTA #2, indicated the resident had refused splint application and hand hygiene for restorative for 2 days. The COTA convinced the resident to let her clean and do passive range of motion (PROM) to the digits and wrists. Upon cleaning and performing PROM to left hand contracture, the COTA noticed a wound on the middle of the palm. Occupational therapy recommended restorative continue right hand hygiene and splint application and left orthotic use on hold until the wound healed. The note indicated nursing dressed the wound and a carrot-shaped palm protector was placed in the left hand to decrease pressure from the thumb touching the wound. Review on the morning of 2/17/12, of a pressure wound skin evaluation report, dated 2/16/12, indicated a new stage 2, pressure area was noted on Resident #2's left palm. The area measured 0.7 x 1.0 centimeters, was pink with a white moist periwound, small amount of serous drainage, and a slight odor. A physician's orders [REDACTED]. Review of the Skin Management Program, with the original date of 3/10, and provided by the medical records LPN, on 2/17/12, at 8:50 a.m., indicated weekly skin assessments would be completed on all residents with or without alterations in skin integrity and documented on the weekly skin assessment form and/or nursing notes. 3.1-40(a)(1) 3.1-40(a)(2)

Based on observation, interviews and record review, the facility failed to provide supervision to prevent falls and prevent a resident altercation which resulted in a fall, injury, hospitalization and death. This deficiency affected 1 of 4 residents in a sample of 5 reviewed, who was injured during a fall/altercation (Resident B) by the actions of a second resident (Resident C). This deficient practice had the potential to affect 26 of 26 residents living on the Alzheimer's/dementia Unit. (Resident B, D, E and C) This deficient practice resulted in Immediate Jeopardy. The Immediate Jeopardy was identified on [DATE] at 4:30 p.m., and began on [DATE], when Resident B sustained an unwitnessed fall in the dining/activity area of the secured unit of the facility. The Administrator, Corporate Director of Operations, Clinical Care Specialist, Social Service Director and Director of Nursing were notified of the Immediate Jeopardy on [DATE] at 4:30 p.m. The Immediate Jeopardy was removed on [DATE], but the facility remained out of compliance at the level of pattern with potential for more than minimal harm that is not immediate jeopardy because of inservicing of staff, evaluation of the activity program and monitoring the presence of staff at all times in the hallways, dining and common areas. Findings include: On [DATE] at 12:00 noon, during the orientation tour, the Director of Nursing (DON) indicated Resident #C had been involved in an altercation with another resident on the secured dementia unit. The DON indicated, after the incident, Resident #C had been hospitalized in a behavioral unit, and had returned to the facility. The resident was observed sitting in a wheelchair in the dining/activity area of the secured unit, with other residents and staff members present. Residents were just finishing the noon meal. The clinical record of Resident C was reviewed on [DATE] at 2:00 p.m. and indicated the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was admitted to a behavioral unit on [DATE] and returned to the facility on [DATE]. Her return [DIAGNOSES REDACTED]. A care plan, initiated on [DATE], indicated Resident C had "...episodes of combative behavior like hitting others." The Minimum Data Set Assessment, dated [DATE], indicated the resident had severe cognitive impairments. Interdisciplinary notes, dated [DATE], indicated, during breakfast at 8:25 a.m., the resident hit Resident E in the right upper arm, when Resident E leaned over her. The incident was witnessed by staff, who were present in the dining room. Resident C was placed on fifteen minute checks and received an initial behavioral psychiatric assessment on [DATE]. The Psychiatric Nurse Practitioner saw her again on [DATE], and wrote in the problem area of the note "Staff asked I see resident 2 (secondary to) increase (sic) behaviors, irritability, and potential risk of resident harming other (sic)." The Nurse Practitioner also ordered Abilify 5 mg daily (an anti-psychotic medication). Nursing notes, dated [DATE] at 10:20 a.m., indicated Resident C was involved in a second altercation with two residents. The note indicated a resident witnessed Resident C push Resident B down. The facility incident report form, for the incident on [DATE], indicated Resident C, Resident B and Resident D were in the main dining room on the Alzheimer's Unit, when staff heard yelling. Upon entering the dining room, Resident B was on the floor and Resident C had Resident B's walker and was attempting to swing it at Resident D, who was hitting Resident C. The report indicated Resident B was injured and had sustained a hematoma on the back of her head. Review of the closed clinical record of Resident B, on [DATE] at 2:00 p.m., indicated she had been admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment, dated [DATE], indicated the facility was unable to determine the resident's mental status due to inattention, disorganized thinking and impaired decision making skills. The MDS also indicated she used a walker for mobility. She was receiving 81 mg of aspirin daily and Naproxen 250 mg as needed for pain. Both medications have side effects which increase the potential for bleeding. Nurses notes, of [DATE] at 10:20 a.m., indicated Resident B had been involved in an altercation with Resident C, and sustained a fall. The nurses notes, dated [DATE] at 12:29 p.m., regarding the incident indicated no staff had been present to witness the fall or to witness the resident being pushed. Resident B became less responsive, according to nurses notes of [DATE], at 10:33 a.m.,and was sent to the hospital. Hospital notes, dated [DATE], in the clinical record, indicated Resident B had been diagnosed by a CT (computed tomography) scan showing the presence of subdural, subarachnoid and intraventricular hemorrhage. The resident returned to the facility on [DATE] with comfort care orders. She expired [DATE]. Review of the death certificate, obtained by the facility on [DATE], indicated the manner of death was homicide and the cause of death was failure to thrive with sequentially listed conditions leading to the cause of death being subdural and subarachnoid hematoma and a fall during an altercation. The description of how the injury occurred was listed as "decedent involved in altercation, fell and struck head." Prior to the fall of [DATE], a resident investigation questionnaire, dated [DATE] at 5:15 p.m., indicated Resident B had been found on the floor in the dining room. The fall had not been witnessed by staff members. The form indicated the resident had been observed prior to the fall walking around with her rolling walker too far in front of her. The form indicated another resident (not identified by facility staff) from the dementia unit saw Resident B fall, and the determination indicated the resident had lost her balance, sustaining the fall. According to nurses notes of [DATE] at 9:45 a.m., no injuries had been noted and the intervention was for the therapy department to assess the walker she was using. The physical therapy assessment, dated [DATE], indicated, "Resident has adequate & (and) appropriate assistive equipment." The three CNAs, who were working at the time of the incident on [DATE], were interviewed and indicated there was no staff person in the dining/activity room at the time of the incident. On [DATE] at 1:35 p.m., CNA #10 indicated three CNA's and a Nurse were working on the Alzheimer's unit, at the time of the incident on [DATE]. She indicated she and another CNA were on the back unit while the third CNA was assisting other residents on the front hall. CNA #10 indicated she heard yelling in the dining room, all three CNAs arrived in the dining room at the same time, and they found Resident B on the floor. CNA #10 indicated when she arrived in the dining/activity room, Resident B was on the floor and Resident C was standing up, swinging Resident B's walker at another resident (Resident D). CNA #10 indicated Resident C had told her she was "tired of (Resident B) following her around." CNA #10 indicated staff members have to "hurry" and get other residents away from Resident C when she is agitated. During an interview with CNA #11, on [DATE] at 2:30 p.m., she indicated she was working on the dementia unit, on [DATE], when the altercation between Resident B and Resident C occurred. She indicated no staff member had been in the dining/activity area and she estimated 5 or 6 other residents had been present in the area at the time. CNA #11 indicated Resident B had a bump on her head and had "hurt" her back. CNA #12 was interviewed, on [DATE] at 2:10 p.m., and indicated she had been working on the Alzheimer's Unit on [DATE], when she heard yelling and something hit the floor in the dining/activity area. She indicated she went to the area and found Resident C swinging a walker at everyone nearby. She indicated Resident B was on the floor with an "egg-sized" bump on her head. She indicated Resident C was standing and several residents were in the area at the time but she was unable to remember who the residents were. On [DATE] at 1:50 p.m., two residents were observed sitting in the main dining/activity room on the Alzheimer's Unit. There was no staff present in the room. The residents were not interacting and were on opposite sides of the room. On [DATE] at 10:55 a.m., LPN #13 was interviewed and indicated she had been working on the Alzheimer's Unit on [DATE], the day of the altercation between Resident B and Resident C. She indicated she had been taking a cordless phone to a resident, when she heard yelling, went to the dining room and found Resident B lying flat on her back on the floor. LPN #13 indicated no staff member saw the incident but Resident F, who was fairly reliable, said Resident C pushed Resident B down. (The clinical record of Resident F was reviewed on [DATE] at 2:30 p.m. Resident F's BIMS (Brief Interview of Mental Status) score on the Quarterly MDS (Minimum Data Set) Assessment, dated [DATE], was 14, indicating the resident's cognition was intact.) On [DATE] at 11:30 a.m., CNA #14, indicated she had worked on the Alzheimer's unit for several years and, at the time of the incident between Resident C and B, staff were suppose to be with the residents in the dining/activity room but in practice, this was not always done because there was only one nurse and one aide covering the front halls. A facility inservice record, dated [DATE], provided by the Director of Nursing, indicated "A staff member is to be in DR (Dining Room) (Activity Room) @ (at) all times when there are 2 or more residents in the room." Review of the current census, provided by the Administrator, on [DATE] at 2:30 p.m., indicated 26 residents were currently living on the secure unit. The care plan aide sheets, provided by the DON, on [DATE] at 12:30 p.m., indicated 17 of the 26 were verbally abusive, 10 of the 26 were physically abusive or combative/hitting, 7 of 26 wandered. The most recent Annual Recertification and State Licensure Survey, dated [DATE], was reviewed on [DATE] at 3:00 p.m., and indicated the facility had been cited for failure to provide adequate supervision to prevent a fall with injury (fractured hip) at a harm level. The report indicated the incident had happened on the secured unit. The report also indicated a lack of supervision in the hallways, lounge area and dining room. The facility response to the [DATE], citation indicated, "The intent of this facility is to provide adequate supervision to prevent falls and to provide adequate supervision to prevent accidents." The plan of correction included measures to provide supervision, increased activities and cueing, plus daily monitoring for supervision and staffing inservices. The facility provided a plan for removal of the ,[DATE]-,[DATE] Immediate Jeopardy on [DATE], which indicated: "Staff member will be in dining room/common area at all times. Schedule developed to cover each shift of the dining room/common area. Nurse Manager's office moved to dining room area. Staff in-service initiated on supervision and safety. This includes ensuring there is a staff member in the dining room/common area at all times on the Dementia Unit. Walkie Talkies purchased to enhance communication. Construction in process, once complete, the Nurses Station will be moved to area making dining room/common area visible." In addition, information regarding the activity program restructuring plan was provided on [DATE] at 3:00 p.m., by the Corporate Nurse. The revised program provided for alternating active and passive activities. An Immediate Jeopardy (IJ) was identified on [DATE] at 4:30 p.m. The Immediate Jeopardy began on [DATE] when the resident sustained [REDACTED]. The Administrator, Corporate Director of Operations, Clinical Care Specialist, Social Service Director and Director of Nursing were notified of the Immediate Jeopardy on [DATE] at 4:30 p.m., related to the lack of supervision to prevent accidents. The facility staff submitted a plan of action to remove the Immediate Jeopardy and the Immediate Jeopardy was removed on [DATE], when through interviews and observation of increased supervision, walkie talkie usage, and enhanced activities, it was determined the facility had implemented the plan of action to remove the Immediate Jeopardy and that the steps taken removed the immediacy of the problem. Even though the facility's corrective action removed the IJ, the facility remained out of compliance at a reduced scope and severity level of pattern with potential for more than minimal harm that is not immediate jeopardy. This federal tag relates to complaint IN 632. 3XXX,[DATE](a)(2)

Based on observation, record review, and interviews, the facility failed to provide adequate supervision to prevent a fall with injury (fractured hip) for 1 of 3 closed records reviewed. (Resident #4) In addition, the facility failed to provide adequate supervision to prevent accidents for 12 of 12 residents residing on the Advanced Alzheimer's Unit (AAU). (Residents #1, 2, 3, 5, 6, 7, 8, 9, 10, 11, 12, and 13) and 1 resident who came to the AAu for dining. (Resident #27) Findings include: 1. Review, on 01/27/11 at 10:00 A.M. , of the closed record for Resident #4, indicated the resident had fallen on 01/04/11. On 01/06/11, the resident was transferred to an acute care center emergency room and diagnosed with [REDACTED]. The resident returned from the acute care facility emergency room , on 01/06/11, with the following new orders: "ASA (aspirin) 81 mg daily, walker to aid ambulation, pt (patient) to be up only with assistance, bed monitor to prevent pt getting up alone, rails to be up to prevent falls." The resident's health care plans were not updated to reflect the new physician orders [REDACTED]. The resident was screened on 01/10/11, by the physical therapy department and added to their caseload due to her fall on 01/04/11. The resident was treated by physical therapy for eight days for standing balance, transferring and mobility needs. Nursing notes, dated 01/19/11 at 3:00 P.M., indicated the following: "Pt was walking in hall on back unit (AAU) Resident # (Resident #10) pushed pts arm, she lost her balance et fell on right hip. Staff alerted writer...." Subsequent nursing notes indicated an x-ray was obtained and indicated the resident had a hip fracture and she was subsequently transferred to an acute care center for treatment. Interview with the DON (Director of Nursing), ADON (Assistant Director of Nursing), and Rehab manager, COTA (Certified Occupational Therapy Assistant) #14, on 01/27/11 at 2:30 P.M. indicated the "assistance" the resident required was the walker, not staff "assistance." They indicated the resident had a bed alarm, so they knew when the resident was up out of bed and knew to make sure the resident had her walker with her. The DON indicated the resident was not being assisted to ambulate when she fell on [DATE] but staff were in the hallway getting ready to take another resident into the shower room for a shower when they saw Resident #4 fall. Interview on 1/27/11 at 11:30 a.m. with the Physical Therapist #16, who had worked with Resident #4, indicated while the resident was making progress, she still required "contact guard" assistance in the therapy room mostly because she was not capable of physically placing the walker correctly and mentally needed cues to remember to utilize the walker and instructions on how to utilize the walker. She indicated she did not instruct the nursing staff to allow the resident to ambulate independently with the walker. 2. On 01/24/11 at 11:53 A.M., the meal trays were delivered on a cart to the AAU dining room. The meal tray for Resident #6 was delivered at 11:53 A.M. The resident was noted to be sleeping at a c-shaped table and did not respond to verbal cues to "wake up" and "eat." The meal tray for Resident #3 was delivered to her and set up for her and she was instructed to eat. The resident was noted to eat with her fingers and pick up her dessert plate, on which she had picked at a piece of cake, and lick the plate. CNA (Certified Nursing Assistant) #5, noticed Resident #3 licking her dessert plate but only commented "Poor (resident's name) - she really likes her sweets." The CNA did not redirect the resident from licking her plate or from eating with her fingers. At 12:15 P.M., the meal tray was delivered to Resident #9 who was sleeping at a c-shaped table. The resident was awakened and instructed to eat. The resident then proceeded to stick the handle part of her fork and her piece of cake into a plastic mug and fell back asleep. Both Residents #6 and 9 were not assisted to eat until 12:19 P.M. On 01/25/11 at 9:00 A.M., there were three residents in the family lounge. Religious music was again playing at maximum volume in the family lounge. There were five residents noted in the dining room and one resident pacing up and down the hallway. CNA #5 was observed to be getting residents out of the dining room and bringing them down to the family lounge. There were no other staff noted on the unit at the time and no supervision for residents in the family lounge while CNA #5 was in the dining room. At 9:12 A.M., the Unit Manager #7, entered the unit and turned the religious music down in volume, then she proceeded into her office. She did not provide supervision for residents on the unit. At 9:15 A.M., there were four residents pacing in the hallway and five residents in the family lounge. CNA#5 was in the dining room clearing up breakfast items. At 9:20 A.M., the Unit Manager #7 exited her office and instructed CNA #5, who was in the hallway, to do "ROM" (Range of Motion) At the same time, QMA #6 entered the unit with a medication cart and proceeded to pass medications on the AAU. At 9:45 A.M., there were four residents in the family lounge, two were asleep and two were awake, and there was one resident walking in the hallway with QMA #6. There was no supervision for residents in the family lounge as QMA #6 was in the hallway walking in a train style with Resident #9. At 9:47 A.M., QMA #6, who was the only employee on the unit at the time, gathered five residents into the family lounge, turned off the religious music, turned on the television, and handed two of the resident magazines to view. While QMA #6 was in the family lounge and CNA #5 was off of the unit, there was no supervision for the two residents who were now pacing in the hallway. At 10:02 A.M., the ADON, assistant director of nursing, delivered snacks onto the AAU. At 10:04 A.M., CNA #5, who had left the unit, returned to the unit. QMA #6 started preparing snacks to pass to residents. At 10:12 A.M., after snacks had been passed, QMA #6 left the unit. The ADON was noted to sit in the family lounge with five residents. The television was playing and the employee was sitting in a recliner without interacting with the residents. CNA #5 also left the unit. There was no supervision for the residents in the hallways pacing or in their rooms. At 10:50 A.M., Resident #5 was heard making loud noises. CNA #5, who had been in the family lounge, responded to her room and noted Resident #10 standing in her room. CNA #5 redirected Resident #10 back into the hallway and while CNA #5 was in Resident #5's room, talking to her, Resident #10 was attempting to hit Resident #8 who was ambulating by Resident #10 holding dolls. CNA #5 was alerted to the situation and redirected Resident #8 away from Resident #9. CNA #5, realizing Resident #10 was agitated, held his hand and ambulated in the hallway with him from 10:50 A.M. - 11:00 A.M. While CNA #5 was ambulating with Resident #9, there were five residents in the family lounge. There was no supervision for the five residents in the family lounge. At 11:03 A.M., the Unit Manager #7 brought Residents #13 and #7 back from the music program, spoke briefly with Resident #10, and went into her office and closed the door. CNA #5 walked with Resident #7, directing her back to her room and assisted her to the toilet. From 11:03 A.M. - 11:06 A.M., there was no direct supervision for residents in the dining room, hallway, or family lounge. At 11:06 A.M., QMA #6 reentered the unit with a milkshake and crackers for Resident #10. At 11:09 A.M., two male residents were pacing in the hallway, Unit Manager #7 was in her office with the door closed, CNA #5 was in Resident #7's room, five residents were seated in the family lounge with the television on and no direct staff supervision. At 11:19 A.M., QMA #6 took Resident #1 in his wheelchair, into the shower room to weigh him. CNA #5 walked Resident #7 and #13 to the dining room. At 11:24 A.M., QMA #6 left the unit. At 11:28 A.M., CNA #5 directed Resident #8 to ambulate into the dining room. Unit Manager #7 exited her office and pushed Resident #1 in his wheelchair to the dining room and then Unit Manager #7 left the unit. At 11:30 A.M., CNA #5 and QMA #6 , who had reentered the unit, took Resident #1 from the dining room, into his room, and again attempted to transfer him to the toilet with the standing lift. While both employees were in Resident #1's room, 3 residents were ambulating in the hallway, five residents were seated in the dining room, a few residents were in their rooms, and one resident was in the family lounge. Resident #8 kept grabbing ahold of Resident #7's walker. Between 11:30 A.M. - 11:42 A.M., there were no employees supervising and/or interacting with the residents, because both CNA #5 and QMA #6 were in Resident #1's room. At 11:42 A.M., the ADON walked onto the unit searching for QMA #6. After realizing both employees were in with Resident #1, the ADON stayed in the dining room, but there was no direct supervision for residents in the hallway or in the family lounge. At 11:43 A.M., Unit Manager #7 reentered the unit, and although she looked at Resident #8 holding onto Resident #7's walker as the two residents ambulated in the hallway, she walked directly to her office without intervening. At 11:44 A.M., QMA #6 exited Resident #1's room and she and the ADON helped Resident #2, who was seated in the family lounge, to stand and ambulate to the dining room. The ADON then exited the unit. At 11:48 A.M., QMA #6 left the unit, CNA #5 was still in the room with Resident #1, there were four residents ambulating in the hallway, five residents in the dining room in chairs, and no staff were supervising the residents. At 11:50 A.M., CNA #5 pushed Resident #1 in his wheelchair to the dining room. CNA #9 brought Resident #27 to the dining room from another nursing unit, then she left the AAU. At 11:56 A.M., CNA #5 got Resident #5 out of her recliner in her room, and ambulated with her to the dining room. CNA #9 entered the unit with the food cart. While CNA #5 was getting Resident #5 out of her recliner in her room, there was no supervision for the residents in the dining room or in the hallway ambulating. At 12:06 P.M., Resident #3's tray was delivered to her. The staff put butter on her sweet potato and left the resident to feed herself. The resident was noted to eat her cherry cobbler dessert directly out of the bowl without using silverware. The dessert dribbled down the resident's chin, clothes, and was noted all over her fingers. She did not receive any cues or supervision to use her silverware. At 12:21 P.M., Resident #27 was noted to be sitting at a table without any staff cues or assistance. The resident's left hand was noted to be lying in his pureed meat and gravy. The resident was attempting to feed himself with his right hand but was noted to have dribbled most of his dessert and vegetable down his chin. CNA #5 left the dining room to deliver a tray to Resident #10's room. She returned at 12:26. From 12:21 P.M. - 12:26 P.M., QMA #6 was in the dining room passing out meal trays but was not supervising Residents #27 or #3. At 12:26 P.M., both CNA #5 and QMA #6 were seated a two c-shaped tables with four residents for each to feed and/or assist. Resident #3 was taking food off of Resident #7's meal tray, and a family member for another resident tried to intervene. There were no observations made from 12:26 P.M. - 1:15 P.M. At 1:15 P.M., CNA #5 was observed the dining room cleaning up from lunch and no staff supervision for residents in the hallway or family lounge. At 1:45 P.M., five residents were in the family lounge and Unit Manager, who was also in the family lounge, attempted to lead a "Visualization" type activity. While Unit Manager was trying to give instructions for the activity, two of the five residents got up and left the room, and one resident was loudly verbalizing non-sensible babble. Four other residents were in the dining room without any stimulation, three residents were wandering in the hallway, and CNA #5 was in a resident room assisting a resident to the toilet. There was no direct supervision for residents in the hallway or dining room. At 1:50 P.M., Unit Manager #7 asked CNA #5, who had reentered the hallway, to repeat the visualization "story" again later this afternoon, and she left the unit. At 2:00 P.M., there were two residents in the family lounge. One of the two residents was noted to be licking a wooden plaque. Four residents were pacing in the hall, and two nursing staff, CNA #5 and QMA #6 were in helping Resident #1 to get into his bed. There were two housekeeping staff sitting in the dining room with two residents. There was no staff supervision for the residents in the hallway or in the family lounge. At 2:07 P.M., the ADON entered the unit, and CNA #5 came out of Resident #1's room. At 2:12 P.M., there were four residents pacing in the hallway. Unit Manager #7 entered the unit and went directly into her office and closed the door. QMA #6 entered the unit and started passing out snacks. At 2:14 P.M., Unit Manager left her office and exited the unit. Five residents were noted to be pacing up and down the hallway. CNA #5 got one of the five residents ambulating in the hallway and directed them into the family lounge. At 2:15 P.M., CNA #5 got Resident #6 out of the dining room and took her into her room to the bathroom. QMA #6 was in the family lounge feeding Resident #12 his pudding. While, CNA #5 was in the bathroom with Resident #6, Resident #9 walked into Resident #6's room and picked up Resident #6's pudding which had been placed on Resident #6's bedside stand. There was no staff supervision for residents ambulating the hallway. At 2:19 P.M., the Administrator entered the unit and stood in the hallway. Four residents were in the family lounge with no staff in the lounge. QMA #6 indicated both Resident #6 and #9 received a 2:00 P.M. pudding, so she was going to switch the bowls of pudding, since Resident #9 had gotten ahold of Resident #6's pudding. At 2:27 P.M., the Administrator was still on the unit, speaking and ambulating with Resident #10. Five other residents were ambulating in the hallway. QMA #6 had briefly left the unit and returned with a treatment cart and proceeded to do treatments and charting. The ADON had also entered the unit and went into the family lounge. At 2:36 P.M., the administrator left the unit, four residents were ambulating up and down the hallway, a family member was walking with one of the four residents, and one resident was in the family lounge sleeping. At 2:42 P.M., the ADON, CNA #5, and QMA #6 were all in the shower room with Resident #3. Six residents were pacing in the hallway unsupervised. At 2:45 P.M.., QMA #10 entered the unit and directed Residents #7 and #11 to the family lounge and then staff member #10 left the unit. At 2:46 P.M., the ADON was noted to be playing balloon toss with two residents in the family lounge. 5 residents were pacing in the hallways, and CNA #5 was still in the bathroom with Resident #3 and QMA #6 was in a resident's room applying a treatment. At 2:47 P.M., Resident #3 reentered the hallway and was walking into Resident #10, who had been ambulating in the hallway. Resident #10 was noted to push Resident #3 away from him. Unit Manager #7, who happened to have entered the unit, attempted to redirect Resident #3 away from Resident #10 but after being unsuccessful, Unit Manager #7 proceeded into her office and shut the door. There was then no supervision for the residents in the hallway ambulating. On 01/26/11 at 8:30 A.M., CNAs #5 and #8 were observed to be working on the AAU. Both CNA'S were noted to be toileting residents from 8:30 A.M. - 8:49 A.M. There was big band music playing at maximum volume in the family lounge. At 8:49 A.M., Unit Manager entered the unit and informed CNA #5 of the residents she wanted to go to the "Exercises" activity off of the unit. While the CNAs were in various resident rooms toileting residents, there was no direct supervision for the residents At 8:52 A.M., Unit Manager #7 took Resident #7 off of the unit for an activity. At 9:00 A.M., QMA #6 took Resident #13 off of the unit for an activity. At 9:08 A.M., CNA #8 was noted to play balloon toss with residents in the family lounge. She played balloon toss from 9:08 A.M. - 9:20 A.M. While she was in the family lounge, there was no supervision for residents in the hallway or dining room. At 9:30 A.M., CNA #5 was noted to be in the family lounge handing four of five residents in the lounge pieces of material. At 9:52 A.M., CNA #5 AND #8 took the stand up lift and Resident #1 and attempted to transfer him to the bathroom. Both employees were noted to be in Resident #1's room from 9:52 A.M. - 10:10 A.M. While staff were in Resident #1's room, the Dietary Manager had entered the unit to replace a name tag on a resident's door and noted one of the residents had had a bowel movement in the doorway to room #233. There were four residents pacing in the hallways and the dietary manager indicated he was "on guard" to make sure no residents stepped in the feces until housekeeping arrived to clean up the mess. There were six other residents noted in the family lounge without supervision. Unit Manager #7 entered the unit at 10:10 A.M., but went straight to her office and shut the door. Interview with the Administrator, on 01/27/11 at 2:15 P.M. indicated there were always two full time staff scheduled on the AAU at all times for only 12 residents and she felt the staffing was adequate. She indicated there was always a possibility for accidents no matter how many staff were available and no matter what type of residents were served. On 1/27/11 at 2:45 p.m., review of the most recent Minimum Data Set (MDS) assessments for all current residents residing on the AAU indicated the following: All 12 were cognitively impaired, 9 of 12 wandered in the hallway occasionally to frequently, 4 residents were at risk for falls, all 12 required extensive staff assistance for dressing and hygiene needs, 11 of 12 required extensive staff assistance for toilet use, 1 of 12 residents was in a wheelchair and required two staff assistance for transferring needs, 2 of 12 required staff assistance of 1 for ambulation needs, and 9 of 12 required extensive staff assistance for eating needs. In addition, Resident #27, who was brought to the dining room from another nursing unit for meals, also required extensive staff assistance of 1 for eating needs. The AAU was one hallway with a shorter wider hallway on one end. The dining room was at the south end of the hallway, the short hallway and the family lounge were on the north end of the hallway. There were no video cameras or mirrors noted to assist staff with visualization on the AAU. 3.1-45(a)(2)